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Witzel TC, Ghobrial A, Palich R, Charles H, Rodger AJ, Sabin C, Sparrowhawk A, Pool ER, Prochazka M, Vivancos R, Sinka K, Folkard K, Burns FM, Saunders J. Experiences of mpox illness and case management among cis and trans gay, bisexual and other men who have sex with men in England: a qualitative study. EClinicalMedicine 2024; 70:102522. [PMID: 38685928 PMCID: PMC11056388 DOI: 10.1016/j.eclinm.2024.102522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 05/02/2024] Open
Abstract
Background The 2022-2024 global mpox outbreak, occurring primarily in the sexual networks of gay, bisexual and other men who have sex with men (GBMSM), has not been accompanied by a focus on patient perspectives of illness. We explore the experiences of GBMSM diagnosed with mpox in England to understand needs for social and clinical support. Methods In-depth interviews (March/July 2023) were conducted with 22 GBMSM diagnosed with mpox in 2022, randomly selected from a national mpox surveillance database, and 4 stakeholders from clinical/community-based organisations. Interviews covered experiences of illness, testing, diagnosis, treatment and contact tracing, and were recorded, transcribed and analysed with a thematic framework. Findings Media coverage drawing on homophobic stereotypes around sex between men contributed to feelings of stigma and shame. GBMSM living with HIV appeared to cope better with mpox stigma, drawing on their experiences of being diagnosed with HIV for resilience. Younger GBMSM with less experience of stigmatising illness found mpox diagnosis more traumatic and sometimes required support beyond what was provided. Accessing testing could be complicated when healthcare professionals did not recognise mpox symptoms. Men felt information on course of illness, isolation and vaccination after recovery was often inconsistent and contradictory. GBMSM described that care from sexual health and infectious disease units usually better met their emotional and medical needs. This was frequently linked by men to these services having skills in working with the GBMSM community and managing infection risk sensitively. General hospital services and centralised contact tracing could increase feelings and experiences of stigma as some staff were perceived to lack skills in supporting GBMSM and, sometimes, clinical knowledge. Long-term impacts described by men included mental health challenges, urethral/rectal symptoms and life-changing disability. Interpretation In this study stigma was a central feature of mpox illness among GBMSM and could be exacerbated or lessened depending on the clinical and social support provided. Involving communities affected by outbreaks in co-producing, planning and delivering care (including contact-tracing) may help improve support provided. Funding TCW, AJR, AS and FMB received support from the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research Programme (Ref: NIHR202038). CS and JS receive support from the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with UKHSA; RV receives support from the NIHR HPRU in Emerging and Zoonotic Infections and NIHR HPRU in Gastrointestinal Infections. The views expressed are those of the author(s) and not necessarily those of the NIHR, UK Health Security Agency, World Health Organization or the Department of Health and Social Care.
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Affiliation(s)
- T Charles Witzel
- Institute for Global Health, University College London, London, UK
| | - Andrew Ghobrial
- Institute for Global Health, University College London, London, UK
| | - Romain Palich
- Institute for Global Health, University College London, London, UK
- AP-HP.Sorbonne Université, Paris, France
| | | | - Alison J. Rodger
- Institute for Global Health, University College London, London, UK
| | - Caroline Sabin
- Institute for Global Health, University College London, London, UK
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in Partnership with (UKHSA), London, UK
| | | | - Erica R.M. Pool
- Institute for Global Health, University College London, London, UK
| | | | - Roberto Vivancos
- UK Health Security Agency (UKHSA), London, UK
- NIHR HPRU in Emerging and Zoonotic Infections at the University of Liverpool, Liverpool, UK
- NIHR HPRU in Gastrointestinal Infections at the University of Liverpool, Liverpool, UK
| | - Katy Sinka
- UK Health Security Agency (UKHSA), London, UK
| | | | - Fiona M. Burns
- Institute for Global Health, University College London, London, UK
| | - John Saunders
- Institute for Global Health, University College London, London, UK
- UK Health Security Agency (UKHSA), London, UK
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in Partnership with (UKHSA), London, UK
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Palich R, Rodger AJ, Nicholls EJ, Wright T, Samba P, Chu IYH, Burns FM, Weatherburn P, Trevelion R, McCabe L, Witzel TC. Experiences with health care services and HIV testing after sexual assault in cisgender gay, bisexual and other men who have sex with men and transgender people. HIV Med 2024. [PMID: 38433523 DOI: 10.1111/hiv.13629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES This qualitative sub-study aimed to explore how cisgender gay, bisexual, and other men who have sex with men (cis-GBMSM) and transgender people who reported non-consensual sex (NCS) accessed health care services, what barriers they faced, and how this experience influenced subsequent HIV testing. METHODS SELPHI is an online randomized controlled trial evaluating both acceptability and efficiency of HIV-self testing among cis-GBMSM and transgender people. Semi-structured interviews were conducted, audio-recorded, transcribed, and analysed through a framework analysis, as a qualitative sub-study. We identified narratives of NCS from interviews and investigated experiences of cis-GBMSM and transgender people accessing health care services following sexual assault. RESULTS Of 95 participants, 15 (16%) spontaneously reported NCS. Participants reported a broad range of NCS, including partner's coercive behaviours, non-consensual removal of condoms, and rapes. All feared HIV transmission, leading them to test for HIV, underlining a marked lack of awareness of post-exposure prophylaxis (PEP). Most had negative experiences in communicating with reception staff in sexual health clinics following these incidents. A lack of confidentiality and empathy was described in these situations of psychological distress. Clinic visits were primarily focused on testing for HIV and sexually transmitted infection, and generally no specific psychological support was offered. Getting a negative HIV result was a key step in regaining control for people who experienced NCS. CONCLUSIONS Sexual health care providers should take care to more fully address the issue of NCS with cis-GBMSM and transgender people when it arises. Recognizing and managing the emotional impact of NCS on affected patients would prevent negative experiences and increase confidence in care.
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Affiliation(s)
- Romain Palich
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
| | - Alison J Rodger
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
| | - Emily Jay Nicholls
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
| | - Talen Wright
- University College London, Division of Psychiatry, London, UK
| | | | - Isaac Yen-Hao Chu
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
- London School of Hygiene and Tropical Medicine, Department of Public Health, Environments and Society, London, UK
| | - Fiona M Burns
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
| | - Peter Weatherburn
- London School of Hygiene and Tropical Medicine, Department of Public Health, Environments and Society, London, UK
| | | | - Leanne McCabe
- University College London, MRC Clinical Trials Unit, London, UK
| | - T Charles Witzel
- University College London, Institute for Global Health, Royal Free Hospital, NHS, London, UK
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Walker EF, Flook M, Rodger AJ, Fielding KL, Stagg HR. Quantifying non-adherence to anti-tuberculosis treatment due to early discontinuation: a systematic literature review of timings to loss to follow-up. BMJ Open Respir Res 2024; 11:e001894. [PMID: 38359965 PMCID: PMC10875541 DOI: 10.1136/bmjresp-2023-001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The burden of non-adherence to anti-tuberculosis (TB) treatment is poorly understood. One type is early discontinuation, that is, stopping treatment early. Given the implications of early discontinuation for treatment outcomes, we undertook a systematic review to estimate its burden, using the timing of loss to follow-up (LFU) as a proxy measure. METHODS Web of Science, Embase and Medline were searched up to 14 January 2021 using terms covering LFU, TB and treatment. Studies of adults (≥ 18 years) on the standard regimen for drug-sensitive TB reporting the timing of LFU (WHO definition) were included. A narrative synthesis was conducted and quality assessment undertaken using an adapted version of Downs and Black. Papers were grouped by the percentage of those who were ultimately LFU who were LFU by 2 months. Three groups were created: <28.3% LFU by 2 months, ≥28.3-<38.3%, ≥38.3%). The percentage of dose-months missed due to early discontinuation among (1) those LFU, and (2) all patients was calculated. RESULTS We found 40 relevant studies from 21 countries. The timing of LFU was variable within and between countries. 36/40 papers (90.0%) reported the percentage of patients LFU by the end of 2 months. 31/36 studies (86.1%) reported a higher than or as expected percentage of patients becoming LFU by 2 months. The percentage of dose-months missed by patients who became LFU ranged between 37% and 77% (equivalent to 2.2-4.6 months). Among all patients, the percentage of dose-months missed ranged between 1% and 22% (equivalent to 0.1-1.3 months). CONCLUSIONS A larger than expected percentage of patients became LFU within the first 2 months of treatment. These patients missed high percentages of dose months of treatment due to early discontinuation. Interventions to promote adherence and retain patients in care must not neglect the early months of treatment. PROSPERO REGISTRATION NUMBER CRD42021218636.
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Affiliation(s)
| | - Mary Flook
- Faculty of Life and Health Sciences, University of Liverpool, Liverpool, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of the Witwatersrand- Johannesburg, Johannesburg, South Africa
| | - Helen R Stagg
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Witzel TC, Nicholls EJ, McCabe L, Weatherburn P, McCormack S, Bonell C, Gafos M, Lampe FC, Speakman A, Dunn D, Ward D, Phillips AN, Pebody R, Gabriel MM, Collaco-Moraes Y, Rodger AJ, Burns FM. Understanding experiences of potential harm among MSM (cis and trans) using HIV self-testing in the SELPHI randomised controlled trial in England and Wales: a mixed-methods study. Sex Transm Infect 2023; 99:534-540. [PMID: 37607814 PMCID: PMC10715485 DOI: 10.1136/sextrans-2023-055840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/15/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND The potential of HIV self-testing (HIVST) to cause harm is a concern hindering widespread implementation. The aim of this paper is to understand the relationship between HIVST and harm in SELPHI (An HIV Self-testing Public Health Intervention), the largest randomised trial of HIVST in a high-income country to date. METHODS 10 111 cis and trans men who have sex with men (MSM) recruited online (geolocation social/sexual networking apps, social media), aged 16+, reporting previous anal intercourse and resident in England or Wales were first randomised 60/40 to baseline HIVST (baseline testing, BT) or not (no baseline testing, nBT) (randomisation A). BT participants reporting negative baseline test, sexual risk at 3 months and interest in further HIVST were randomised to three-monthly HIVST (repeat testing, RT) or not (no repeat testing, nRT) (randomisation B). All received an exit survey collecting data on harms (to relationships, well-being, false results or being pressured/persuaded to test). Nine participants reporting harm were interviewed in-depth about their experiences in an exploratory substudy; qualitative data were analysed narratively. RESULTS Baseline: predominantly cis MSM, 90% white, 88% gay, 47% university educated and 7% current/former pre-exposure prophylaxis (PrEP) users. Final survey response rate was: nBT=26% (1056/4062), BT=45% (1674/3741), nRT=41% (471/1147), RT=50% (581/1161).Harms were rare and reported by 4% (n=138/3691) in exit surveys, with an additional two false positive results captured in other study surveys. 1% reported harm to relationships and to well-being in BT, nRT and RT combined. In all arms combined, being pressured or persuaded to test was reported by 1% (n=54/3678) and false positive results in 0.7% (n=34/4665).Qualitative analysis revealed harms arose from the kit itself (technological harms), the intervention (intervention harms) or from the social context of the participant (socially emergent harms). Intervention and socially emergent harms did not reduce HIVST acceptability, whereas technological harms did. DISCUSSION HIVST harms were rare but strategies to link individuals experiencing harms with psychosocial support should be considered for HIVST scale-up. TRIAL REGISTRATION NUMBER ISRCTN20312003.
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Affiliation(s)
- T Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
- Institute for Global Health, University College London, London, UK
| | | | - Leanne McCabe
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Peter Weatherburn
- Social & Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Christopher Bonell
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Mitzy Gafos
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
| | - Andrew Speakman
- Institute for Global Health, University College London, London, UK
| | - David Dunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Denise Ward
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | - Michelle M Gabriel
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Fiona M Burns
- Institute for Global Health, University College London, London, UK
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Cambiano V, Miners A, Lampe FC, McCormack S, Gill ON, Hart G, Fenton KA, Cairns G, Thompson M, Delpech V, Rodger AJ, Phillips AN. The effect of combination prevention strategies on HIV incidence among gay and bisexual men who have sex with men in the UK: a model-based analysis. Lancet HIV 2023; 10:e713-e722. [PMID: 37923485 DOI: 10.1016/s2352-3018(23)00204-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In the UK, the number of new HIV diagnoses among gay and bisexual men who have sex with men (GBMSM) has decreased substantially. We aimed to understand the contribution of different interventions in reducing HIV incidence so far; to estimate future HIV incidence with continuation of current policies and with further scaling up of current interventions; and to estimate the maximum additional annual cost that should be spent towards these interventions for them to offer value for money. METHODS We calibrated a dynamic, individual-based, stochastic simulation model, the HIV Synthesis Model, to multiple sources of data on HIV among GBMSM aged 15 years or older in the UK. Primarily these were routine HIV surveillance data collected by the UK Health Security Agency. We compared HIV incidence in 2022 with the counterfactual incidence: if HIV testing rates stopped increasing in 2012 and the policy of antiretroviral therapy (ART) at diagnosis was not introduced in mid-2015; if pre-exposure prophylaxis (PrEP) was not introduced; if condom use was low from 2012 in all GBMSM, at levels similar to those observed in 1980; and in the first and second scenario combined. We also projected future outcomes under the assumption of continuation of current policies and considering increases in PrEP and HIV testing uptake and a decrease in condomless sex. FINDINGS Our model estimated a 77% (90% uncertainty interval [UI] 61-88) decline in HIV incidence since around 2014, with an estimated 597 infections ([90% UI 312-956]; 1·1 per 1000 person-years [90% UI 0·6-1·8]) in men aged 15-64 years in 2022. Both PrEP introduction and increased HIV testing with ART initiation at diagnosis each had a substantial effect on HIV incidence. Without PrEP introduction, we estimate there would have been 2·16 times the number of infections that actually occurred (90% UI 1·06-3·75) between 2012 and 2022; without increased HIV testing and ART initiation at diagnosis there would have been 2·18 times the number of infections that actually occurred (1·18-3·60), and if condomless sex was at the levels before the HIV epidemic, there would have been 2·27 times the number of infections that actually occurred (0·9-5·4). If rates of testing, ART use, and PrEP use remain as they are currently, there is a predicted decline in incidence to 388 HIV infections in 2025 (90% UI 226-650) and to 263 (137-433) in 2030. Increases in HIV testing and PrEP use were predicted to accelerate the decline in HIV incidence. Given the quality-adjusted life-year (QALY) benefit and a cost-effectiveness threshold of £30 000 per QALY gained, in order to be cost-effective an additional £1·62 million could be spent per year to increase testing levels by 34% (90% UI 25-46) and PrEP use by 55% (10-107). To achieve that, a 16% reduction in the cost of delivery of testing and PrEP would be required. INTERPRETATION Combination prevention, including a PrEP strategy, played a major role in the reduction in HIV incidence observed so far in the UK among GBMSM. Continuation of current activities should lead to a continued decline; however, it is unlikely to lead to reaching the target of fewer than 50 HIV infections per year among GBMSM by 2030. It will be important to reduce costs for testing and PrEP for their continued expansion to be cost-effective. FUNDING National Institute for Health Research under its Programme Grants for Applied Research Programme and Medical Research Council-UK Research and Innovation.
