This guideline offers recommendations on the diagnosis, treatment and health promotion principles needed for the effective management of human papillomavirus (HPV)-related warts at anogenital sites including the external genitals, vagina, cervix, urethra, perianus and anal canal. The guideline is aimed primarily at patients aged 16 years or older presenting to healthcare professionals working in level 3 sexual health services in the United Kingdom. However, the principles of the recommendations may be applied in other care settings, including in primary care, using locally adapted care pathways where appropriate. The management of HPV-related anogenital dysplasia or warts at other extragenital sites is outside the scope of this guideline.

Objectives Since June 2022, there has been a rise in the number of ceftriaxone-resistant Neisseria gonorrhoeae cases detected in England (n = 15), of which a third were XDR. We describe the demographic and clinical details of the recent cases and investigate the phenotypic and molecular characteristics of the isolates. For a comprehensive overview, we also reviewed 16 ceftriaxone-resistant cases previously identified in England since December 2015 and performed a global genomic comparison of all publicly available ceftriaxone-resistant N. gonorrhoeae strains with mosaic penA alleles. Methods All N. gonorrhoeae isolates resistant to ceftriaxone (MIC > 0.125 mg/L) were whole-genome sequenced and compared with 142 global sequences of ceftriaxone-resistant N. gonorrhoeae. Demographic, behavioural and clinical data were collected. Results All cases were heterosexual, and most infections were associated with travel from the Asia-Pacific region. However, some had not travelled outside England within the previous few months. There were no ceftriaxone genital treatment failures, but three of five pharyngeal infections and the only rectal infection failed treatment. The isolates represented 13 different MLST STs, and most had the mosaic penA-60.001 allele. The global genomes clustered into eight major phylogroups, with regional associations. All XDR isolates belonged to the same phylogroup, represented by MLST ST16406. Conclusions Most cases of ceftriaxone-resistant N. gonorrhoeae detected in England were associated with travel from the Asia-Pacific region. All genital infections were successfully treated with ceftriaxone, but there were extragenital treatment failures. Ceftriaxone resistance continues to be associated with the penA-60.001 allele within multiple genetic backgrounds and with widespread dissemination in the Asia-Pacific region.

Background Since June 2022, there has been a rise in the number of ceftriaxone resistant Neisseria gonorrhoeae cases detected in England (n = 15), of which one third were extensively-drug resistant (XDR). We describe the demographic and clinical details of the recent cases and investigate the phenotypic and molecular characteristics of the isolates. For a comprehensive overview, we also reviewed 16 ceftriaxone-resistant cases previously identified in England since December 2015 and performed a global genomic comparison of all publicly available ceftriaxone-resistant N. gonorrhoeae strains with mosaic penA alleles. Methods All N. gonorrhoeae isolates resistant to ceftriaxone (MIC >0.125 mg/L) were whole-genome sequenced and compared with 142 global sequences of ceftriaxone-resistant N. gonorrhoeae. Demographic, behavioural, and clinical data were collected, including treatment and outcomes. Results All cases were heterosexuals, and most infections were associated with travel to or from the Asia-Pacific region. However, some had not travelled outside England within the previous few months. There were no ceftriaxone genital treatment failures, but 3/5 pharyngeal infections and the only rectal infection failed treatment. The isolates represented 13 different multi-locus sequence types (MLSTs), and most had the mosaic penA-60.001 allele. The global genomes clustered into eight major phylogroups, with regional associations. All XDR isolates belonged to the same phylogroup, represented by MLST 16406. Conclusion Ceftriaxone resistance in N. gonorrhoeae continues to be associated with the penA-60.001 allele within multiple genetic backgrounds and with widespread dissemination in the Asia-Pacific region. Heightened surveillance activities have been initiated to detect further cases with the aim of interrupting further transmission. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by UKHSA ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Research Ethics and Governance Group of the UK Health Security Agency waived ethical approval for this work. This analysis was undertaken for health protection purposes under permissions granted to UKHSA to collect and process confidential patient data under Regulation 3 of The Health Service (Control of Patient Information) Regulations 2020 and Section 251 of the National Health Service Act 2006. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Objectives: HTLV-1 is predominantly a sexually-transmitted infection but testing is not mentioned in HIV-PrEP guidelines. We ascertained HTLV-1/HTLV-2 seroprevalence amongst HIV-PrEP users in England. Methods: An unlinked anonymous seroprevalence study. Results: Amongst 2015 HIV-PrEP users, 95% were men, 76% of white ethnicity and 83% had been born in Europe. There were no HTLV-1/HTLV-2 seropositive cases (95% confidence interval 0% - 0.18%). Conclusions: There were no HTLV positive cases, likely reflecting the demographic of mostly white and European-born individuals. Similar studies are needed worldwide to inform public health recommenda-tions for HIV-PrEP using populations, particularly in HTLV-endemic settings. Crown Copyright (c) 2023 Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

