OBJECTIVES:The incidence of sexually transmitted infections (STIs) and HIV infection remains high in gay, bisexual, and other men who have sex with men (MSM) in the UK, and sexualized drug use ("chemsex") and injecting drug use ("slamsex") may play a part in this. We aimed to characterize HIV-positive MSM engaging in chemsex/slamsex and to assess the associations with self-reported STI diagnoses and sexual behaviours.METHODS:Data from a 2014 survey of people attending HIV clinics in England and Wales were linked to clinical data from national HIV surveillance records and weighted to be nationally representative. Multivariable logistic regression assessed the associations of chemsex and slamsex with self-reported unprotected anal intercourse (UAI), serodiscordant UAI (sdUAI) (i.e. UAI with an HIV-negative or unknown HIV status partner), sdUAI with a detectable viral load (>50 HIV-1 RNA copies/mL), hepatitis C, and bacterial STIs.RESULTS:In the previous year, 29.5% of 392 sexually active participants engaged in chemsex, and 10.1% in slamsex. Chemsex was significantly associated with increased odds of UAI [adjusted odds ratio (AOR) 5.73; P < 0.001], sdUAI (AOR 2.34; P < 0.05), sdUAI with a detectable viral load (AOR 3.86; P < 0.01), hepatitis C (AOR 6.58; P < 0.01), and bacterial STI diagnosis (AOR 2.65; P < 0.01). Slamsex was associated with increased odds of UAI (AOR 6.11; P < 0.05), hepatitis C (AOR 9.39; P < 0.001), and bacterial STI diagnosis (AOR 6.11; P < 0.001).CONCLUSIONS:Three in ten sexually active HIV-positive MSM engaged in chemsex in the past year, which was positively associated with self-reported depression/anxiety, smoking, nonsexual drug use, risky sexual behaviours, STIs, and hepatitis C. Chemsex may therefore play a role in the ongoing HIV and STI epidemics in the UK.

OBJECTIVES:The aim of the study was to determine whether behaviourally informed short message service (SMS) primer and reminder messages could increase the return rate of HIV self-sampling kits ordered online.METHODS:The study was a 2 × 2 factorial design randomized control trial. A total of 9585 individuals who ordered a self-sampling kit from www.freetesting.hiv different SMS combinations: 1) standard reminders sent days 3 and 7 after dispatch (control); 2) primer sent 1 day after dispatch plus standard reminders; 3) behavioural insights (BI) reminders (no primer); or 4) primer plus BI reminders. The analysis was restricted to individuals who received all messages (n = 8999). We used logistic regression to investigate independent effects of the primer and BI reminders and their interaction. We explored the impact of sociodemographic characteristics on kit return as a secondary analysis.RESULTS:Those who received the primer and BI reminders had a return rate 4% higher than that of those who received the standard messages. We found strong evidence of a positive effect of the BI reminders (odds ratio 1.13; 95% confidence interval 1.04-1.23; P = 0.003) but no evidence for an effect of the primer, or for an interaction between the two interventions. Odds of kit return increased with age, with those aged ≥ 65 years being almost 2.5 times more likely to return the kit than those aged 25-34 years. Men who have sex with men were 1.5-4.5 times more likely to return the kit compared with other sexual behaviour and gender identity groups. Non-African black clients were 25% less likely to return the kit compared with other ethnicities.CONCLUSIONS:Adding BI to reminder messages was successful in improving return rates at no additional cost.

OBJECTIVES:In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing.METHODS:Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported.RESULTS:Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17).CONCLUSIONS:The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM.

OBJECTIVES:The aim of the study was to determine HIV incidence among men who have sex with men (MSM) who repeat test for HIV at sexually transmitted infection (STI) clinics in England, and identify associated factors.METHODS:Annual HIV incidence and 95% confidence interval (CI) were calculated for a national cohort of MSM who tested HIV negative at any STI clinic in England in 2012 and had a follow-up test within 1 year using routinely collected data. Cox regression analyses were performed to identify predictors of HIV acquisition and population attributable risk for HIV infection was calculated for predictors.RESULTS:In 2012, 85 500 MSM not known to be HIV positive attended any STI clinic in England, and 31% tested for HIV at least twice within 1 year at the same clinic. HIV incidence was 2.0 per 100 person-years (PY; 95% CI 1.8-2.2) among repeat testers. Incidence was higher among MSM of black ethnicity (3.2 per 100 PY) and those with a bacterial STI diagnosis at the initial attendance (3.2 per 100 PY). MSM with a previous syphilis or gonorrhoea infection were at significantly greater risk of acquiring HIV in the subsequent year [adjusted hazard ratio 4.1 (95% CI 2.0-8.3) and 2.1 (95% CI 1.4-3.2), respectively]. The predictors accounted for 37% of HIV infections.CONCLUSIONS:Annual HIV incidence among MSM attending STI clinics in England is high. Previous STIs were predictors of HIV acquisition but only accounted for one in five infections. More discriminatory behavioural predictors of HIV acquisition could provide better triaging of HIV prevention services for MSM attending STI clinics.