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Affiliation(s)
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
| | - Sheena McCormack
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Graham Hart
- Institute for Global Health, University College London, London, UK
| | - Kevin A Fenton
- Office for Health Improvement and Disparities (London) and NHS London, London, UK
| | | | | | | | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
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Rodger AJ, McCabe L, Phillips AN, Lampe FC, Burns F, Ward D, Delpech V, Weatherburn P, Witzel TC, Pebody R, Kirwan P, Gabriel M, Khawam J, Brady M, Fenton KA, Trevelion R, Collaco-Moraes Y, McCormack S, Dunn D. Free HIV self-test for identification and linkage to care of previously undetected HIV infection in men who have sex with men in England and Wales (SELPHI): an open-label, internet-based, randomised controlled trial. Lancet HIV 2022; 9:e838-e847. [PMID: 36460023 DOI: 10.1016/s2352-3018(22)00266-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND High levels of HIV testing in men who have sex with men remain key to reducing the incidence of HIV. We aimed to assess whether the offer of a single, free HIV self-testing kit led to increased HIV diagnoses with linkage to care. METHODS SELPHI was an internet-based, open-label, randomised controlled trial that recruited participants via sexual and social networking sites. Eligibility criteria included being a man or trans woman (although trans women are reported separately); being resident in England or Wales, UK; being aged 16 years or older; having had anal intercourse with a man; not having a positive HIV diagnosis; and being willing to provide name, email address, date of birth, and consent to link to national HIV databases. Participants were randomly allocated (3:2) by computer-generated number sequence to receive a free HIV self-test kit (BT group) or to not receive this free kit (nBT group). Online surveys collected data at baseline, 2 weeks after enrolment (BT group only), 3 months after enrolment, and at the end of the study. The primary outcome was confirmed (linked to care) new HIV diagnosis within 3 months of enrolment, analysed by intention to treat. Those assessing the primary outcome were masked to allocation. This study is registered with the ISRCTN Clinical Trials Register, number ISRCTN20312003. FINDINGS 10 111 participants (6049 in BT group and 4062 in nBT group) enrolled between Feb 16, 2017, and March 1, 2018. The median age of participants was 33 years (IQR 26-44 years); 9000 (89%) participants were White; 8118 (80%) participants were born in the UK; 81 (1%) participants were transgender men; 4706 (47%) participants were university educated; 1537 (15%) participants had never been tested for HIV; and 389 (4%) participants were taking pre-exposure prophylaxis. At enrolment, 7282 (72%) participants reported condomless anal sex with at least one male partner in the previous 3 months. In the BT group, of the 4511 participants for whom HIV testing information was available, 4263 (95%) reported having used the free HIV self-test kit within 3 months.Within 3 months of enrolment there were 19 confirmed new HIV diagnoses (0·31%) in 6049 participants in the BT group and 15 (0·37%) of 4062 in the nBT group (p=0·64). INTERPRETATION The offer of a single, free HIV self-test did not lead to increased rates of new HIV diagnoses, which could reflect decreasing HIV incidence rates in the UK. Nonetheless, the offer of a free HIV self-testing kit resulted in high HIV testing rates, indicating that self-testing is an attractive testing option for a large group of men who have sex with men. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Alison J Rodger
- Institute for Global Health, University College London, London, UK.
| | - Leanne McCabe
- UK MRC Clinical Trials Unit, University College London, London, UK
| | | | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London, London, UK
| | - Denise Ward
- UK MRC Clinical Trials Unit, University College London, London, UK
| | - Valerie Delpech
- National Infection Service, UK Health Security Agency, London, UK
| | - Peter Weatherburn
- Department of Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - T Charles Witzel
- Institute for Global Health, University College London, London, UK
| | | | - Peter Kirwan
- National Infection Service, UK Health Security Agency, London, UK
| | - Michelle Gabriel
- UK MRC Clinical Trials Unit, University College London, London, UK
| | - Jameel Khawam
- National Infection Service, UK Health Security Agency, London, UK
| | - Michael Brady
- Department of Sexual Health and HIV, King's College Hospital, London, UK
| | | | | | | | - Sheena McCormack
- UK MRC Clinical Trials Unit, University College London, London, UK
| | - David Dunn
- UK MRC Clinical Trials Unit, University College London, London, UK
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7
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Whittaker C, Watson OJ, Alvarez-Moreno C, Angkasekwinai N, Boonyasiri A, Carlos Triana L, Chanda D, Charoenpong L, Chayakulkeeree M, Cooke GS, Croda J, Cucunubá ZM, Djaafara BA, Estofolete CF, Grillet ME, Faria NR, Figueiredo Costa S, Forero-Peña DA, Gibb DM, Gordon AC, Hamers RL, Hamlet A, Irawany V, Jitmuang A, Keurueangkul N, Kimani TN, Lampo M, Levin AS, Lopardo G, Mustafa R, Nayagam S, Ngamprasertchai T, Njeri NIH, Nogueira ML, Ortiz-Prado E, Perroud MW, Phillips AN, Promsin P, Qavi A, Rodger AJ, Sabino EC, Sangkaew S, Sari D, Sirijatuphat R, Sposito AC, Srisangthong P, Thompson HA, Udwadia Z, Valderrama-Beltrán S, Winskill P, Ghani AC, Walker PGT, Hallett TB. Understanding the Potential Impact of Different Drug Properties on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Transmission and Disease Burden: A Modelling Analysis. Clin Infect Dis 2022; 75:e224-e233. [PMID: 34549260 PMCID: PMC9402649 DOI: 10.1093/cid/ciab837] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The public health impact of the coronavirus disease 2019 (COVID-19) pandemic has motivated a rapid search for potential therapeutics, with some key successes. However, the potential impact of different treatments, and consequently research and procurement priorities, have not been clear. METHODS Using a mathematical model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, COVID-19 disease and clinical care, we explore the public-health impact of different potential therapeutics, under a range of scenarios varying healthcare capacity, epidemic trajectories; and drug efficacy in the absence of supportive care. RESULTS The impact of drugs like dexamethasone (delivered to the most critically-ill in hospital and whose therapeutic benefit is expected to depend on the availability of supportive care such as oxygen and mechanical ventilation) is likely to be limited in settings where healthcare capacity is lowest or where uncontrolled epidemics result in hospitals being overwhelmed. As such, it may avert 22% of deaths in high-income countries but only 8% in low-income countries (assuming R = 1.35). Therapeutics for different patient populations (those not in hospital, early in the course of infection) and types of benefit (reducing disease severity or infectiousness, preventing hospitalization) could have much greater benefits, particularly in resource-poor settings facing large epidemics. CONCLUSIONS Advances in the treatment of COVID-19 to date have been focused on hospitalized-patients and predicated on an assumption of adequate access to supportive care. Therapeutics delivered earlier in the course of infection that reduce the need for healthcare or reduce infectiousness could have significant impact, and research into their efficacy and means of delivery should be a priority.
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Affiliation(s)
- Charles Whittaker
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Oliver J Watson
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Carlos Alvarez-Moreno
- Clínica Universitaria Colombia, Clínica Colsanitas, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Nasikarn Angkasekwinai
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Luis Carlos Triana
- Hospital Universitario San Ignacio -Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Duncan Chanda
- Adult Infectious Diseases Centre, University Teaching Hospital, Lusaka, Zambia
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Lantharita Charoenpong
- Bamrasnaradura Infectious Diseases Institute, Department of Diseases Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Methee Chayakulkeeree
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
- NIHR Biomedical Research Centre, Imperial College NHS Trust, London, UK
| | - Julio Croda
- Oswaldo Cruz Foudantion, Mato Grosso do Sul, Campo Grande, Brazil
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Zulma M Cucunubá
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
- Departamento de Epidemiología Clínica y Bioestadística. Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Bimandra A Djaafara
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Cassia F Estofolete
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, Brazil
| | - Maria Eugenia Grillet
- Instituto de Zoologia y Ecologia Tropical, Facultad de Ciencias, Universidad Central de Venezuela, Caracas, Venezuela
| | - Nuno R Faria
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
- Departamento de Molestias Infecciosas e Parasitarias and Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Zoology, University of Oxford, Oxford, UK
| | - Silvia Figueiredo Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - David A Forero-Peña
- Biomedical Research and Therapeutic Vaccines Institute, Ciudad Bolívar, Venezuela
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Arran Hamlet
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Vera Irawany
- Fatmawati General Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
| | - Anupop Jitmuang
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Margarita Lampo
- Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela
| | - Anna S Levin
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Rima Mustafa
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Shevanthi Nayagam
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Mauricio L Nogueira
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, Brazil
| | - Esteban Ortiz-Prado
- OneHealth Global Research Group, Universidad de las Américas, Quito, Ecuador
| | | | | | - Panuwat Promsin
- Critical Care Division, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ambar Qavi
- School of Public Health, Imperial College London, London, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Ester C Sabino
- Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sorawat Sangkaew
- Section of Adult Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Djayanti Sari
- Department of Anesthesiology and Intensive Theraphy, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada. Public Hospital Dr. Sardjito, Yogyakarta, Indonesia
| | - Rujipas Sirijatuphat
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Andrei C Sposito
- Atherosclerosis and Vascular Biology Laboratory, State University of Campinas, Campinas, Brazil
| | | | - Hayley A Thompson
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | | | - Sandra Valderrama-Beltrán
- Division of Infectious Diseases. School of Medicine. Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Peter Winskill
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Azra C Ghani
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Patrick G T Walker
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Timothy B Hallett
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
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8
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Nicholls EJ, Samba P, McCabe L, Gafos M, Philips AN, Trevelion R, Rodger AJ, Burns FM, Weatherburn P, Witzel TC. Experiences of and attitudes towards HIV testing for Asian, Black and Latin American men who have sex with men (MSM) in the SELPHI (HIV Self-Testing Public Health Intervention) randomized controlled trial in England and Wales: implications for HIV self-testing. BMC Public Health 2022; 22:809. [PMID: 35459233 PMCID: PMC9034480 DOI: 10.1186/s12889-022-13189-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 04/01/2022] [Indexed: 11/11/2022] Open
Abstract
Background HIV self-testing (HIVST) could play an important role in improving access to testing and therefore reducing inequalities related to late diagnosis of HIV, while also improving access to HIV prevention interventions such as HIV pre-exposure prophylaxis. This study sought to understand the potential role of HIVST by exploring the experiences of Asian, Black and Latin American men who have sex with men (MSM) accessing the gay scene and the circulation of HIV testing norms; experiences of accessing HIV testing services; HIVST acceptability and preferences for intervention adaptations. Methods Twenty-nine qualitative interviews were conducted with Asian, Black and Latin American MSM who had participated in SELPHI, an HIVST randomised controlled trial. Topics included HIV testing history, HIV testing patterns, experiences of accessing sexual health services, mental health, engagement with HIVST and SELPHI, and experiences of the gay scene. Interviews were audio recorded, transcribed and then analysed using a thematic framework. Results The gay scene was identified as an important site for learning about HIV and being exposed to norms reinforcing the importance of protective behaviours. However, experiences of discomfort due to perceptions of ‘whiteness’ on the scene or experiences of racism may hinder the protective function the scene could play in developing norms influencing HIV testing behaviour. Discomfort in clinic waiting rooms was identified as a substantial barrier to accessing clinical services and many interviewees expressed preferences regarding the personal characteristics of healthcare providers. HIVST was found to be acceptable and some interviewees suggested potential adaptations of the HIVST offer, such as packaging HIVST with at home sexually transmitted infections testing options. Conclusions HIVST responds to some service access barriers experienced by Asian, Black and Latin American MSM. The decoupling of HIV testing and clinic attendance may be particularly valuable for MSM of minority ethnic backgrounds who are likely to experience anxiety and discomfort in clinic waiting rooms more acutely than White MSM due to concerns around implied disclosure. This suggests that HIVST may have the potential to increase testing uptake and frequency, particularly for those with complex relationships with clinical services. Trial Registration SELPHI was prospectively registered with the ISRCTN (ref: ISRCTN 20312003).
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Affiliation(s)
- Emily Jay Nicholls
- Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, 5-17 Tavistock Place, London, WC1H 9SH, UK. .,Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.
| | - Phil Samba
- Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, 5-17 Tavistock Place, London, WC1H 9SH, UK
| | - Leanne McCabe
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 5-17 Tavistock Place, London, WC1H 9SH, UK
| | - Andrew N Philips
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Roy Trevelion
- HIV I-Base, 107 The Maltings, 169 Tower Bridge Road, London, SE1 3LJ, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Fiona M Burns
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Peter Weatherburn
- Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, 5-17 Tavistock Place, London, WC1H 9SH, UK
| | - T Charles Witzel
- Department of Public Health, Environment and Society, London School of Hygiene and Tropical Medicine, 5-17 Tavistock Place, London, WC1H 9SH, UK.,Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
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9
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Jones TPW, Lampe FC, Arenas-Pinto A, Smith C, McDonnell J, Haddow L, Johnson M, Yousef E, Lascar M, Maria Geretti A, Sherr L, Collins S, Phillips AN, Rodger AJ. Alcohol, smoking, recreational drug use and association with virological outcomes among people living with HIV: cross-sectional and longitudinal analyses. HIV Med 2021; 23:209-226. [PMID: 34634176 PMCID: PMC9293433 DOI: 10.1111/hiv.13156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/23/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES There is increasing evidence to suggest that people living with HIV (PLWH) have significant morbidity from alcohol, recreational drug use and cigarette smoking. Our aim was to report associations of these factors with antiretroviral therapy (ART) non-adherence, viral non-suppression and subsequent viral rebound in PLWH. METHODS The Antiretroviral Sexual Transmission Risk and Attitudes (ASTRA) study recruited PLWH attending eight outpatient clinics in England between February 2011 and December 2012. Data included self-reported excessive drinking (estimated consumption of > 20 units of alcohol/week), alcohol dependency (CAGE score ≥ 2 with current alcohol consumption), recreational drug use (including injection drug use in the past 3 months), and smoking status. Among participants established on ART, cross-sectional associations with ART non-adherence [missing ≥2 consecutive days of ART on ≥2 occasions in the past three months] and viral-non suppression [viral load (VL) > 50 copies/mL] were assessed using logistic regression. In participants from one centre, longitudinal associations with subsequent viral rebound (first VL > 200 copies/mL) in those on ART with VL ≤ 50 copies/mL at baseline were assessed using Cox regression during a 7-year follow-up. RESULTS Among 3258 PLWH, 2248 (69.0%) were men who have sex with men, 373 (11.4%) were heterosexual men, and 637 (19.6%) were women. A CAGE score ≥ 2 was found in 568 (17.6%) participants, 325 (10.1%) drank > 20 units/week, 1011 (31.5%) currently smoked, 1242 (38.1%) used recreational drugs and 74 (2.3%) reported injection drug use. In each case, prevalence was much more common among men than among women. Among 2459 people on ART who started at least 6 months previously, a CAGE score ≥ 2, drinking > 20 units per week, current smoking, injection and non-injection drug use were all associated with ART non-adherence. After adjusting for demographic and socioeconomic factors, CAGE score ≥ 2 [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.09-2.13], current smoking (aOR = 1.58, 95% CI: 1.10-2.17) and injection drug use (aOR = 2.11, 95% CI: 1.00-4.47) were associated with viral non-suppression. During follow-up of a subset of 592 people virally suppressed at recruitment, a CAGE score ≥ 2 [adjusted hazard ratio (aHR) = 1.66, 95% CI: 1.03-2.74], use of 3 or more non-injection drugs (aHR = 1.82, 95% CI: 1.12-3.57) and injection drug use (aHR = 2.73, 95% CI: 1.08-6.89) were associated with viral rebound. CONCLUSIONS Screening and treatment for alcohol, cigarette and drug use should be integrated into HIV outpatient clinics, while clinicians should be alert to the potential for poorer virological outcomes.