IntroductionA complex virtual pre-exposure prophylaxis (PrEP) MDT clinic was set up to review patients with medical complexities including renal or bone impairment, side effects and intolerances. We reviewed 6 months of data.MethodA retrospective case note review was conducted of all patients referred to the complex clinic from July 2022-Feb 2023. Data collected included patient demographics, reason for referral, PrEP outcomes and discontinuation rates.Results2,521 patients received PrEP over 6 months - 618 referrals were made for 563 (22%) patients; 97% male, median age of 36 years and 75% on daily dosing.DiscussionNearly a quarter of patients seen for PrEP required a virtual review due to medical complexities most commonly renal impairment. The clinic has been able to provide more options such as alternative generic brand formulations and CAB, acting as a safety net enabling patients to access and remain on PrEP.

You have accessJournal of UrologyCME1 Apr 2023MP15-01 THE NEW PANDEMIC: MONKEYPOX AND ITS UROLOGICAL PRESENTATIONS Alex Murray, Piotr Śluzar, Anna Daunt, Aatish Patel, Nori Achyuta, Geraldine O'Hara, and Tet Yap Alex MurrayAlex Murray More articles by this author , Piotr ŚluzarPiotr Śluzar More articles by this author , Anna DauntAnna Daunt More articles by this author , Aatish PatelAatish Patel More articles by this author , Nori AchyutaNori Achyuta More articles by this author , Geraldine O'HaraGeraldine O'Hara More articles by this author , and Tet YapTet Yap More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003235.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Monkeypox (MPX) is a zoonotic virus, endemic to Central and Western Africa. Since early May 2022, there has been an outbreak of the virus with 3,548 confirmed cases in the UK for 2022, predominantly affecting men who have sex with men (MSM). Due to the virus’ capacity to transmit via exchange of bodily fluids, colonisation of the genitalia is not uncommon. Despite this, there is a paucity of available literature concerning urological manifestations. This case series seeks to elucidate the natural history of MPX from a urological perspective. METHODS: We reviewed all MPX antigen-positive cases at Guy’s & St Thomas’ NHS Trust, and affiliated sexual health centres in south London, between May and October 2022. Patients that presented with penile lesions were identified — of those, cases that required specialist urological input were selected. RESULTS: 199 men with Monkeypox were identified. Of those, 10% (19/199) presented with penile lesions and required treatment in an isolation ward with full personal protection equipment; 4% (8/199) required input from the urology team. Their average age was 41.6 (±7.1) years. 62.5% (5/8) of these patients were HIV positive but only one was poorly controlled (>200 copies/mL). 75% (6/8) of patients experienced penile oedema and 50% (3/6) of these patients experienced paraphimosis. One patient experienced paraphimosis without oedema, another experienced penile cyanosis concomitant with severe distal oedema. Rarely, urinary insufficiency will develop. The average number of penile lesions was 6 (range: 1-14, s.d. ±5.4). Lesions demonstrated a range of presentations — some initially appeared as pustules and papules, while more severe cases developed extensive, wet ulcerations; in some cases secondary infections were superimposed on the lesions, leading to necrosis. All lesions, however, were painful and required analgesia. On average, patients would present to health services 5.4 (±1.6) days after onset of symptoms, and would take 21 (±7.9) days for all lesions to heal. CONCLUSIONS: MPX urological presentations seem to observe a continuum of severity. Currently, the long-term urological sequelae of MPX are unknown but small lesions seem to heal without issue. By assessing the number of penile lesions and the presence of/potential for superimposed infections, a clinical picture for the course of the infection can be constructed and be used to inform management. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e191 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alex Murray More articles by this author Piotr Śluzar More articles by this author Anna Daunt More articles by this author Aatish Patel More articles by this author Nori Achyuta More articles by this author Geraldine O'Hara More articles by this author Tet Yap More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND:Since May, 2022, a large global outbreak of human mpox (formerly known as monkeypox) has predominantly affected men who have sex with men. The strain responsible, Clade IIb, has mutated substantially from precursors originating from the 2017-18 outbreak in Nigeria. Immunity to smallpox, another orthopoxvirus, via previous infection or vaccination provides lifelong immunity. However, since the 2022 mpox outbreak, recent clusters were described in individuals with presumed immunity through recent infection or vaccination. We aim to describe the epidemiological and clinical characteristics of mpox in individuals with past infection or vaccination to improve the understanding of this disease in the setting of previous immunity. METHODS:In this global case series, international collaborators from nine countries provided data on individuals with PCR-confirmed mpox after documented previous infection or vaccination between May 11, 2022, and June 30, 2023. We excluded cases that could not confirm vaccination status or cases with partial immunisation or any doses received before the current multi-national mpox outbreak (cutoff date May 1, 2022). Data were collected via a case report spreadsheet that reported on dates of infection and vaccination, route of immunisation, demographic characteristics, clinical findings, HIV status, concomitant sexually transmitted infections, and markers of disease severity (mpox severity score system). We describe case epidemiology, clinical course, and mpox severity scores; all analyses were descriptive. FINDINGS:We report mpox infections in 37 gay and bisexual men who have sex with men: seven individuals had mpox reinfections, 29 individuals had mpox infections that occurred after two appropriately spaced Modified Vaccinia Ankara-Bavarian Nordic vaccine courses, and one individual had an infection that met the criteria for both reinfection and infection after vaccination. The median age of individuals was 36 years (IQR 30-45; range 21-58). Those with natural immunity after initial infection had a shorter disease course with less mucosal disease upon reinfection than with their initial infection. Infections post-vaccination were characterised by few lesions, little mucosal disease, and minimal analgesia requirements; two people received oral tecovirimat. Overall, there were no deaths, no bacterial superinfections, and all individuals were managed in the ambulatory clinic with one hospital admission for a necrotising neck lesion. INTERPRETATION:The epidemiology of people with mpox reinfection or infection post-vaccination was similar to other published cohorts during the 2022 outbreak-predominantly young, sexually active gay and bisexual men who have sex with men. Clinical features and outcomes of repeat infection and infection after vaccination appear to be less clinically severe than those described in 2022 case literature. Specifically, compared with the 2022 case series, these individuals in the present study had fewer confluent lesions, less mucosal involvement, reduced analgesia requirement, and fewer admissions. Natural immunity and vaccine-induced immunity are not fully protective against mpox infection. However, in this small series both disease duration and severity appear to be reduced. FUNDING:None.