ObjectivesThe aim of the study was to explore HIV testing frequency among UK men who have sex with men (MSM) in order to direct intervention development.MethodsCross-sectional surveys were completed by 2409 MSM in Edinburgh, Glasgow and London in 2011 and a Scotland-wide online survey was carried out in 2012/13. The frequency of HIV testing in the last 2 years was measured.ResultsOverall, 21.2% of respondents reported at least four HIV tests and 33.7% reported two or three tests in the last 2 years, so we estimate that 54.9% test annually. Men reporting at least four HIV tests were younger and less likely to be surveyed in London. They were more likely to report higher numbers of sexual and anal intercourse partners, but not "higher risk" unprotected anal intercourse (UAI) with at least two partners, casual partners and/or unknown/discordant status partners in the previous 12 months. Only 26.7% (238 of 893) of men reporting higher risk UAI reported at least four tests. Among all testers (n = 2009), 56.7% tested as part of a regular sexual health check and 35.5% tested following a risk event. Differences were observed between surveys, and those testing in response to a risk event were more likely to report higher risk UAI.ConclusionsGuidelines recommend that all MSM test annually and those at "higher risk" test more frequently, but our findings suggest neither recommendation is being met. Additional efforts are required to increase testing frequency and harness the opportunities provided by biomedical HIV prevention. Regional, demographic and behavioural differences and variations in the risk profiles of testers suggest that it is unlikely that a "one size fits all" approach to increasing the frequency of testing will be successful.

ObjectivesFollowing national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings.MethodsResource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis.ResultsIn the pilots, cost per test ranged from 8.55 to 13.50 pound, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, 6 pound and 80% for ACUs, and 5 minutes, 9.60 pound and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was 3230 pound in ACUs and 7930 pound in GPs for tests performed by a Band 3 staff member, and 5940 pound in ACUs and 18800 pound in GPs for tests performed by either hospital consultants or GPs.ConclusionsExpanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

Introduction Convenience samples of MSM are typically skewed towards gay-identified and community-attached men who do not necessarily represent all MSM, a key population for STI/HIV transmission. Comparing convenience samples with a probability sample of MSM enables us to assess their representativeness. Methods We compared 148 MSM in Britain’s third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), with men in Britain’s key convenience surveys of gay men: 15,500 in the European MSM Internet Survey (EMIS), 1,012 in the Gay Men’s Sexual Health Survey London (GMSHS-London), 1,234 in the Gay Men’s Sexual Health Survey Scotland (GMSHS-Scotland), all undertaken 2010–2012. Men were aged 18–64, resident in Britain, and reported >=1 male sexual partners (past year). Comparisons include demographic, health characteristics and sexual behaviours, using identically-worded questions. Multivariable analyses accounted for socio-demographic differences between the samples. Results Convenience samples had significantly younger and better educated men than Natsal-3, and a larger proportion of men identifying as gay (88%–95% vs. 62%). Partner numbers were larger and same-sex anal sex more commonly reported by convenience samples but no significant differences were observed in age at first sex or reporting unprotected anal intercourse. Compared to Natsal-3, men in convenience samples were more likely to report HIV testing (past year) (all adjusted odds ratios (AORs) >=2.30, 95% CI lower bounds >=1.49) and gonorrhoea diagnoses (all AORs >=7.99, 95% CI lower bounds >=1.11). However, fewer differences between samples were observed when analyses focused on MSM who identified as gay. Conclusion Participation bias may mean convenience samples of MSM demographically misrepresent and over-estimate sexual activity and HIV testing for the entire MSM population. However, they may be more representative of gay-identified MSM, capture a broader range of behaviours and achieve larger samples, relative to general population surveys. Methods are needed to triangulate data from different surveys to strengthen the evidence-base for MSM.