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Affiliation(s)
| | - Fiona C Lampe
- Research Department of Infection & Population, University College London, London, UK
| | | | - Colette Smith
- Research Department of Infection & Population, University College London, London, UK
| | - Jeff McDonnell
- Research Department of Infection & Population, University College London, London, UK
| | - Lewis Haddow
- Research Department of Infection & Population, University College London, London, UK
| | | | - Elaney Yousef
- Brighton and Sussex University Hospitals, Brighton, UK
| | | | - Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Lorraine Sherr
- Research Department of Infection & Population, University College London, London, UK
| | | | - Andrew N Phillips
- Research Department of Infection & Population, University College London, London, UK
| | - Alison J Rodger
- Research Department of Infection & Population, University College London, London, UK
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10
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Jamil MS, Eshun-Wilson I, Witzel TC, Siegfried N, Figueroa C, Chitembo L, Msimanga-Radebe B, Pasha MS, Hatzold K, Corbett E, Barr-DiChiara M, Rodger AJ, Weatherburn P, Geng E, Baggaley R, Johnson C. Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis. EClinicalMedicine 2021; 38:100991. [PMID: 34278282 PMCID: PMC8271120 DOI: 10.1016/j.eclinm.2021.100991] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We updated a 2017 systematic review and compared the effects of HIV self-testing (HIVST) to standard HIV testing services to understand effective service delivery models among the general population. METHODS We included randomized controlled trials (RCTs) comparing testing outcomes with HIVST to standard testing in the general population and published between January 1, 2006 and June 4, 2019. Random effects meta-analysis was conducted and pooled risk ratios (RRs) were reported. The certainty of evidence was determined using the GRADE methodology. FINDINGS We identified 14 eligible RCTs, 13 of which were conducted in sub-Saharan Africa. Support provided to self-testers ranged from no/basic support to one-on-one in-person support. HIVST increased testing uptake overall (RR:2.09; 95% confidence interval: 1.69-2.58; p < 0.0001;13 RCTs; moderate certainty evidence) and by service delivery model including facility-based distribution, HIVST use at facilities, secondary distribution to partners, and community-based distribution. The number of persons diagnosed HIV-positive among those tested (RR:0.81, 0.45-1.47; p = 0.50; 8 RCTs; moderate certainty evidence) and number linked to HIV care/treatment among those diagnosed (RR:0.95, 0.79-1.13; p = 0.52; 6 RCTs; moderate certainty evidence) were similar between HIVST and standard testing. Reported harms/adverse events with HIVST were rare and appeared similar to standard testing (RR:2.52: 0.52-12.13; p = 0.25; 4 RCTs; very low certainty evidence). INTERPRETATION HIVST appears to be safe and effective among the general population in sub-Saharan Africa with a range of delivery models. It identified and linked additional people with HIV to care. These findings support the wider availability of HIVST to reach those who may not otherwise access testing.
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Affiliation(s)
- Muhammad S. Jamil
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
- Corresponding author.
| | - Ingrid Eshun-Wilson
- Washington University School of Medicine in St. Louis, St Louis, United States
| | - T. Charles Witzel
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, South Africa
| | - Carmen Figueroa
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Lastone Chitembo
- World Health Organization Country Office for Zambia, Lusaka, Zambia
| | | | - Muhammad S. Pasha
- World Health Organization Country Office for Pakistan, Islamabad, Pakistan
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Elizabeth Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - Alison J. Rodger
- Institute for Global Health, University College London, London, United Kingdom
| | - Peter Weatherburn
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elvin Geng
- Washington University School of Medicine in St. Louis, St Louis, United States
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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11
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Wright T, Nicholls EJ, Rodger AJ, Burns FM, Weatherburn P, Pebody R, McCabe L, Wolton A, Gafos M, Witzel TC. Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people's accounts of navigating gender identity clinics. BMC Health Serv Res 2021; 21:609. [PMID: 34182985 PMCID: PMC8240290 DOI: 10.1186/s12913-021-06661-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/18/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transgender, or trans, people experience a number of barriers to accessing gender-affirming healthcare and have a range of barriers and facilitators to primary care and specialist services, commonly citing discrimination and cisgenderism playing a central role in shaping accessibility. The pathway through primary care to specialist services is a particularly precarious time for trans people, and misinformation and poorly applied protocols can have a detrimental impact on wellbeing. METHOD We recruited trans participants from an HIV Self-Testing Public Health Intervention (SELPHI) trial to interviews which explored contemporary gender-affirming service experiences, with an aim to examine the path from primary care services through to specialist gender services, in the UK. RESULTS A narrative synthesis of vignettes and thematic analysis of in-depth qualitative interviews were conducted with twenty trans individuals. We summarise positive and negative accounts of care under three broad categories: Experiences with primary care physicians, referrals to gender identity clinics (GICs), and experiences at GICs. CONCLUSIONS We discuss implications of this research in terms of how to improve best practice for trans people attempting to access gender-affirming healthcare in the UK. Here we highlight the importance of GP's access to knowledge around pathways and protocols and clinical practice which treats trans patients holistically.
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Affiliation(s)
- Talen Wright
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK.
| | - Emily Jay Nicholls
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London , UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Fiona M Burns
- Institute for Global Health, University College London, London, UK
| | - Peter Weatherburn
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London , UK
| | | | - Leanne McCabe
- MRC Clinical Trials Unit, University College London, London, UK
| | | | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - T Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London , UK
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12
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Rein SM, Lampe FC, Chaloner C, Stafford A, Rodger AJ, Johnson MA, McDonnell J, Burns F, Madge S, Miners A, Sherr L, Collins S, Speakman A, Phillips AN, Smith CJ. Causes of hospitalisation among a cohort of people with HIV from a London centre followed from 2011 to 2018. BMC Infect Dis 2021; 21:395. [PMID: 33926373 PMCID: PMC8082756 DOI: 10.1186/s12879-021-06082-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background We describe the spectrum of ICD-10 classified causes for hospitalisations occurring between 2011 and 2018 in a cohort of people living with HIV (PLHIV). Methods This sub-study includes 798 PLHIV participating in the Antiretroviral, Sexual Transmission Risk and Attitudes (ASTRA) questionnaire study who were recruited from a large London centre. A medical record review identified the occurrence and causes of hospitalisation from the date of questionnaire completion (February–December 2011) until 1 June 2018. Up to five causes were classified by an HIV clinician using the ICD-10 system. Results There were 274 hospitalisations in 153 people (rate = 5.8/100 person-years; 95% CI: 5.1, 6.5). Causes were wide-ranging; the most common were circulatory (16.8%), digestive (13.1%), respiratory (11.7%), infectious diseases (11.0%), injury/poisoning (10.6%), genitourinary diseases (9.9%) and neoplasms (9.1%). A tenth (27/274) of hospitalisations were related to at least one AIDS-defining illness. Median duration of hospitalisation was 5 days (IQR 2–9). At the time of hospitalisation, median CD4 count was high (510 cells/μl; IQR: 315–739), while median CD4 nadir was relatively low (113 cells/μl; IQR: 40–239). At admission, half of individuals (51%) had a previous AIDS-defining illness and 21% had viral load > 50 copies/ml. Individuals admitted for infectious diseases were particularly likely to have unfavourable HIV-related clinical characteristics (low CD4, viral non-suppression, not on antiretroviral therapy (ART), previous AIDS). Conclusions In the modern combination antiretroviral therapy era, the spectrum of causes of hospitalisation in PLHIV in the UK is wide-ranging, highlighting the importance of holistic care for PLHIV, including prevention, early detection and treatment of comorbidities.
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Affiliation(s)
- Sophia M Rein
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK.
| | - Fiona C Lampe
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | - Clinton Chaloner
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | | | - Alison J Rodger
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | | | - Jeffrey McDonnell
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - Sara Madge
- Royal Free London NHS Foundation Trust, London, UK
| | - Alec Miners
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Lorraine Sherr
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | | | - Andrew Speakman
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | - Andrew N Phillips
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
| | - Colette J Smith
- Institute for Global Health, University College London (UCL), Royal Free Campus, Rowland Hill St, NW3 2PF, London, UK
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13
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Witzel TC, Wright T, McCabe L, Gabriel MM, Wolton A, Gafos M, Ward D, Lampe FC, Phillips AN, Trevelion R, Collaco-Moraes Y, Harbottle J, Speakman A, Bonell C, Dunn DD, McCormack S, Burns FM, Weatherburn P, Rodger AJ. Impact and acceptability of HIV self-testing for trans men and trans women: A mixed-methods subgroup analysis of the SELPHI randomised controlled trial and process evaluation in England and Wales. EClinicalMedicine 2021; 32:100700. [PMID: 33681732 PMCID: PMC7910695 DOI: 10.1016/j.eclinm.2020.100700] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Globally, trans people are disproportionately affected by HIV, but research on strategies to increase testing are limited. SELPHI is a randomised-controlled-trial (RCT) of 10,135 cis men, trans men, and trans women reporting lifetime anal intercourse with male partners (cis or trans), evaluating whether the offer of free HIV self-testing (HIVST) increases diagnosis. This subgroup analysis from the SELPHI RCT aims to describe key HIVST outcomes and HIVST acceptability for trans people. METHODS SELPHI recruited using social networking and trans focused social media. Participants were randomised 60/40 to baseline HIVST (Biosure™) (BT) vs no baseline HIVST (nBT); and at 3-months (if completed the survey and reported recent CAI) 50/50 to 3-monthly HIVST (RT) vs no repeat HIVST (nRT). Outcomes were self-reported through online surveys. We conducted a qualitative study of semi-structured peer-led participant interviews (n = 20) exploring HIVST motivations and experiences. These were analysed using a framework approach. FINDINGS SELPHI recruited and randomised 118 trans men and trans women (94 trans men, 24 trans women), of whom 20 (16 trans men, 4 trans women) underwent the second randomisation. Median age at baseline was 29 (IQR: 22, 37), 79% were white, 79% were UK born, 37% had degree level education, and 31% had never tested for HIV. 62% (n = 59) of trans men completed the 3-month survey, but survey completion by trans women in nBT was too low (1/11) for randomised comparison. In trans men HIV testing uptake by 3 months was significantly higher in BT (95% 36/38) vs nBT (29%, 6/21) (RR=3.32 (1.68, 6.55) p<0.001). Trans people randomised to RT reported 3 times higher rate of HIV testing compared to nRT during the two-year follow-up (IRR 3.66 (1.86, 8.01) p<0.0001). STI testing frequency (mean number of tests during each 13 week period/ 2-year follow-up) was not significantly different across interventions: RT (0.03) and nRT (0.01) (IRR=1.86 95%CI; 0.77, 5.15; p = 0.15). Social harms were rare. Acceptability was very high in BT: 97% (38/39) found instructions easy to understand, 97% (37/38) found the HIVST simple to use and 100% (39/39) reported good overall experience. In interviews, reported HIVST benefits included increased autonomy, privacy, convenience and avoidance of health care providers perceived to be discriminatory and services that increased dysphoria. Minor lancet and test processing issues were reported. INTERPRETATION HIVST significantly increased testing uptake and frequency in trans men and trans people overall, although recruitment and retention of trans women was low. HIVST acceptability was high and indicates easy access to this novel technology may increase HIV testing access for this key population.
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Affiliation(s)
- T. Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
- Corresponding author.
| | - Talen Wright
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Leanne McCabe
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Michelle M. Gabriel
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Aedan Wolton
- 56T, Chelsea and Westminster NHS Hospital Foundation Trust, 56 Dean Street, London W1D 4PR, United Kingdom
| | - Mitzy Gafos
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Denise Ward
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Fiona C. Lampe
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Andrew N. Phillips
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Roy Trevelion
- HIV i-base, 107 The Maltings, 169 Tower Bridge Road, London SE1 3LJ, United Kingdom
| | - Yolanda Collaco-Moraes
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Justin Harbottle
- SH:24, 35a Westminster Bridge Road, South Bank, London SE1 7JB, United Kingdom
| | - Andrew Speakman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - David D. Dunn
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom
| | - Fiona M. Burns
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Peter Weatherburn
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Alison J. Rodger
- Institute for Global Health, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
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14
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Miltz AR, Rodger AJ, Sewell J, Gilson R, Allan S, Scott C, Sadiq T, Farazmand P, McDonnell J, Speakman A, Sherr L, Phillips AN, Johnson AM, Collins S, Lampe FC. Recreational drug use and use of drugs associated with chemsex among HIV-negative and HIV-positive heterosexual men and women attending sexual health and HIV clinics in England. Int J Drug Policy 2021; 91:103101. [PMID: 33494013 PMCID: PMC8188422 DOI: 10.1016/j.drugpo.2020.103101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 11/27/2020] [Accepted: 12/22/2020] [Indexed: 11/27/2022]
Abstract
Background There is little information on the prevalence of recreational drug use among UK heterosexual men and women, in particular on use of drugs associated with ‘chemsex’ within gay communities. The aim of this study was to examine among HIV-negative and HIV-positive heterosexual men and women in England: (i) the prevalence of recreational drug use (including use of drugs associated with chemsex), (ii) socio-economic/lifestyle correlates of drug use, and (iii) the association of drug use with sexual behavior measures and mental health symptoms. Methods Data are from the AURAH study of HIV-negative individuals attending sexual health clinics across England (2013–2014) and the ASTRA study of HIV-positive individuals attending HIV outpatient clinics in England (2011–2012). Prevalence of recreational drug use (past three months) and associations are presented separately among the four sample groups: HIV-negative (N = 470) and HIV-positive (N = 373) heterosexual men and HIV-negative (N = 676) and HIV-positive (N = 637) women. Results The age standardized prevalence of any drug use was 22.9%, 17.1%, 15.3%, and 7.1% in the four sample groups respectively. In all groups, cannabis was the drug most commonly used (range from 4.7% to 17.9%) followed by cocaine (1.6% to 8.5%). The prevalence of use of drugs associated with chemsex was very low among HIV-negative participants (1.0% heterosexual men, 0.2% women) and zero among HIV-positive men and women. In age-adjusted analysis, factors linked to drug use overall and/or to cannabis and cocaine use specifically in the four sample groups included Black/mixed Caribbean and white (vs. Black/mixed African) ethnicity, lower level of education , cigarette smoking, and higher risk alcohol consumption. Associations of recreational drug use with measures of condomless sex, depression, and anxiety were observed in the four groups, but were particularly strong/apparent among women. Conclusion Providers need to be aware of cannabis and cocaine use and its potential link with sexual risk behavior and symptoms of depression and anxiety among heterosexual men and women attending sexual health and HIV clinics.
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Affiliation(s)
- Ada R Miltz
- Institute for Global Health, University College London, London, UK.
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Janey Sewell
- Institute for Global Health, University College London, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London, London, UK
| | - Sris Allan
- City of Coventry Healthcare Centre, Coventry, UK
| | | | - Tariq Sadiq
- Courtyard Clinic, St George's Healthcare NHS Trust, London, UK
| | | | - Jeffrey McDonnell
- Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Andrew Speakman
- Institute for Global Health, University College London, London, UK
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
| | | | - Anne M Johnson
- Institute for Global Health, University College London, London, UK
| | | | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
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15
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Miltz AR, Rodger AJ, Phillips AN, Sewell J, Edwards S, Allan S, Sherr L, Johnson AM, Burman WJ, Lampe FC. Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men. Sex Transm Infect 2021; 97:613-618. [PMID: 33431606 PMCID: PMC8606445 DOI: 10.1136/sextrans-2020-054634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/18/2020] [Accepted: 12/06/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men (GBMSM). METHODS Data are from the Antiretrovirals, Sexual Transmission Risk and Attitude (ASTRA) study of people living with HIV and attending one of eight HIV outpatient clinics in England (2011-2012) and the Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) study of HIV-negative/unknown status individuals attending one of 20 genitourinary medicine clinics in England (2013-2014). This analysis included GBMSM only. For each study, the prevalence of depressive symptoms (Patient Health Questionnaire-9 score ≥10) was presented according to three categories of sex in the past 3 months (considering anal/vaginal sex with men/women and anal sex with men in separate definitions): (1) no sex, (2) condom-protected sex only and (3) CLS. Multinomial logistic regression with 'condom-protected sex only' as the reference group was used to adjust for age and (for ASTRA participants) time since HIV diagnosis. RESULTS There were opposing associations of depression with recent sexual behaviour: the prevalence of depression was higher among those who reported no sex and those who reported CLS, compared with those who reported condom-protected sex only. Among the 2170 HIV-positive GBMSM in ASTRA, considering anal/vaginal sex with men/women, the prevalence of depressive symptoms was 32%, 20% and 28%, respectively, among men reporting no sex (n=783), condom-protected sex only (n=551) and CLS (n=836) (global p<0.001). Among the 1477 HIV-negative GBMSM in AURAH, the prevalence of depressive symptoms was 12%, 8% and 13%, respectively, for no sex (n=137), condom-protected sex only (n=487) and CLS (n=853) (global p=0.017). Patterns were similar after adjustment and when only considering anal sex between men. CONCLUSIONS Depression may be linked both to lack of sexual activity and to sexual risk taking. When investigating associations between depression and CLS, it is important to separate out individuals reporting condom-protected sex only from those reporting no sex.
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Affiliation(s)
- Ada R Miltz
- Institute for Global Health, University College London, London, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | | | - Janey Sewell
- Institute for Global Health, University College London, London, UK
| | - Simon Edwards
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Sris Allan
- City of Coventry NHS Healthcare Centre, Coventry, UK
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
| | - Anne M Johnson
- Institute for Global Health, University College London, London, UK
| | | | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
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16
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Rein SM, Smith CJ, Chaloner C, Stafford A, Rodger AJ, Johnson MA, McDonnell J, Burns F, Madge S, Miners A, Sherr L, Collins S, Speakman A, Phillips AN, Lampe FC. Prospective association of social circumstance, socioeconomic, lifestyle and mental health factors with subsequent hospitalisation over 6-7 year follow up in people living with HIV. EClinicalMedicine 2021; 31:100665. [PMID: 33554077 PMCID: PMC7846674 DOI: 10.1016/j.eclinm.2020.100665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Predictors of hospitalisation in people with HIV (PLHIV) in the contemporary treatment era are not well understood. METHODS This ASTRA sub-study used clinic data linkage and record review to determine occurrence of hospitalisations among 798 PLHIV from baseline questionnaire (February to December 2011) until 1 June 2018. Associations of baseline social circumstance, socioeconomic, lifestyle, mental health, demographic and clinical factors with repeated all-cause hospitalisation from longitudinal data were investigated using Prentice-Williams-Peterson models. Associations were also assessed in 461 individuals on antiretroviral therapy (ART) with viral load ≤50 copies/ml and CD4 count ≥500 cells/ µl. FINDINGS Rate of hospitalisation was 5.8/100 person-years (95% CI: 5.1-6.5). Adjusted for age, demographic group and time with diagnosed HIV, the following social circumstance, socioeconomic, lifestyle and mental health factors predicted hospitalisation: no stable partner (adjusted hazard ratio (aHR)=1.59; 95% CI=1.16-2.20 vs living with partner); having children (aHR=1.50; 1.08-2.10); non-employment (aHR=1.56; 1.07-2.27 for unemployment; aHR=2.39; 1.70-3.37 for sick/disabled vs employed); rented housing (aHR=1.72; 1.26-2.37 vs homeowner); not enough money for basic needs (aHR=1.82; 1.19-2.78 vs enough); current smoking (aHR=1.39; 1.02-1.91 vs never); recent injection-drug use (aHR=2.11; 1.30-3.43); anxiety symptoms (aHRs=1.39; 1.01-1.91, 2.06; 1.43-2.95 for mild and moderate vs none/minimal); depressive symptoms (aHRs=1.67; 1.17-2.38, 1.91; 1.30-2.78 for moderate and severe vs none/minimal); treated/untreated depression (aHRs=1.65; 1.03-2.64 for treated depression only, 1.87; 1.39-2.52 for depressive symptoms only; 1.53; 1.05-2.24; for treated depression and depressive symptoms, versus neither). Associations were broadly similar in those with controlled HIV and high CD4. INTERPRETATION Social circumstance, socioeconomic disadvantage, adverse lifestyle factors and poorer mental health are strong predictors of hospitalisation in PLHIV, highlighting the need for targeted interventions and care. FUNDING British HIV Association (BHIVA) Research Award (2017); SMR funded by a PhD fellowship from the Royal Free Charity.
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Affiliation(s)
- Sophia M. Rein
- Institute for Global Health, UCL, London, United Kingdom
| | | | | | - Adam Stafford
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Fiona Burns
- Institute for Global Health, UCL, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Sara Madge
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Alec Miners
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Lorraine Sherr
- Institute for Global Health, UCL, London, United Kingdom
| | | | | | | | - Fiona C. Lampe
- Institute for Global Health, UCL, London, United Kingdom
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17
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Witzel TC, Eshun-Wilson I, Jamil MS, Tilouche N, Figueroa C, Johnson CC, Reid D, Baggaley R, Siegfried N, Burns FM, Rodger AJ, Weatherburn P. Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis. BMC Med 2020; 18:381. [PMID: 33267890 PMCID: PMC7713313 DOI: 10.1186/s12916-020-01835-z] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. METHODS We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. RESULTS After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. CONCLUSIONS HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.
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Affiliation(s)
- T Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | - Muhammad S Jamil
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Nerissa Tilouche
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Carmen Figueroa
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - David Reid
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, Republic of South Africa
| | - Fiona M Burns
- Institute for Global Health, University College London, London, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Peter Weatherburn
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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18
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Hanum N, Cambiano V, Sewell J, Phillips AN, Rodger AJ, Speakman A, Nwokolo N, Asboe D, Gilson R, Clarke A, Miltz AR, Collins S, Lampe FC. Use of HIV pre-exposure prophylaxis among men who have sex with men in England: data from the AURAH2 prospective study. Lancet Public Health 2020; 5:e501-e511. [PMID: 32888443 PMCID: PMC7462627 DOI: 10.1016/s2468-2667(20)30186-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since October, 2017 (and until October, 2020), pre-exposure prophylaxis (PrEP) has only been available in England, UK, through the PrEP Impact Trial, by purchasing it from some genitourinary medicine clinics, or via online sources. Here we report changes from 2013 to 2018 in PrEP and postexposure prophylaxis (PEP) awareness and use among HIV-negative gay, bisexual, and other men who have sex with men (MSM) and assess predictors of PrEP initiation. METHODS In the prospective cohort study Attitudes to, and Understanding of Risk of Acquisition of HIV 2 (AURAH2), MSM were recruited from three sexual health clinics in England: two in London and one in Brighton, UK. Men were eligible if they were aged 18 years or older and HIV-negative or of unknown HIV status. Participants self-completed a baseline paper questionnaire at one of the three clinics between July 30, 2013, and April 30, 2016, and were subsequently able to complete 4-monthly and annual online questionnaires, which were available between March 1, 2015, and March 31, 2018, and collected information on sociodemographics, health and wellbeing, HIV status, and sexual behaviours. PrEP and PEP use in the previous 12 months was obtained at baseline and in annual questionnaires. We assessed trends over calendar time in 3-month periods from first enrolment to the end of the study period (July-December, 2013, was counted as one period) in use of PrEP and PEP using generalised estimating equation logistic models. We used age-adjusted Poisson models to assess factors associated with PrEP initiation among participants who reported never having used PrEP at baseline. FINDINGS 1162 men completed a baseline questionnaire, among whom the mean age was 34 years (SD 10·4), and of those with available data, 942 (82%) of 1150 were white, 1076 (94%) of 1150 were gay, and 857 (74%) of 1159 were university educated. 622 (54%) of 1162 men completed at least one follow-up online questionnaire, of whom 483 (78%) completed at least one annual questionnaire. Overall, PrEP use in the past year increased from 0% (none of 28 respondents) in July to December, 2013, to 43% (23 of 53) in January to March, 2018. The corresponding increase in PrEP use among men who reported condomless sex with two or more partners was from 0% (none of 13 respondents) to 78% (21 of 27). PEP use peaked in April to June, 2016, at 28% (41 of 147 respondents), but decreased thereafter to 8% (four of 53) in January to March, 2018. Among 460 men who had never used PrEP at baseline, predictors of initiating PrEP included age 40-44 years (incidence rate ratio [IRR] 4·25, 95% CI 1·14-15·79) and 45 years and older (3·59, 1·08-11·97) versus younger than 25 years; and after adjustment for age, recent HIV test (5·17, 1·89-14·08), condomless sex (5·01, 2·16-11·63), condomless sex with two or more partners (5·43, 2·99-9·86), group sex (1·69, 1·01-2·84), and non-injection chemsex-related drugs use (2·86, 1·67-4·91) in the past 3 months, PEP use (4·69, 2·83-7·79) in the past 12 months, and calendar year (Jan 1, 2017, to March 31, 2018 vs July 30, 2013, to Dec 31, 2015: 21·19, 9·48-47·35). Non-employment (0·35, 0·14-0·91) and unstable or no housing (vs homeowner 0·13, 0·02-0·95) were associated with reduced rates of PrEP initiation after adjustment for age. About half of PrEP was obtained via the internet, even after the PrEP Impact trial had started (11 [48%] of 23 respondents in January to March, 2018). INTERPRETATION PrEP awareness and use increased substantially from 2013 to 2018 among a cohort of MSM in England. Improving access to PrEP by routine commissioning by National Health Service England could increase PrEP use among all eligible MSM, but should include public health strategies to target socioeconomic and demographic disparities in knowledge and use of PrEP. FUNDING National Institute for Health Research.
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Affiliation(s)
- Nadia Hanum
- Institute for Global Health, University College London, London, UK.
| | | | - Janey Sewell
- Institute for Global Health, University College London, London, UK
| | | | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Andrew Speakman
- Institute for Global Health, University College London, London, UK
| | - Nneka Nwokolo
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - David Asboe
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London, London, UK; Central and North West London NHS Foundation Trust, London, UK
| | - Amanda Clarke
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK; Brighton & Sussex Medical School, Brighton, UK
| | - Ada R Miltz
- Institute for Global Health, University College London, London, UK
| | | | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
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19
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Rodger AJ, Dunn D, McCabe L, Weatherburn P, Lampe FC, Witzel TC, Burns F, Ward D, Pebody R, Trevelion R, Brady M, Kirwan PD, Khawam J, Delpech VC, Gabriel M, Collaco-Moraes Y, Phillips AN, McCormack S. Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial. HIV Med 2020; 21:588-598. [PMID: 32776431 DOI: 10.1111/hiv.12919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 04/21/2020] [Accepted: 06/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)]. METHODS Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners. RESULTS A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months. CONCLUSIONS Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.
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Affiliation(s)
- A J Rodger
- Institute for Global Health, University College London, London, UK
| | - D Dunn
- MRC Clinical Trials Unit at UCL, London, UK
| | - L McCabe
- MRC Clinical Trials Unit at UCL, London, UK
| | - P Weatherburn
- London School of Hygiene & Tropical Medicine, London, UK
| | - F C Lampe
- Institute for Global Health, University College London, London, UK
| | - T C Witzel
- London School of Hygiene & Tropical Medicine, London, UK
| | - F Burns
- Institute for Global Health, University College London, London, UK
| | - D Ward
- MRC Clinical Trials Unit at UCL, London, UK
| | | | | | - M Brady
- King's College Hospital NHS Foundation Trust, London, UK
| | - P D Kirwan
- National Infection Service, Public Health England, London, UK
| | - J Khawam
- National Infection Service, Public Health England, London, UK
| | - V C Delpech
- National Infection Service, Public Health England, London, UK
| | - M Gabriel
- MRC Clinical Trials Unit at UCL, London, UK
| | | | - A N Phillips
- Institute for Global Health, University College London, London, UK
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20
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Logan L, Fakoya I, Howarth A, Murphy G, Johnson AM, Rodger AJ, Burns F, Nardone A. Combination prevention and HIV: a cross-sectional community survey of gay and bisexual men in London, October to December 2016. ACTA ACUST UNITED AC 2020; 24. [PMID: 31241039 PMCID: PMC6593902 DOI: 10.2807/1560-7917.es.2019.24.25.1800312] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Men who have sex with men (MSM) are at risk of HIV and are an important population to monitor and ameliorate combination prevention efforts. Aim To estimate HIV prevalence and identify factors associated with frequent HIV testing (≥ 2 HIV tests in the last year) and pre-exposure prophylaxis (PrEP) use among MSM in London. Methods For this cross-sectional study, MSM recruited from 22 social venues provided oral-fluid samples for anonymous HIV antibody (Ab) testing and completed a questionnaire. Factors associated with frequent HIV testing and PrEP use were identified through logistic regression. Results Of 767 men recruited, 545 provided an eligible oral specimen. Among these, 38 MSM (7.0%) were anti-HIV positive including five (13.2%; 5/38) who reported their status as negative. Condomless anal sex within the previous 3 months was reported by 60.1% (412/685) men. Frequent HIV testing was associated with, in the past year, a reported sexually transmitted infection (adjusted odds ratio (AOR): 5.05; 95% confidence interval (CI): 2.66–9.58) or ≥ 2 casual condomless partners (AOR 2–4 partners: 3.65 (95% CI: 1.87–7.10); AOR 5–10 partners: 3.34(95% CI: 1.32–8.49). Age ≥ 35 years was related to less frequent HIV testing (AOR 35–44 years: 0.34 (95% CI: 0.16–0.72); AOR ≥ 45 years: 0.29 (95% CI: 0.12–0.69). PrEP use in the past year was reported by 6.2% (46/744) of MSM and associated with ≥ 2 casual condomless sex partners (AOR: 2.86; 95% CI: 1.17–6.98) or chemsex (AOR: 2.31; 95% CI: 1.09–4.91). Conclusion This bio-behavioural study of MSM found high rates of behaviours associated with increased risk of HIV transmission. Combination prevention, including frequent HIV testing and use of PrEP, remains crucial in London.
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Affiliation(s)
- Louise Logan
- HIV and STIs Department, Public Health England, London, United Kingdom
| | - Ibidun Fakoya
- Institute for Global Health, University College London, United Kingdom
| | - Alison Howarth
- Institute for Global Health, University College London, United Kingdom
| | - Gary Murphy
- Laboratory Services, National Infections Service, Public Health England, London, United Kingdom
| | - Anne M Johnson
- Institute for Global Health, University College London, United Kingdom
| | - Alison J Rodger
- Royal Free London NHS Foundation Trust, London, United Kingdom.,Institute for Global Health, University College London, United Kingdom
| | - Fiona Burns
- Royal Free London NHS Foundation Trust, London, United Kingdom.,Institute for Global Health, University College London, United Kingdom
| | - Anthony Nardone
- HIV and STIs Department, Public Health England, London, United Kingdom
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Miltz AR, Rodger AJ, Lepri AC, Sewell J, Nwokolo NC, Allan S, Scott C, Ivens D, Lascar M, Speakman A, Phillips AN, Sherr L, Collins S, Elford J, Lampe FC. Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation. AIDS Behav 2020; 24:1793-1806. [PMID: 31782068 PMCID: PMC7220884 DOI: 10.1007/s10461-019-02724-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013–2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.
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Affiliation(s)
- A R Miltz
- Institute for Global Health, University College London, London, UK.
| | - A J Rodger
- Institute for Global Health, University College London, London, UK
| | - A Cozzi Lepri
- Institute for Global Health, University College London, London, UK
| | - J Sewell
- Institute for Global Health, University College London, London, UK
| | | | - S Allan
- City of Coventry Healthcare Centre, Coventry, UK
| | - C Scott
- West London Centre for Sexual Health, London, UK
| | - D Ivens
- Royal Free Hospital, London, UK
| | - M Lascar
- Whipps Cross Hospital, London, UK
| | - A Speakman
- Institute for Global Health, University College London, London, UK
| | - A N Phillips
- Institute for Global Health, University College London, London, UK
| | - L Sherr
- Institute for Global Health, University College London, London, UK
| | | | - J Elford
- City, University of London, London, UK
| | - F C Lampe
- Institute for Global Health, University College London, London, UK
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22
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Daskalopoulou M, Rodger AJ, Phillips AN, Gilson R, Sherr L, Wayal S, Anderson J, Aderogba K, McDonnell J, Wilkins E, Youssef E, Speakman A, Burman WJ, Lampe FC. Attitudes to disclosure of HIV-serostatus to new sexual partners and sexual behaviours among HIV-diagnosed gay, bisexual and other men who have sex with men in the UK. AIDS Care 2020; 32:1323-1332. [PMID: 32114800 DOI: 10.1080/09540121.2020.1728218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We assessed attitudes to disclosure to new sexual partners and association with sexual behaviours among HIV-diagnosed gay, bisexual, and other men who have sex with men (GBMSM) in the UK Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study in 2011-12. Among 1373 GBMSM diagnosed with HIV for ≥3 months and reporting sex in the past three months (84% on antiretroviral therapy (ART), 75% viral load (VL) ≤50c/mL), 56.3% reported higher sexual disclosure ("agree" or "tend to agree" with "I'd expect to tell a new partner I'm HIV-positive before we have sex"). GBMSM on ART with self-reported undetectable VL had lower disclosure than those on ART without self-reported undetectable VL and those not on ART. Higher sexual disclosure was associated with higher prevalence of CLS in the past three months; this was due to its association with CLS with other HIV-positive partners. Higher sexual disclosure was more common among GBMSM who had CLS with other HIV-positive partners only (72.1%) compared to those who had higher-risk CLS with HIV-serodifferent partners (55.6%), other CLS with HIV-serodifferent partners (45.9%), or condom-protected sex only (47.6%). Findings suggest mutual HIV-disclosure and HIV-serosorting were occurring in this population. Knowledge of VL status may have impacted on disclosure to sexual partners.