Objectives: Sexually transmitted infections, HIV and unplanned pregnancies continue to be a major public health problem in England, especially in young adults. Strengthening the provision of free condoms, HIV testing, chlamydia screening and contraception within primary care will contribute to reducing poor sexual and reproductive health outcomes. Recent research demonstrated the benefit for general practices of educational support visits based on behaviour change theory. Public Health England (PHE) has piloted an educational training programme to improve the delivery of sexual health services and HIV testing within general practice.Study design & methods: The 3Cs & HIV programme used practice based workshops to improve staffs' awareness and skills in order to increase opportunistic offers of chlamydia testing, provision of contraceptive service information and free condoms (the '3Cs') to 15-24 year olds and HIV testing according to national guidelines. The programme was based on the theory of planned behaviour and has been implemented using a stepped wedge design. Process evaluation, testing and diagnosis data, plus qualitative interviews were all used in the evaluation. The primary outcome measures were chlamydia testing and diagnosis rates. Secondary outcome measures were HIV testing and diagnoses rates within each practice and rates of consultations where long acting reversible contraceptives had been discussed.Conclusion: A key strength of the 3Cs & HIV programme has been the evidence base underpinning the development of the resources and the formal process evaluation of its implementation. The programme was designed to encourage sustainable relationships between general practice staff and local sexual health services as well as the knowledge, awareness and behaviours cultivated during the programme. Crown Copyright (C) 2015 Published by Elsevier Ltd on behalf of The Royal Society for Public Health. All rights reserved.

Introduction The National Chlamydia Screening Programme (NCSP) was nationally implemented in England in 2008. The programme recommends that sexually-active under-25 year-olds are tested for chlamydia annually and on change of partner with the aim of interrupting transmission and preventing complications. We undertook a seroprevalence study to explore the impact of chlamydia screening on the cumulative incidence of infection up to 2012. Methods Anonymised sera from participants in the Health Survey for England (HSE), a series of nationally-representative household surveys, were tested for anti-chlamydia antibodies using an ELISA based on the Chlamydia trachomatis -specific antigen Pgp3. Factors associated with seropositivity among 16–44 year-olds in 2010 and 2012 (years when sexual behaviour questions were included) were investigated using logistic regression. Seroprevalence trends were investigated for 1994–2012. Results In 2010/2012, Pgp3 seroprevalence was 24% (95% CI: 22%–27%) in women and 14% (12%–16%) in men. Seroprevalence increased with age to 34% (28%–40%) in 30–34 year-old women and 20% (15%–27%) in 35–39 year-old men, and with numbers of lifetime sexual partners (17% with 1–4 partners versus 43% in those with ≥10 in women; 6% vs. 27% in men). 78% of seropositive 16–24 year-old women did not report a previous chlamydia diagnosis. Among 16–24 year-old women, there was no significant trend in seroprevalence over time and no difference in age-specific seroprevalence between birth cohorts exposed to different levels of chlamydia screening. Conclusion In 2010–12, at least one third of women had been exposed to chlamydia by age 30–34. Most of those with evidence of previous infection did not report a previous diagnosis, presenting consequent risks of transmission and complications. A decrease in cumulative incidence among young adults following the implementation of the NCSP has not yet been demonstrated. Additional years of screening may be needed to have a measurable effect on cumulative incidence. Continued monitoring of seroprevalence is required. Disclosure of interest statement The study was funded by the Health Protection Agency (now part of Public Health England). No pharmaceutical or diagnostic company grants were received in the development of this study.

HIV seroadaptive behaviours may have contributed to greater sexually transmitted infection (STI) transmission in HIV-positive men who have sex with men(MSM) and to the global increase in STIs. Using multiple national surveillance data sources and population survey data, we estimated the risk of STIs in HIV-positive MSM and assessed whether transmission in HIV-positive MSM has contributed to recent STI epidemics in England. Since 2009, an increasing proportion of STIs has been diagnosed in HIV-positive MSM, and currently, the population rate of acute bacterial STIs is up to four times that of HIV-negative or undiagnosed MSM. Almost one in five of all diagnosed HIV-positive MSM in England had an acute STI diagnosed in 2013. From 2009 to 2013, the odds of being diagnosed with syphilis increased from 2.71 (95% confidence interval (CI) 2.41–3.05, p<0.001) to 4.05 (95%CI 3.70-4.45, p<0.001) in HIV-positive relative to HIV negative/undiagnosed MSM. Similar trends were seen for gonorrhoea and chlamydia. Bacterial STI re-infection rates were considerably higher in HIV-positive MSM over a five-year follow-up period, indicative of rapid transmission in more dense sexual networks.These findings strongly suggest that the sexual health of HIV-positive MSM in England is worsening, which merits augmented public health interventions and continued monitoring.