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Affiliation(s)
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | | | - Richard Gilson
- Institute for Global Health, University College London, London, UK
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
| | - Sonali Wayal
- Institute for Global Health, University College London, London, UK
| | - Jane Anderson
- Homerton University Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | - Andrew Speakman
- Institute for Global Health, University College London, London, UK
| | | | - Fiona C Lampe
- Institute for Global Health, University College London, London, UK
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23
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Witzel TC, Weatherburn P, Bourne A, Rodger AJ, Bonell C, Gafos M, Trevelion R, Speakman A, Lampe F, Ward D, Dunn DT, Gabriel MM, McCabe L, Harbottle J, Collaco Moraes Y, Michie S, Phillips AN, McCormack S, Burns FM. Exploring Mechanisms of Action: Using a Testing Typology to Understand Intervention Performance in an HIV Self-Testing RCT in England and Wales. Int J Environ Res Public Health 2020; 17:ijerph17020466. [PMID: 31936798 PMCID: PMC7014239 DOI: 10.3390/ijerph17020466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/12/2019] [Accepted: 12/17/2019] [Indexed: 12/02/2022]
Abstract
SELPHI involves two interventions: A provides one HIV self-testing (HIVST) kit; B offers 3-monthly repeat HIVST kits if participants report ongoing risk. A logic model underpinned by the Behaviour Change Wheel informed the design of the intervention. SELPHI recruited 10,135 cis-men and trans people in England and Wales, all reporting anal sex with a man. This paper explores how the interventions were experienced and the mechanisms of action leading to impact for different groups of trial participants. In-depth interviews with 37 cis-men who have sex with men (MSM) were used to inductively categorise participants based on sexual and HIV testing histories. Themes relating to intervention experiences and impacts were mapped onto SELPHI-hypothesised intermediate outcomes to consider intervention impacts. Three groups were identified: ‘inexperienced testers’ engaged with SELPHI to overcome motivational and social and physical opportunity testing barriers. For ‘pro self-testers’, testing frequency was constrained by psychological and social barriers and lack of opportunity. ‘Opportunistic adopters’ engaged in HIVST for novelty and convenience. Perceived impacts for inexperienced testers were most closely aligned with the logic model, but for opportunistic adopters there was little evidence of impact. Distinctive groups were discernible with divergent intervention experiences. Using COM-B as a model for understanding behaviour change in relation to HIVST, our results indicate how HIVST interventions could be adapted to respond to different needs based on the target population’s demographic and behavioural features.
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Affiliation(s)
- T. Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (P.W.); (C.B.)
- Correspondence:
| | - Peter Weatherburn
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (P.W.); (C.B.)
| | - Adam Bourne
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne 3086, Australia;
| | - Alison J. Rodger
- Institute for Global Health, University College London, London NW3 2PF, UK; (A.J.R.); (A.S.); (F.L.); (A.N.P.); (F.M.B.)
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (P.W.); (C.B.)
| | - Mitzy Gafos
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1h 9SH, UK;
| | | | - Andrew Speakman
- Institute for Global Health, University College London, London NW3 2PF, UK; (A.J.R.); (A.S.); (F.L.); (A.N.P.); (F.M.B.)
| | - Fiona Lampe
- Institute for Global Health, University College London, London NW3 2PF, UK; (A.J.R.); (A.S.); (F.L.); (A.N.P.); (F.M.B.)
| | - Denise Ward
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | - David T. Dunn
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | - Michelle M. Gabriel
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | - Leanne McCabe
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | | | - Yolanda Collaco Moraes
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | - Susan Michie
- Centre for Behaviour Change, University College London, London WC1N 3AZ, UK;
| | - Andrew N. Phillips
- Institute for Global Health, University College London, London NW3 2PF, UK; (A.J.R.); (A.S.); (F.L.); (A.N.P.); (F.M.B.)
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V 6LJ, UK; (D.W.); (D.T.D.); (M.M.G.); (L.M.); (Y.C.M.); (S.M.)
| | - Fiona M. Burns
- Institute for Global Health, University College London, London NW3 2PF, UK; (A.J.R.); (A.S.); (F.L.); (A.N.P.); (F.M.B.)
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24
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Witzel TC, Bourne A, Burns FM, Rodger AJ, McCabe L, Gabriel MM, Gafos M, Ward D, Collaco-Moraes Y, Dunn DT, Speakman A, Bonell C, Pebody R, Lampe FC, Harbottle J, Phillips AN, McCormack S, Weatherburn P. HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales. HIV Med 2019; 21:189-197. [PMID: 31821698 PMCID: PMC7065141 DOI: 10.1111/hiv.12818] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/21/2019] [Accepted: 09/17/2019] [Indexed: 11/30/2022]
Abstract
Objectives SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST. Methods Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis. Results Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage. Conclusions Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.
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Affiliation(s)
- T C Witzel
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Bourne
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, VIC, Australia
| | - F M Burns
- Institute for Global Health, University College London, London, UK
| | - A J Rodger
- Institute for Global Health, University College London, London, UK
| | - L McCabe
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - M M Gabriel
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - M Gafos
- Medical Research Council Clinical Trials Unit, University College London, London, UK.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D Ward
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Y Collaco-Moraes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - D T Dunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - A Speakman
- Institute for Global Health, University College London, London, UK
| | - C Bonell
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - F C Lampe
- Institute for Global Health, University College London, London, UK
| | | | - A N Phillips
- Institute for Global Health, University College London, London, UK
| | - S McCormack
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - P Weatherburn
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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25
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Curtis TJ, Rodger AJ, Burns F, Nardone A, Copas A, Wayal S. Patterns of sexualised recreational drug use and its association with risk behaviours and sexual health outcomes in men who have sex with men in London, UK: a comparison of cross-sectional studies conducted in 2013 and 2016. Sex Transm Infect 2019; 96:197-203. [PMID: 31744928 PMCID: PMC7167300 DOI: 10.1136/sextrans-2019-054139] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/26/2019] [Accepted: 10/25/2019] [Indexed: 11/30/2022] Open
Abstract
Objective London has one of the highest identified prevalence of chemsex (sexualised recreational drug use) among men who have sex with men (MSM) in Europe. We examine MSM’s patterns of chemsex and its association with HIV/STI risk behaviours, STI diagnoses, and sexual healthcare-seeking behaviours, including if HIV testing behaviour met UK national guidelines (3-monthly if engaging in chemsex). Methods Cross-sectional survey data from 2013 (n=905) and 2016 (n=739) were collected using anonymous, self-administered questionnaires from MSM recruited in commercial gay venues in London, UK. Descriptive and multivariable analyses, stratified by self-reported HIV status, were conducted. Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were calculated. Results Comparing the 2013 and 2016 surveys; chemsex prevalence in the past year remained stable, in both HIV-negative/unknown-status MSM (20.9% in 2013 vs 18.7% in 2016, p=0.301) and HIV-positive MSM (41.6% in 2013 vs 41.7% in 2016, p=0.992). Combined 2013-2016 data showed that compared to other MSM, those reporting chemsex were more likely to report HIV/STI risk behaviours, including condomless anal intercourse with serodifferent HIV-status partners (HIV-negative/unknown-status men: aPR 2.36, 95% CI 1.68-3.30; HIV-positive men: aPR 4.19, 95% CI 1.85-9.50), and STI diagnoses in the past year (HIV-negative/unknown-status men: aPR 2.10, 95% CI 1.64-2.69; HIV-positive men: aPR 2.56, 95% CI 1.57-4.20). 68.6% of HIV-negative/unknown-status men reporting chemsex attended sexual health clinics and 47.6% had tested for HIV more than once in the past year. Conclusions Chemsex in London MSM remained stable but high, particularly among HIV-positive men. Irrespective of HIV status, chemsex was associated with engagement in HIV/STI risk behaviours. Frequency of HIV testing in the past year among HIV-negative/unknown-status men was below national recommendations. Promoting combination prevention strategies, including 3-monthly HIV/STI testing, access to PrEP/ART, and behavioural interventions among MSM reporting chemsex, remain vital to address sexual health inequalities in MSM.
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Affiliation(s)
- Tyrone J Curtis
- Institute for Global Health, University College London, London, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London, London, UK
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Sonali Wayal
- Institute for Global Health, University College London, London, UK
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26
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Witzel TC, Gabriel MM, McCabe L, Weatherburn P, Gafos M, Speakman A, Pebody R, Burns FM, Bonell C, Lampe FC, Dunn DT, Ward D, Harbottle J, Phillips AN, McCormack S, Rodger AJ. Pilot phase of an internet-based RCT of HIVST targeting MSM and transgender people in England and Wales: advertising strategies and acceptability of the intervention. BMC Infect Dis 2019; 19:699. [PMID: 31391003 PMCID: PMC6686516 DOI: 10.1186/s12879-019-4247-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/01/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The SELPHI study (An HIV Self-Testing Public Health Intervention) is an online randomised controlled trial (RCT) of HIV self-testing (HIVST). The aim of this study was to assess the feasibility of recruiting UK men who have sex with men (cis and trans) and trans women who have sex with men to the SELPHI pilot, and the acceptability of the HIVST intervention used among those randomised to receive a kit. METHODS A mixed-methods approach to assessing trial feasibility and intervention acceptability was taken, using quantitative data from advertising sources and RCT surveys alongside qualitative data from a nested sub-study. RESULTS Online recruitment and intervention delivery was feasible. The recruitment strategy led to the registration of 1370 participants of whom 76% (1035) successfully enrolled and were randomised 60/40 to baseline testing vs no baseline testing. Advertising platforms performed variably. Reported HIVST kit use increased from 83% at two weeks to 96% at three months. Acceptability was very high across all quantitative measures. Participants described the instructions as easy to use, and the testing process as simple. The support structures in SELPHI were felt to be adequate. Described emotional responses to HIVST varied. CONCLUSIONS Recruiting to a modest sized HIVST pilot RCT is feasible, and the recruitment, intervention and HIVST kit were acceptable. Research on support needs of individuals with reactive results is warranted.
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Affiliation(s)
- T Charles Witzel
- Sigma Research, Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | | | - Peter Weatherburn
- Sigma Research, Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mitzy Gafos
- MRC Clinical Trials Unit at UCL, London, UK.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Fiona M Burns
- Institute for Global Health, UCL, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - Chris Bonell
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Alison J Rodger
- Institute for Global Health, UCL, London, UK.,Royal Free London NHS Foundation Trust, London, UK
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27
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Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, Corbelli GM, Estrada V, Geretti AM, Beloukas A, Raben D, Coll P, Antinori A, Nwokolo N, Rieger A, Prins JM, Blaxhult A, Weber R, Van Eeden A, Brockmeyer NH, Clarke A, Del Romero Guerrero J, Raffi F, Bogner JR, Wandeler G, Gerstoft J, Gutiérrez F, Brinkman K, Kitchen M, Ostergaard L, Leon A, Ristola M, Jessen H, Stellbrink HJ, Phillips AN, Lundgren J. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019; 393:2428-2438. [PMID: 31056293 PMCID: PMC6584382 DOI: 10.1016/s0140-6736(19)30418-0] [Citation(s) in RCA: 515] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The level of evidence for HIV transmission risk through condomless sex in serodifferent gay couples with the HIV-positive partner taking virally suppressive antiretroviral therapy (ART) is limited compared with the evidence available for transmission risk in heterosexual couples. The aim of the second phase of the PARTNER study (PARTNER2) was to provide precise estimates of transmission risk in gay serodifferent partnerships. METHODS The PARTNER study was a prospective observational study done at 75 sites in 14 European countries. The first phase of the study (PARTNER1; Sept 15, 2010, to May 31, 2014) recruited and followed up both heterosexual and gay serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex, whereas the PARTNER2 extension (to April 30, 2018) recruited and followed up gay couples only. At study visits, data collection included sexual behaviour questionnaires, HIV testing (HIV-negative partner), and HIV-1 viral load testing (HIV-positive partner). If a seroconversion occurred in the HIV-negative partner, anonymised phylogenetic analysis was done to compare HIV-1 pol and env sequences in both partners to identify linked transmissions. Couple-years of follow-up were eligible for inclusion if condomless sex was reported, use of pre-exposure prophylaxis or post-exposure prophylaxis was not reported by the HIV-negative partner, and the HIV-positive partner was virally suppressed (plasma HIV-1 RNA <200 copies per mL) at the most recent visit (within the past year). Incidence rate of HIV transmission was calculated as the number of phylogenetically linked HIV infections that occurred during eligible couple-years of follow-up divided by eligible couple-years of follow-up. Two-sided 95% CIs for the incidence rate of transmission were calculated using exact Poisson methods. FINDINGS Between Sept 15, 2010, and July 31, 2017, 972 gay couples were enrolled, of which 782 provided 1593 eligible couple-years of follow-up with a median follow-up of 2·0 years (IQR 1·1-3·5). At baseline, median age for HIV-positive partners was 40 years (IQR 33-46) and couples reported condomless sex for a median of 1·0 years (IQR 0·4-2·9). During eligible couple-years of follow-up, couples reported condomless anal sex a total of 76 088 times. 288 (37%) of 777 HIV-negative men reported condomless sex with other partners. 15 new HIV infections occurred during eligible couple-years of follow-up, but none were phylogenetically linked within-couple transmissions, resulting in an HIV transmission rate of zero (upper 95% CI 0·23 per 100 couple-years of follow-up). INTERPRETATION Our results provide a similar level of evidence on viral suppression and HIV transmission risk for gay men to that previously generated for heterosexual couples and suggest that the risk of HIV transmission in gay couples through condomless sex when HIV viral load is suppressed is effectively zero. Our findings support the message of the U=U (undetectable equals untransmittable) campaign, and the benefits of early testing and treatment for HIV. FUNDING National Institute for Health Research.
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Affiliation(s)
- Alison J Rodger
- Institute for Global Health, University College London, London, UK.
| | | | - Tina Bruun
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pietro Vernazza
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, St Gallen, Switzerland
| | | | - Olaf Degen
- University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vicente Estrada
- Hospital Clinico San Carlos and Universidad Complutense, Madrid, Spain
| | - Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Apostolos Beloukas
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK; Department of Biomedical Sciences, University of West Attica, Athens, Greece
| | - Dorthe Raben
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pep Coll
- AIDS Research Institute-IrsiCaixa, Hospital Universitari Germans Trias i Pujol and BCN Checkpoint, Badalona and Barcelona, Spain
| | - Andrea Antinori
- Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Nneka Nwokolo
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | | | - Jan M Prins
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Rainer Weber
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Norbert H Brockmeyer
- Centre for Sexual Health and Medicine, Walk in Ruhr, Ruhr University Bochum, Bochum, Germany
| | - Amanda Clarke
- Brighton and Sussex University Hospitals NHS Trust, and Brighton and Sussex Medical School, Brighton, UK
| | | | - Francois Raffi
- Infectious Diseases Department, University Hospital (Centre Hospitalier Universitaire de Nantes) Hotel-Dieu, and INSERM UIC 1413 Nantes University, Nantes, France
| | - Johannes R Bogner
- Medizinische Klinik und Poliklinik IV, University Hospital Munich, Munich, Germany
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Felix Gutiérrez
- Hospital General de Elche and Universidad Miguel Hernández, Alicante, Spain
| | - Kees Brinkman
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands
| | | | | | - Agathe Leon
- Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Matti Ristola
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | | | | | - Jens Lundgren
- Department of Infectious Diseases (CHIP), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Sewell J, Cambiano V, Speakman A, Lampe FC, Phillips A, Stuart D, Gilson R, Asboe D, Nwokolo N, Clarke A, Rodger AJ. Changes in chemsex and sexual behaviour over time, among a cohort of MSM in London and Brighton: Findings from the AURAH2 study. Int J Drug Policy 2019; 68:54-61. [PMID: 30999243 DOI: 10.1016/j.drugpo.2019.03.021] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence has suggested that chemsex (the use of mephedrone, crystal methamphetamine and γ -hydroxybutyrate/ γ -butryolactone (GHB/GBL) to enable, enhance and prolong sexual interactions) has increased among men having sex with men (MSM) attending sexual health clinics in large UK cities. To date there has been no data from the UK or Europe that describes changes in chemsex over time within a cohort of MSM. METHODS The prospective cohort study, Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2), collected online questionnaire data from HIV negative or undiagnosed MSM (at enrolment) from 2015 to 2018, recruited from sexual health clinics. We aim to investigate changes in chemsex, three individual drugs associated with chemsex, frequency of chemsex sessions and measures of sexual behaviour, among the cohort of MSM over the study's 3 year follow-up period. RESULTS In total 622 MSM completed at least one online questionnaire for the AURAH2 study, of which 400 (64.3%) were still engaged with the study within the last six months of follow-up. Prevalence of chemsex significantly declined during the follow-up from 31.8% (198/622) at the first online questionnaire, to 11.1% (8/72; p < 0.001) at the 9th. This decline was reflected in the proportion of MSM reporting use of two of the three individual chemsex drugs: mephedrone use had significantly declined from 25.2% at the first online questionnaire to 9.7% (p < 0.001) at the 9th, GHB/GBL use had also declined from 19.9% to 8.3% (p = 0.001). While crystal methamphetamine use declined, but not significantly (11.1%-6.9% [p = 0.289]). Most measures of sexual behaviour (any anal sex, group sex, recent HIV test and bacterial STI) also tended to decline over the follow-up period, with the exception of CLAI with more than one and more than two partners. CONCLUSIONS Chemsex and use of two individual chemsex drugs (mephedrone and GHB/GBL) significantly declined over time among individuals in the study, alongside most measures of sexual behaviour with the exception of those related to CLAI. Focusing health promotion and HIV prevention, such as awareness of post-exposure prophylaxis (PEP) and access to pre-exposure prophylaxis (PrEP), on MSM that report chemsex, and in particular problematic chemsex, would be highly beneficial, potentially only necessary for a relatively short period of time for individuals, and could have long term benefits for HIV and STI prevention.
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Affiliation(s)
- Janey Sewell
- UCL Institute for Global Health, UCL, London, United Kingdom
| | | | - Andrew Speakman
- UCL Institute for Global Health, UCL, London, United Kingdom
| | - Fiona C Lampe
- UCL Institute for Global Health, UCL, London, United Kingdom
| | - Andrew Phillips
- UCL Institute for Global Health, UCL, London, United Kingdom
| | - David Stuart
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Gilson
- UCL Institute for Global Health, UCL, London, United Kingdom
| | - David Asboe
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Nneka Nwokolo
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Amanda Clarke
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Alison J Rodger
- UCL Institute for Global Health, UCL, London, United Kingdom.
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Miners A, Nadarzynski T, Witzel C, Phillips AN, Cambiano V, Rodger AJ, Llewellyn CD. Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment. PLoS Med 2019; 16:e1002779. [PMID: 30973868 PMCID: PMC6459507 DOI: 10.1371/journal.pmed.1002779] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 03/12/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare. METHODS AND FINDINGS Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world. CONCLUSIONS Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.
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Affiliation(s)
- Alec Miners
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tom Nadarzynski
- Department of Psychology, University of Southampton, Southampton, United Kingdom
- Royal South Hants Hospital, Solent NHS Trust, Southampton, United Kingdom
| | - Charles Witzel
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Andrew N. Phillips
- Institute for Global Health, University College London, London, United Kingdom
| | - Valentina Cambiano
- Institute for Global Health, University College London, London, United Kingdom
| | - Alison J. Rodger
- Institute for Global Health, University College London, London, United Kingdom
| | - Carrie D. Llewellyn
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
- * E-mail:
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Fakoya I, Logan L, Ssanyu-Sseruma W, Howarth A, Murphy G, Johnson AM, Nardone A, Rodger AJ, Burns F. HIV Testing and Sexual Health Among Black African Men and Women in London, United Kingdom. JAMA Netw Open 2019; 2:e190864. [PMID: 30901043 PMCID: PMC6583286 DOI: 10.1001/jamanetworkopen.2019.0864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/30/2019] [Indexed: 01/12/2023] Open
Abstract
Importance Black African adults are disproportionately affected by HIV in the United Kingdom. Many within this population acquire HIV after migration or are diagnosed late. Data are needed to inform targeted interventions to increase HIV testing and prevention in this population. Objective To inform future HIV prevention strategies by estimating diagnosed and undiagnosed HIV infection and measuring changes in HIV testing rates in black African adults in London, United Kingdom. Design, Setting, and Participants This cross-sectional study used a self-completed survey conducted from September 20 to December 3, 2016. Questionnaires were linked to an optional, anonymous oral fluid HIV test and compared with data from a previous survey (2004). Respondents were recruited from social and commercial venues frequented by black African adults in London. Of 2531 individuals approached in 63 venues, 752 agreed to participate. Data were analyzed initially in March 2017 (as part of internal reporting) and again in August 2018. Main Outcomes and Measures Self-reported HIV testing within the past 5 years; diagnosed and undiagnosed HIV prevalence. Logistic regression examined factors associated with HIV testing by sex. Results In total, 292 women (median [interquartile range] age, 31 [25.0-41.5] years) and 312 men (median [interquartile range] age, 35 [25.0-41.5] years) were included in the analysis. More than half of men (159 [51.0%]) and women (154 [52.7%]) had been tested for HIV in the past 5 years. In multivariable analysis, HIV testing was associated with a range of factors in both sexes, including health service attendance, time in the United Kingdom, and sexually transmitted infection diagnosis. Increases in HIV testing in the past 5 years were observed between 2004 and 2016 for both sexes. In the 2016 sample, 219 of 235 women (93.2%) and 206 of 228 men (90.4%) tested HIV negative. Among those testing positive, 56.3% of women (9 of 16) and 40.9% of men (9 of 22) self-reported as HIV negative or untested, indicating they were living with undiagnosed HIV. A fifth of women (20.7%) and 25.0% of men reported condomless last sex with a partner of different or unknown HIV status in the past year. Conclusions and Relevance Despite efforts to increase HIV testing, uptake in black African communities in London remains modest. This study identified a large fraction of undiagnosed infection-greater than other at-risk populations-suggesting that the prevention and care needs of this group are not adequately met.
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Affiliation(s)
- Ibidun Fakoya
- Institute for Global Health, University College London, London, United Kingdom
| | - Louise Logan
- HIV and STIs Department, Public Health England, London, United Kingdom
| | | | - Alison Howarth
- Institute for Global Health, University College London, London, United Kingdom
| | - Gary Murphy
- HIV and STIs Department, Public Health England, London, United Kingdom
| | - Anne M. Johnson
- Institute for Global Health, University College London, London, United Kingdom
| | - Anthony Nardone
- HIV and STIs Department, Public Health England, London, United Kingdom
| | - Alison J. Rodger
- Institute for Global Health, University College London, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Fiona Burns
- Institute for Global Health, University College London, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
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Simpson N, Bartley A, Davies A, Perman S, Rodger AJ. Getting the balance right-tackling the obesogenic environment by reducing unhealthy options in a hospital shop without affecting profit. J Public Health (Oxf) 2018; 40:e545-e551. [PMID: 29635521 DOI: 10.1093/pubmed/fdy053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 03/05/2018] [Indexed: 01/20/2023] Open
Abstract
Background UK hospitals have been criticized for fuelling obesity by allowing contracts with food retailers selling high fat and high-sugar products on hospital premises. Methods We assessed the impact for a major retailer of increasing healthy food choices at their Royal Free London NHS Foundation Trust outlet. To assess the impact on sales, profit and acceptability to customers, a multi-component intervention based on behavioural insights theory was enacted over 2 months (November-December 2014) at the Royal Free site WHSmith. Sales data on all food and drink were assessed over three time periods: (i) 2 months immediately prior to, and (ii) immediately after the intervention, and (iii) the equivalent period 10 months later. Acceptability to customers was assessed via questionnaires, and profit assessed as a proxy for retailer satisfaction. Results Compared to the pre-intervention period, total sales increased immediately after the intervention, and again 10 months after the intervention. Sales of healthier options increased as a proportion of total sales following the intervention, sales of sweets and chocolates decreased, while the relative sales of other items remained similar. Conclusions We demonstrated that healthier alternatives could be provided in a hospital retail premises without negatively affecting total sales, retailer or customer satisfaction.
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Affiliation(s)
- Nandi Simpson
- Department of Public Health, Royal Free NHS London Foundation Trust, London, UK
| | - Angela Bartley
- Department of Public Health, Royal Free NHS London Foundation Trust, London, UK
| | - Alisha Davies
- Department of Public Health, Royal Free NHS London Foundation Trust, London, UK.,Research and Development, Public Health Wales, Cardiff, UK
| | - Sarah Perman
- Department of Public Health, Royal Free NHS London Foundation Trust, London, UK
| | - Alison J Rodger
- Department of Public Health, Royal Free NHS London Foundation Trust, London, UK.,Institute for Global Health, University College London, London, UK
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Gabriel MM, Dunn DT, Speakman A, McCabe L, Ward D, Witzel TC, Harbottle J, Collins S, Gafos M, Burns FM, Lampe FC, Weatherburn P, Phillips A, McCormack S, Rodger AJ. Protocol, rationale and design of SELPHI: a randomised controlled trial assessing whether offering free HIV self-testing kits via the internet increases the rate of HIV diagnosis. BMC Infect Dis 2018; 18:531. [PMID: 30352556 PMCID: PMC6199717 DOI: 10.1186/s12879-018-3433-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 10/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among men who have sex with men (MSM) in the UK, an estimated 28% have never tested for HIV and only 27% of those at higher risk test at least every 6 months. HIV self-testing (HIVST), where the person takes their own blood/saliva sample and processes it themselves, offers the opportunity to remove many structural and social barriers to testing. Although several randomised controlled trials are assessing the impact of providing HIVST on rates of HIV testing, none are addressing whether this results in increased rates of HIV diagnoses that link to clinical care. Linking to care is the critical outcome because it is the only way to access antiretroviral treatment (ART). We describe here the design of a large, internet-based randomised controlled trial of HIVST, called SELPHI, which aims to inform this key question. METHODS/DESIGN The SELPHI study, which is ongoing is promoted via social networking website and app advertising, and aims to enroll HIV negative men, trans men and trans women, aged over 16 years, who are living in England and Wales. Apart from the physical delivery of the test kits, all trial processes, including recruitment, take place online. In a two-stage randomisation, participants are first randomised (3:2) to receive a free baseline HIVST or no free baseline HIVST. At 3 months, participants allocated to receive a baseline HIVST (and meeting further eligibility criteria) are subsequently randomised (1:1) to receive the offer of regular (every 3 months) free HIVST, with testing reminders, versus no such offer. The primary outcome from both randomisations is a laboratory-confirmed HIV diagnosis, ascertained via linkage to a national HIV surveillance database. DISCUSSION SELPHI will provide the first reliable evidence on whether offering free HIVST via the internet increases rates of confirmed HIV diagnoses and linkage to clinical care. The two randomisations reflect the dual objectives of detecting prevalent infections (possibly long-standing) and the more rapid diagnosis of incident HIV infections. It is anticipated that the results of SELPHI will inform future access to HIV self-testing provision in the UK. TRIAL REGISTRATION DOI 10.1186/ISRCTN20312003 registered 24/10/2016.
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Affiliation(s)
- Michelle M. Gabriel
- MRC Clinical Trials Unit at UCL, London, UK
- Trial Sponsor – University College London via MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 90 High Holborn, 2nd Floor, London, WC1V 6LJ UK
| | | | - Andrew Speakman
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, UCL, London, UK
| | | | | | - T. Charles Witzel
- Department of Social and Environmental Health Research, Sigma Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Mitzy Gafos
- MRC Clinical Trials Unit at UCL, London, UK
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | | | - Fiona C. Lampe
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, UCL, London, UK
| | - Peter Weatherburn
- Department of Social and Environmental Health Research, Sigma Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Phillips
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, UCL, London, UK
| | | | - Alison J. Rodger
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, UCL, London, UK
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Haddow LJ, Laverick R, Daskalopoulou M, McDonnell J, Lampe FC, Gilson R, Speakman A, Antinori A, Balestra P, Bruun T, Gerstoft J, Nielsen L, Vassilenko A, Collins S, Rodger AJ. Multicenter European Prevalence Study of Neurocognitive Impairment and Associated Factors in HIV Positive Patients. AIDS Behav 2018; 22:1573-1583. [PMID: 28144792 PMCID: PMC5902513 DOI: 10.1007/s10461-017-1683-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We conducted a cross-sectional study in 448 HIV positive patients attending five European outpatient clinics to determine prevalence of and factors associated with neurocognitive impairment (NCI) using computerized and pen-and-paper neuropsychological tests. NCI was defined as a normalized Z score ≤-1 in at least 2 out of 5 cognitive domains. Participants' mean age was 45.8 years; 84% male; 87% white; 56% university educated; median CD4 count 550 cells/mm3; 89% on antiretroviral therapy. 156 (35%) participants had NCI, among whom 26 (17%; 5.8% overall) reported a decline in activities of daily living. Prevalence of NCI was lower in those always able to afford basic needs (adjusted prevalence ratio [aPR] 0.71, 95% confidence interval [CI] 0.54-0.94) or with a university education (aPR 0.72, 95% CI 0.54-0.97) and higher in those with severe depressive symptoms (aPR 1.53, 95% CI 1.09-2.14) or a significant comorbid condition (aPR 1.40, 95% CI 1.03-1.90).
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Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK.
| | - Rosanna Laverick
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Marina Daskalopoulou
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | | | - Fiona C Lampe
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Richard Gilson
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Andrew Speakman
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Andrea Antinori
- National Institute for Infectious Diseases, Lazzaro Spallanzani, Rome, Italy
| | - Pietro Balestra
- National Institute for Infectious Diseases, Lazzaro Spallanzani, Rome, Italy
| | - Tina Bruun
- Department of Infectious Diseases, Rigshospitalet, Centre for Health & Infectious Disease Research (CHIP), University of Copenhagen, Copenhagen, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Rigshospitalet, Centre for Health & Infectious Disease Research (CHIP), University of Copenhagen, Copenhagen, Denmark
| | - Lars Nielsen
- Infektionsmedicinsk Afdeling, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Alison J Rodger
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
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Miltz AR, Cambiano V, Lampe FC, Sewell J, Speakman A, Phillips AN, Ivens DR, Asboe D, Collins S, Brady M, Nwokolo NC, Rodger AJ. Eligibility for PrEP among MSM attending GUM clinics in the UK. Sex Transm Infect 2017; 93:571. [DOI: 10.1136/sextrans-2017-053268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 05/29/2017] [Accepted: 07/09/2017] [Indexed: 11/04/2022] Open
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Sewell J, Daskalopoulou M, Nakagawa F, Lampe FC, Edwards S, Perry N, Wilkins E, O'Connell R, Jones M, Collins S, Speakman A, Phillips AN, Rodger AJ. Accuracy of self-report of HIV viral load among people with HIV on antiretroviral treatment. HIV Med 2017; 18:463-473. [PMID: 28004523 PMCID: PMC5516233 DOI: 10.1111/hiv.12477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of the study was to assess, among people living with HIV, knowledge of their latest HIV viral load (VL) and CD4 count. METHODS Agreement between self-report and clinic record was assessed among 2771 HIV-diagnosed individuals on antiretroviral treatment (ART) in the UK Antiretrovirals, Sexual Transmission Risk and Attitudes Study (2011-2012). A confidential self-completed questionnaire collected information on demographic, socioeconomic, HIV-related and health-related factors. Participants were asked to self-report their latest VL [undetectable (≤ 50 copies/mL), detectable (> 50 copies/mL) or "don't know"] and CD4 count (< 200, 200-350, 351-500 or > 500 cells/μL, or "don't know"). Latest clinic-recorded VL and CD4 count were documented. RESULTS Of 2678 participants on ART, 434 (16.2%) did not accurately report whether their VL was undetectable. Of 2334 participants with clinic-recorded VL ≤ 50 copies/mL, 2061 (88.3%) correctly reported undetectable VL; 49 (2.1%) reported detectable VL; 224 (9.6%) did not know their VL. Of 344 participants with clinic-recorded VL > 50 copies/mL, 183 (53.2%) correctly reported detectable VL; 76 (22.1%) reported undetectable VL; 85 (24.7%) did not know their VL. Of 2137 participants who reported undetectable VL, clinic-recorded VL was ≤ 50 copies/mL for 2061 (96.4%) and <1000 copies/mL for 2122 (99.3%). In analyses adjusted for gender/sexual orientation, ethnicity, age and time since starting ART, factors strongly associated with inaccurate self-report of VL (including "don't know") included socioeconomic disadvantage [prevalence ratio (95% CI) for "not" vs. "always" having enough money for basic needs: 2.4 (1.9, 3.1)], poor English fluency [3.5 (2.4, 5.1) vs. UK born], nondisclosure of HIV status [1.7 (1.3, 2.1)], ART nonadherence [2.1 (1.7, 2.7) for three or more missed doses vs. none in the past 2 weeks] and depressive symptoms (PHQ-9 score ≥ 10) [1.9 (1.6, 2.2)]. Overall, 612 (22.9%) of 2667 participants on ART did not accurately self-report whether or not their CD4 count was ≤ 350 cells/μL. CONCLUSIONS There is a high level of accuracy of a self-report of undetectable VL in people on ART in the UK. Overall, accurate knowledge of personal VL level varied according to demographic, socioeconomic, HIV-related and health-related factors. Active identification of people who may benefit from increased levels of support and engagement in care is important.
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Affiliation(s)
- J Sewell
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - M Daskalopoulou
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - F Nakagawa
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - FC Lampe
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - S Edwards
- Mortimer Market CentreCentral and North West London NHS Foundation TrustLondonUK
| | - N Perry
- Brighton and Sussex University Hospitals NHS TrustBrightonUK
| | - E Wilkins
- Pennine Acute Hospitals NHS TrustManchesterUK
| | | | - M Jones
- East Sussex Healthcare NHS TrustEastbourneUK
| | | | - A Speakman
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - AN Phillips
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - AJ Rodger
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
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36
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Daskalopoulou M, Rodger AJ, Phillips AN, Sherr L, Elford J, McDonnell J, Edwards S, Perry N, Wilkins E, Collins S, Johnson AM, Burman WJ, Speakman A, Lampe FC. Condomless sex in HIV-diagnosed men who have sex with men in the UK: prevalence, correlates, and implications for HIV transmission. Sex Transm Infect 2017; 93:590-598. [PMID: 28679630 PMCID: PMC5739863 DOI: 10.1136/sextrans-2016-053029] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/12/2017] [Accepted: 04/18/2017] [Indexed: 11/18/2022] Open
Abstract
Objective HIV transmission is ongoing among men who have sex with men (MSM) in the UK. Sex without a condom (condomless sex, CLS) is the main risk factor. We investigated the prevalence of and factors associated with types of CLS. Methods Cross-sectional questionnaire study in UK HIV clinics in 2011/2012 (ASTRA). MSM diagnosed with HIV for ≥3 months reported on anal and vaginal sex, CLS with HIV-serodifferent partners (CLS-D) and CLS with HIV-seroconcordant (CLS-C) partners in the previous 3 months. Mutually exclusive sexual behaviours were as follows: (1) Higher HIV risk CLS-D (not on antiretroviral therapy (ART) or clinic-recorded viral load(VL) >50 c/mL), (2) Other CLS-D, (3) CLS-C without CLS-D, (4) Condom-protected sex only and (5) No anal or vaginal sex. Associations were examined of sociodemographic, HIV-related, lifestyle, and other sexual measures with the five categories of sexual behaviour. We examined the prevalence of higher HIV risk CLS-D incorporating (in addition to ART and VL) time on ART, ART non-adherence, and recent sexually transmitted infections (STIs). Results Among 2189 HIV-diagnosed MSM (87% on ART), prevalence of any CLS in the past 3 months was 38.2% (95% CI 36.2% to 40.4%) and that of any CLS-D was 16.3% (14.8%–17.9%). The five-category classification was as follows: (1) Higher HIV risk CLS-D: 4.2% (3.5% to 5.2%), (2) Other CLS-D: 12.1% (10.8% to 13.5%), (3) CLS-C without CLS-D: 21.9% (20.2% to 23.7%), (4) Condom-protected sex only: 25.4% (23.6% to 27.3%) and (5) No anal or vaginal sex: 36.4% (34.3% to 38.4%). Compared with men who reported condom-protected sex only, MSM who reported any CLS in the past 3 months had higher prevalence of STIs, chemsex-associated drug use, group sex, higher partner numbers, and lifetime hepatitis C. Prevalence of higher HIV risk CLS-D ranged from 4.2% to 7.5% according to criteria included. Conclusion CLS was prevalent among HIV-diagnosed MSM, but CLS-D with higher HIV transmission risk was overall low. CLS-D is no longer the most appropriate measure of HIV transmission risk behaviour among people with diagnosed HIV; accounting for VL is important.
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Affiliation(s)
- Marina Daskalopoulou
- Research Department of Infection and Population Health, University College London, London, UK
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew N Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Lorraine Sherr
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Jeffrey McDonnell
- Research Department of Infection and Population Health, University College London, London, UK
| | - Simon Edwards
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Nicky Perry
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ed Wilkins
- Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | - Anne M Johnson
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Andrew Speakman
- Research Department of Infection and Population Health, University College London, London, UK
| | - Fiona C Lampe
- Research Department of Infection and Population Health, University College London, London, UK
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Miltz AR, Rodger AJ, Sewell J, Speakman A, Phillips AN, Sherr L, Gilson RJ, Asboe D, Nwokolo NC, Clarke A, Gompels MM, Allan S, Collins S, Lampe FC. Clinically significant depressive symptoms and sexual behaviour among men who have sex with men. BJPsych Open 2017; 3:127-137. [PMID: 28507772 PMCID: PMC5421094 DOI: 10.1192/bjpo.bp.116.003574] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 01/13/2017] [Accepted: 03/06/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The relationship between depression and sexual behaviour among men who have sex with men (MSM) is poorly understood. AIMS To investigate prevalence and correlates of depressive symptoms (Patient Health Questionnaire-9 score ≥10) and the relationship between depressive symptoms and sexual behaviour among MSM reporting recent sex. METHOD The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) is a cross-sectional study of UK genitourinary medicine clinic attendees without diagnosed HIV (2013-2014). RESULTS Among 1340 MSM, depressive symptoms (12.4%) were strongly associated with socioeconomic disadvantage and lower supportive network. Adjusted for key sociodemographic factors, depressive symptoms were associated with measures of condomless sex partners in the past 3 months (≥2 (prevalence ratio (PR) 1.42, 95% CI 1.17-1.74; P=0.001), unknown or HIV-positive status (PR 1.43, 95% CI 1.20-1.71; P<0.001)), sexually transmitted infection (STI) diagnosis (PR 1.46, 95% CI 1.19-1.79; P<0.001) and post-exposure prophylaxis use in the past year (PR 1.83, 95% CI 1.33-2.50; P<0.001). CONCLUSIONS Management of mental health may play a role in HIV and STI prevention. DECLARATION OF INTEREST A.N.P. has received payments for presentations made at meetings sponsored by Gilead in spring 2015. N.C.N. has received support for attendance at conferences, speaker fees and payments for attendance at advisory boards from Gilead Sciences, Viiv Healthcare, Janssen Pharmaceuticals and Bristol-Myers Squibb and a research grant from Gilead Sciences. D.A. served on the advisory board for Gilead in January 2016. M.M.G. has had sponsorship to attend conferences by Bristol-Myers Squibb, been on the BioCryst advisory board and run trials for Merck, Gilead, SSAT, BioCryst and Novartis. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Ada R Miltz
- , MSc, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Alison J Rodger
- , MD, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Janey Sewell
- , BNurs, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew Speakman
- , PhD, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew N Phillips
- , PhD, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Lorraine Sherr
- , PhD, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK
| | - Richard J Gilson
- , MBBS, Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Mortimer Market Centre, University College London, London, UK
| | | | | | | | | | - Sris Allan
- , MBBS, City of Coventry Healthcare Centre, Coventry, UK
| | | | - Fiona C Lampe
- , PhD, HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK, for the AURAH Study Group
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Witzel TC, Weatherburn P, Burns FM, Johnson CC, Figueroa C, Rodger AJ. Consolidating emerging evidence surrounding HIVST and HIVSS: a rapid systematic mapping protocol. Syst Rev 2017; 6:72. [PMID: 28381283 PMCID: PMC5382504 DOI: 10.1186/s13643-017-0452-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 03/06/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND HIV self-testing (HIVST) is becoming popular with policy makers and commissioners globally, with a key aim of expanding access through reducing barriers to testing for individuals at risk of HIV infection. HIV self-sampling (HIVSS) was available previously to self-testing but was confined mainly to the USA and the UK. It remains to be seen whether the momentum behind HIVST will also energise efforts to expand HIVSS. Recent years have seen a rapid growth in the type of evidence related to these interventions as well as several systematic reviews. The vast majority of this evidence relates to acceptability as well as values and preferences, although new types of evidence are emerging. This systematic map aims to consolidate all emerging evidence related to HIVST and HIVSS to respond to this rapidly changing area. METHODS We will systematically search databases and the abstracts of five conferences from 2006 to the present date, with monthly-automated database searches. Searches will combine key terms relating to HIV (e.g. HIV, AIDS, human immune-deficiency syndrome) with terms related to self-testing (e.g. home-test, self-test, mail-test, home dried blood spot test). Abstracts will be reviewed against inclusion criteria in duplicate. Data will be manually extracted through a standard form and then entered to an open access relational map (HIVST.org). When new and sufficient evidence emerges which addresses existing knowledge gaps, we will complete a review on a relevant topic. DISCUSSION This innovative approach will allow rapid cataloguing, documenting and dissemination of new evidence and key findings as they emerge into the public domain. SYSTEMATIC REVIEW REGISTRATION This protocol has not been registered with PROSPERO as they do not register systematic maps.
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Affiliation(s)
- T Charles Witzel
- Sigma Research, Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Peter Weatherburn
- Sigma Research, Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Fiona M Burns
- Research Department of Infection & Population Health, UCL and Royal Free London NHS Foundation Trust, London, UK
| | - Cheryl C Johnson
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Carmen Figueroa
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Alison J Rodger
- Research Department of Infection & Population Health, UCL and Royal Free London NHS Foundation Trust, London, UK
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Warren-Gash C, Childs K, Thornton A, Bhagani S, Demma S, Srivastava A, Leen C, Agarwal K, Rodger AJ, Sabin CA. Cirrhosis and liver transplantation in patients co-infected with HIV and hepatitis B or C: an observational cohort study. Infection 2017; 45:215-220. [PMID: 28054251 PMCID: PMC5374166 DOI: 10.1007/s15010-016-0976-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/19/2016] [Indexed: 12/11/2022]
Abstract
This study assessed the likelihood of referral for liver transplantation assessment in a prospective cohort of patients co-infected with HIV and hepatitis B or C with complications of cirrhosis. There were 141 co-infected patients from 11 UK centres with at least one complication of cirrhosis recorded (either decompensation or hepatocellular carcinoma) out of 772 identified with cirrhosis and/or HCC. Only 23 of these 141 (16.3%) were referred for liver transplantation assessment, even though referral is recommended for co-infected patients after the first decompensation episode.
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Affiliation(s)
- Charlotte Warren-Gash
- Institute of Health Informatics, University College London, London, UK.
- The Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.
| | - Kate Childs
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alicia Thornton
- Research Department of Infection and Population Health, University College London, London, UK
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - Shirin Demma
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
- Hepatology Unit, Department of Experimental and Clinical Medicine, University of Catania, Catania, Italy
| | - Ankur Srivastava
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Clifford Leen
- Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London, London, UK
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - Caroline A Sabin
- Research Department of Infection and Population Health, University College London, London, UK
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Sewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN, Stuart D, Gilson R, Asboe D, Nwokolo N, Clarke A, Collins S, Hart G, Elford J, Rodger AJ. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. Int J Drug Policy 2017; 43:33-43. [PMID: 28189979 DOI: 10.1016/j.drugpo.2017.01.001] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/20/2016] [Accepted: 01/03/2017] [Indexed: 10/24/2022]
Abstract
BACKGROUND Recreational drug use and associated harms continue to be of significant concern in men who have sex with men (MSM) particularly in the context of HIV and STI transmission. METHODS Data from 1484 HIV-negative or undiagnosed MSM included in the AURAH study, a cross-sectional, self-completed questionnaire study of 2630 individuals from 20 sexual health clinics in the United Kingdom in 2013-2014, was analysed. Two measures of recreational drug use in the previous three months were defined; (i) polydrug use (use of 3 or more recreational drugs) and (ii) chemsex drug use (use of mephedrone, crystal methamphetamine or GHB/GBL). Associations of socio-demographic, health and lifestyle factors with drug use, and associations of drug use with sexual behaviour, were investigated. RESULTS Of the 1484 MSM, 350 (23.6%) reported polydrug use and 324 (21.8%) reported chemsex drug use in the past three months. Overall 852 (57.5%) men reported condomless sex in the past three months; 430 (29.0%) had CLS with ≥2 partners, 474 (31.9%) had CLS with unknown/HIV+ partner(s); 187 (12.6%) had receptive CLS with an unknown status partner. For polydrug use, prevalence ratios (95% confidence interval) for association with CLS measures, adjusted for socio-demographic factors were: 1.38 (1.26, 1.51) for CLS; 2.11 (1.80, 2.47) for CLS with ≥2 partners; 1.89 (1.63, 2.19) for CLS with unknown/HIV+ partner(s); 1.36 (1.00, 1.83) for receptive CLS with an unknown status partner. Corresponding adjusted prevalence ratios for chemsex drug use were: 1.38 (1.26, 1.52); 2.07 (1.76, 2.43); 1.88 (1.62, 2.19); 1.49 (1.10, 2.02). Polydrug and chemsex drug use were also strongly associated with previous STI, PEP use, group sex and high number of new sexual partners. Associations remained with little attenuation after further adjustment for depressive symptoms and alcohol intake. CONCLUSION There was a high prevalence of polydrug use and chemsex drug use among HIV negative MSM attending UK sexual health clinics. Drug use was strongly associated with sexual behaviours linked to risk of acquisition of STIs and HIV.
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Affiliation(s)
- Janey Sewell
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Ada Miltz
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Fiona C Lampe
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Valentina Cambiano
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Andrew Speakman
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Andrew N Phillips
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - David Stuart
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Gilson
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - David Asboe
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Nneka Nwokolo
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Amanda Clarke
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | | | - Graham Hart
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | | | - Alison J Rodger
- Research Department of Infection & Population Health, University College London, London, United Kingdom.
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McGowan JA, Sherr L, Rodger AJ, Fisher M, Miners A, Anderson J, Johnson MA, Elford J, Collins S, Hart G, Phillips AN, Speakman A, Lampe FC. Age, time living with diagnosed HIV infection, and self-rated health. HIV Med 2017; 18:89-103. [PMID: 27385511 PMCID: PMC5245118 DOI: 10.1111/hiv.12398] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2016] [Indexed: 12/05/2022]
Abstract
OBJECTIVES An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV. METHODS The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011-2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity. RESULTS The age distribution of participants was: < 30 years, 5%; 30-39 years, 23%; 40-49 years, 43%; 50-59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis). CONCLUSIONS Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.
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Affiliation(s)
- JA McGowan
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - L Sherr
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - AJ Rodger
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - M Fisher
- Brighton and Sussex University Hospitals NHS TrustBrightonUK
| | - A Miners
- London School of Hygiene and Tropical MedicineLondonUK
| | - J Anderson
- Homerton University Hospital NHS Foundation TrustLondonUK
| | - MA Johnson
- Royal Free London NHS Foundation TrustLondonUK
| | - J Elford
- School of Health SciencesCity UniversityLondonUK
| | | | - G Hart
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - AN Phillips
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - A Speakman
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - FC Lampe
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
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Affiliation(s)
- Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | - Jens Lundgren
- Department of Infectious Diseases, Rigshospitalet/CHIP, Copenhagen, Denmark
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Burch LS, Smith CJ, Anderson J, Sherr L, Rodger AJ, O'Connell R, Geretti AM, Gilson R, Fisher M, Elford J, Jones M, Collins S, Azad Y, Phillips AN, Speakman A, Johnson MA, Lampe FC. Socioeconomic status and treatment outcomes for individuals with HIV on antiretroviral treatment in the UK: cross-sectional and longitudinal analyses. Lancet Public Health 2016; 1:e26-e36. [PMID: 28299369 PMCID: PMC5341147 DOI: 10.1016/s2468-2667(16)30002-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Few studies have assessed the effect of socioeconomic status on HIV treatment outcomes in settings with universal access to health care. Here we aimed to investigate the association of socioeconomic factors with antiretroviral therapy (ART) non-adherence, virological non-suppression, and virological rebound, in HIV-positive people on ART in the UK. Methods We used data from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) questionnaire study, which recruited participants aged 18 years or older with HIV from eight HIV outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012. Participants self-completed a confidential questionnaire on sociodemographic, health, and lifestyle issues. In participants on ART, we assessed associations of financial hardship, employment, housing, and education with: self-reported ART non-adherence at the time of the questionnaire; virological non-suppression (viral load >50 copies per mL) at the time of questionnaire in those who started ART at least 6 months ago (cross-sectional analysis); and subsequent virological rebound (viral load >200 copies per mL) in those with initial viral load of 50 copies per mL or lower (longitudinal analysis). Findings Of the 3258 people who completed the questionnaire, 2771 (85%) reported being on ART at the time of the questionnaire, and 2704 with complete data were included. 873 (32%) of 2704 participants reported non-adherence to ART and 219 (9%) of 2405 had virological non-suppression in cross-sectional analysis. Each of the four measures of lower socioeconomic status was strongly associated with non-adherence to ART, and with virological non-suppression (prevalence ratios [PR] adjusted for gender/sexual orientation, age, and ethnic origin: greatest financial hardship vs none 2·4, 95% CI 1·6–3·4; non-employment 2·0, 1·5–2·6; unstable housing vs homeowner 3·0, 1·9–4·6; non-university education 1·6, 1·2–2·2). 139 (8%) of 1740 individuals had subsequent virological rebound (rate=3·6/100 person-years). Low socioeconomic status was predictive of longitudinal rebound risk (adjusted hazard ratio [HR] for greatest financial hardship vs none 2·3, 95% CI 1·4–3·9; non-employment 3·0, 2·1–4·2; unstable housing vs homeowner 3·3, 1·8–6·1; non-university education 1·6, 1·1–2·3). Interpretation Socioeconomic disadvantage was strongly associated with poorer HIV treatment outcomes in this setting with universal health care. Adherence interventions and increased social support for those most at risk should be considered. Funding National Institute for Health Research.
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Affiliation(s)
- Lisa S Burch
- Research Department of Infection and Population Health, University College London, London, UK
| | - Colette J Smith
- Research Department of Infection and Population Health, University College London, London, UK
| | - Jane Anderson
- Centre for the Study of Sexual Health and HIV, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Lorraine Sherr
- Research Department of Infection and Population Health, University College London, London, UK
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Anna-Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Richard Gilson
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Jonathan Elford
- School of Health Sciences, City, University of London, London, UK
| | - Martin Jones
- East Sussex Healthcare NHS Trust, Eastbourne, UK
| | | | | | - Andrew N Phillips
- Research Department of Infection and Population Health, University College London, London, UK
| | - Andrew Speakman
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - Fiona C Lampe
- Research Department of Infection and Population Health, University College London, London, UK
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Witzel TC, Rodger AJ, Burns FM, Rhodes T, Weatherburn P. HIV Self-Testing among Men Who Have Sex with Men (MSM) in the UK: A Qualitative Study of Barriers and Facilitators, Intervention Preferences and Perceived Impacts. PLoS One 2016; 11:e0162713. [PMID: 27611777 PMCID: PMC5017738 DOI: 10.1371/journal.pone.0162713] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/26/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Innovative strategies, such as HIV self-testing (HIVST), could increase HIV testing rates and diagnosis. Evidence to inform the design of an HIVST intervention in the UK is scarce with very little European data on this topic. This study aims to understand values and preferences for HIVST interventions targeting MSM in the UK. We explore the acceptability of HIVST among MSM in the context of known barriers and facilitators to testing for HIV; assess preferences for, and the concerns about, HIVST. METHODS Six focus group discussions (FGD) were conducted with 47 MSM in London, Manchester and Plymouth. HIVST as a concept was discussed and participants were asked to construct their ideal HIVST intervention. OraQuickTM and BioSureTM kits were then demonstrated and participants commented on procedure, design and instructions. FGDs were recorded and transcribed verbatim, then analysed thematically. RESULTS Convenience and confidentiality of HIVST was seen to facilitate testing. Issues with domestic privacy problematised confidentiality. HIVST kits and instructions were thought to be unnecessarily complicated, and did not cater to the required range of abilities. The window period was the most important element of an HIVST, with strong preference for 4th generation testing. Kits which used a blood sample were more popular than those using saliva due to higher perceived accuracy although phobia of needles and/or blood meant some would only access HIVST if a saliva sample option was available. A range of access options was important to maintain convenience and privacy. HIVST kits were assumed to increase frequency of testing, with concerns related to the dislocation of HIVST from sexual health care pathways and services. DISCUSSION Utility of HIVST arises from relatively high levels of confidentiality and convenience. Until 4th generation assays are available HIVST will be seen as supplementary in a UK context.
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Affiliation(s)
- T. Charles Witzel
- Sigma Research, Department of Social and Environmental Health Research, Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Alison J. Rodger
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Fiona M. Burns
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Tim Rhodes
- Department of Social and Environmental Health Research, Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Weatherburn
- Sigma Research, Department of Social and Environmental Health Research, Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, Corbelli GM, Estrada V, Geretti AM, Beloukas A, Asboe D, Viciana P, Gutiérrez F, Clotet B, Pradier C, Gerstoft J, Weber R, Westling K, Wandeler G, Prins JM, Rieger A, Stoeckle M, Kümmerle T, Bini T, Ammassari A, Gilson R, Krznaric I, Ristola M, Zangerle R, Handberg P, Antela A, Allan S, Phillips AN, Lundgren J. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA 2016; 316:171-81. [PMID: 27404185 DOI: 10.1001/jama.2016.5148] [Citation(s) in RCA: 915] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE A key factor in assessing the effectiveness and cost-effectiveness of antiretroviral therapy (ART) as a prevention strategy is the absolute risk of HIV transmission through condomless sex with suppressed HIV-1 RNA viral load for both anal and vaginal sex. OBJECTIVE To evaluate the rate of within-couple HIV transmission (heterosexual and men who have sex with men [MSM]) during periods of sex without condoms and when the HIV-positive partner had HIV-1 RNA load less than 200 copies/mL. DESIGN, SETTING, AND PARTICIPANTS The prospective, observational PARTNER (Partners of People on ART-A New Evaluation of the Risks) study was conducted at 75 clinical sites in 14 European countries and enrolled 1166 HIV serodifferent couples (HIV-positive partner taking suppressive ART) who reported condomless sex (September 2010 to May 2014). Eligibility criteria for inclusion of couple-years of follow-up were condomless sex and HIV-1 RNA load less than 200 copies/mL. Anonymized phylogenetic analysis compared couples' HIV-1 polymerase and envelope sequences if an HIV-negative partner became infected to determine phylogenetically linked transmissions. EXPOSURES Condomless sexual activity with an HIV-positive partner taking virally suppressive ART. MAIN OUTCOMES AND MEASURES Risk of within-couple HIV transmission to the HIV-negative partner. RESULTS Among 1166 enrolled couples, 888 (mean age, 42 years [IQR, 35-48]; 548 heterosexual [61.7%] and 340 MSM [38.3%]) provided 1238 eligible couple-years of follow-up (median follow-up, 1.3 years [IQR, 0.8-2.0]). At baseline, couples reported condomless sex for a median of 2 years (IQR, 0.5-6.3). Condomless sex with other partners was reported by 108 HIV-negative MSM (33%) and 21 heterosexuals (4%). During follow-up, couples reported condomless sex a median of 37 times per year (IQR, 15-71), with MSM couples reporting approximately 22,000 condomless sex acts and heterosexuals approximately 36,000. Although 11 HIV-negative partners became HIV-positive (10 MSM; 1 heterosexual; 8 reported condomless sex with other partners), no phylogenetically linked transmissions occurred over eligible couple-years of follow-up, giving a rate of within-couple HIV transmission of zero, with an upper 95% confidence limit of 0.30/100 couple-years of follow-up. The upper 95% confidence limit for condomless anal sex was 0.71 per 100 couple-years of follow-up. CONCLUSIONS AND RELEVANCE Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex, during median follow-up of 1.3 years per couple, there were no documented cases of within-couple HIV transmission (upper 95% confidence limit, 0.30/100 couple-years of follow-up). Additional longer-term follow-up is necessary to provide more precise estimates of risk.
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Affiliation(s)
- Alison J Rodger
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | - Valentina Cambiano
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | - Tina Bruun
- Department of Infectious Diseases/CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pietro Vernazza
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, St Gallen, Switzerland
| | | | - Jan van Lunzen
- University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | | | - Vicente Estrada
- Hospital Clinico San Carlos and Universidad Complutense, Madrid, Spain
| | - Anna Maria Geretti
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Apostolos Beloukas
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - David Asboe
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | | | - Félix Gutiérrez
- Hospital General de Elche & Universidad Miguel Hernández, Alicante, Spain
| | - Bonaventura Clotet
- IrsiCaixa Foundation, UAB, UVIC-UCC, Hospital Universitari "Germans Trias i Pujol," Badalona, Catalonia, Spain
| | - Christian Pradier
- Department of Public Health, Nice University Hospital and EA 6312, University Nice Sophia-Antipolis, France
| | | | - Rainer Weber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Katarina Westling
- Unit of Infectious Diseases and Dermatology, Department of Medicine, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Gilles Wandeler
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan M Prins
- Academic Medical Center, Amsterdam, the Netherlands
| | | | - Marcel Stoeckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Tim Kümmerle
- Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | | | | | - Richard Gilson
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | | | - Matti Ristola
- Helsinki University Central Hospital, Helsinki, Finland
| | | | - Pia Handberg
- Hvidovre Universitets Hospital, Hvidovre, Denamrk
| | - Antonio Antela
- Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Sris Allan
- Coventry and Warwickshire Hospital, Coventry, United Kingdom
| | - Andrew N Phillips
- Research Department of Infection and Population Health, University College London, London, United Kingdom
| | - Jens Lundgren
- Department of Infectious Diseases/CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Sewell J, Speakman A, Phillips AN, Cambiano V, Lampe FC, Gilson R, Asboe D, Nwokolo N, Clarke A, Ogilvy A, Collins S, Rodger AJ. Attitudes to and Understanding of Risk of Acquisition of HIV Over Time: Design and Methods for an Internet-based Prospective Cohort Study Among UK Men Who Have Sex With Men (the AURAH2 Study). JMIR Res Protoc 2016; 5:e128. [PMID: 27307218 PMCID: PMC4927873 DOI: 10.2196/resprot.5582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/29/2016] [Accepted: 03/16/2016] [Indexed: 11/18/2022] Open
Abstract
Background The annual number of new human immunodeficiency virus (HIV) infections among men who have sex with men (MSM) has risen in the United Kingdom and, of those who are HIV positive, the proportion undiagnosed is high. Objective The prospective AURAH2 study aims to assess factors associated with HIV acquisition among MSM in the United Kingdom and to investigate changes over time within individuals in sexual behavior and HIV-testing practices. Methods AURAH2 is a prospective study among MSM without diagnosed HIV, aiming to recruit up to 1000 sexually active MSM attending sexual health clinics in London and Brighton in the United Kingdom. Participants complete an initial paper-based questionnaire, followed by online follow-up questionnaires every 4 months collecting sociodemographic, health and behavioral data, including sexual behavior, recreational and other drug use, HIV testing practices, and pre-exposure prophylaxis use, over a planned 3-year period. Results The study is ongoing. Conclusions The results from AURAH2 study will provide important insight into established and emerging risk behaviors that may be associated with acquisition of HIV in MSM in the United Kingdom, changes over time within individuals in sexual behavior, and information on HIV testing practices. These data will be crucial to inform future HIV prevention strategies.
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Affiliation(s)
- Janey Sewell
- Department of Infection and Population Health, UCL, London, United Kingdom.
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Bailey SR, Field N, Townsend CL, Rodger AJ, Brocklehurst P. Antibiotic prophylaxis for women undergoing caesarean section and infant health. BJOG 2015; 123:875-6. [PMID: 26435171 DOI: 10.1111/1471-0528.13701] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2015] [Indexed: 11/28/2022]
Affiliation(s)
- S R Bailey
- UCL Institute of Child Health, University College London, London, UK
| | - N Field
- Research Department of Infection and Population Health, University College London, London, UK
| | - C L Townsend
- UCL Institute of Child Health, University College London, London, UK
| | - A J Rodger
- Research Department of Infection and Population Health, University College London, London, UK
| | - P Brocklehurst
- Institute for Women's Health, University College London, London, UK
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Haddow LJ, Pierce KJ, Daskalopoulou M, Lampe F, Rodger AJ. Neurocognitive change observed in the CHARTER HIV cohort could be due to chance, and may be a cause as well as a consequence of detectable viremia. Clin Infect Dis 2015; 60:1441-2. [PMID: 25645215 DOI: 10.1093/cid/civ043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, University College London
| | - Katherine J Pierce
- Community Neurology and Stroke Service, Central and North West London NHS Foundation Trust, United Kingdom
| | - Marina Daskalopoulou
- Research Department of Infection and Population Health, University College London
| | - Fiona Lampe
- Research Department of Infection and Population Health, University College London
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London
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Rodger AJ, Lampe FC, Grulich AE, Fisher M, Friedland G, Phanuphak N, Bogner JR, Pereira LC, Rietmeijer C, Burman W, Phillips AN. Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:64-76. [PMID: 25711325 PMCID: PMC4341939 DOI: 10.1111/hiv.12235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants. METHODS All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months. RESULTS A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low. CONCLUSIONS A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.
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Affiliation(s)
- A J Rodger
- Research Department of Infection and Population Health, University College London, London, UK
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McCormick AL, Moynihan L, Macartney MJ, Garcia-Diaz A, Smith C, Johnson MA, Rodger AJ, Bhagani S, Haque T, Webster DP. Baseline drug resistance mutations are detectable in HCV genes NS3 and NS5A but not NS5B in acute and chronic HIV-coinfected patients. Antivir Ther 2014; 20:361-3. [PMID: 25279548 DOI: 10.3851/imp2871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Adele L McCormick
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK.
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