You have accessJournal of UrologyCME1 Apr 2023MP15-03 MONKEYPOX AND THE PENIS: AN EMPIRICAL CARE PATHWAY Piotr Sluzar, Alex Murray, Anna Daunt, Aatish Patel, Achyuta Nori, Geraldine O'Hara, and Tet Yap Piotr SluzarPiotr Sluzar More articles by this author , Alex MurrayAlex Murray More articles by this author , Anna DauntAnna Daunt More articles by this author , Aatish PatelAatish Patel More articles by this author , Achyuta NoriAchyuta Nori More articles by this author , Geraldine O'HaraGeraldine O'Hara More articles by this author , and Tet YapTet Yap More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003235.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Monkeypox is a viral illness affecting predominantly gay, bisexual and other men having sex with men. The rapid progression of the recent outbreak meant genital manifestations preceded any guidelines for cases with urological symptoms. This study aims to develop an empirical care pathway for patients presenting with penile and scrotal symptoms secondary to monkeypox. METHODS: From May to September 2022, 198 patients with monkeypox who presented to a tertiary referral hospital were assessed for genital involvement by the infectious disease team, with the involvement of a urologist. Of these, 19 patients (10%) were admitted with genital lesions and were treated in an isolation ward with full personal protection equipment (PPE) in use. Symptoms requiring urological input were present in 8 individuals (4%). The mean time from the onset of symptoms to resolution was 25.3 (range 9-63) days. Based on the management of these patients, an empirical care pathway for genital monkeypox was developed. RESULTS: Four stages of genital monkeypox were observed (Figure 1). Limited penile oedema and discrete lesions should be managed conservatively with analgesia, cold compresses and elevation for swelling control. Patients with moderate oedema, paraphimosis and large coalescing ulcers should be considered for a topical 1% hydrocortisone cream to reduce the inflammation. In severe oedema with necrotic ulcers glyceryl trinitrate (GTN) patches are crucial to improve the vascularization of the necrotic ulcers on the penis. Cases of widespread necrosis and oedema may require imaging to assess the need for surgical debridement. GTN patches require daily changes for tissue salvage. Catheterization should be guided by the extent of oedema, the presence of paraphimosis and lesions close to the external urethral orifice. CONCLUSIONS: Monkeypox cases presenting through lesions on the penis and scrotum often require urological management to reduce penile oedema and prevent catheterisation. All admitted patients require isolation with full PPE. The initial stages of the infection should be managed conservatively with cold compresses, elevation and analgesia. Patients with advanced genital symptoms can benefit from the early use of topical steroid creams and GTN patches applied over the necrotic areas to reduce swelling and aid perfusion. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e192 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Piotr Sluzar More articles by this author Alex Murray More articles by this author Anna Daunt More articles by this author Aatish Patel More articles by this author Achyuta Nori More articles by this author Geraldine O'Hara More articles by this author Tet Yap More articles by this author Expand All Advertisement PDF downloadLoading ...

IntroductionThe efficacy of HIV Pre-Exposure Prophylaxis (PrEP) is well established, however success largely depends on reach, access and medication adherence. This review describes the expanding role of a pharmacist within a sexual and reproductive health (SRH) clinic including the benefits of improved quality of care and access to PrEP.MethodData was collected on successful service improvements implemented by a specialist HIV PrEP pharmacist.ResultsSince being in post from July 2022 the pharmacist alongside members of the MDT has led on the following service improvements:- • Implementation of a streamlined all-day nurse led clinic for routine PrEP through patient group directive sign offs and education and training. This has led to an increase in uptake of PrEP by 30%. • Establishing a weekly virtual complex PrEP MDT clinic to review medical complexities such as side effects and renal impairment. This has allowed us to provide options and nephrology referrals for patients who cannot take NHS PrEP. Over 500 patients which is over 20% of our cohort has been reviewed over a 6-month period. • Creation of an online appointment system for PrEP appointments. • Implementation of a weekly Pharmacist PrEP clinic for training new staff and reviewing complex patients (up to 5 patients/week). • Strategic planning for novel deliveries of PrEP to increase capacity and access for marginalised communities (e.g. via medication lockers and remote pathways).DiscussionPharmacists are experts in medication, adherence counselling, adverse effects and monitoring which are critical to clinically successful and safe PrEP usage. PrEP service leadership by a pharmacist skilled in HIV/SRH with an understanding of contracts and supply chain has proven to be beneficial. Together with other clinicians, pharmacists should be directly involved in driving PrEP service development to improve access, reach and lead complex MDTs.

Introduction Our local clinic policy for management of chlamydia contacts (PNC) offers epidemiological treatment to all reporting last sexual contact (LSI) towith the index case within 14 days, and all symptomatic contacts. Asymptomatic PNC reporting LSI over 14 days are tested and treated as per results. Our aim was to evaluate contact tracing outcomes and adherence to local policy. Methods We conducted a retrospective case note review of patients coded PNC over a 3-month period. Results Of 90 patients coded PNC, 67% were male, 40% under 25 years. 44% of all PNC tested positive for chlamydia. 64% (48/75) PNC attended within 14 days of documented LSI with index, 44% had chlamydia. 77% (37/48) were Index Verified (IV) contacts, with 57% (21/37) positivity. 100% of unverified contacts tested negative. 36% (27/75) PNC attended over 14 days from documented LSI with index, 37% had chlamydia. 85% (23/27) received epidemiological treatment on the day including all those testing positive, and 48% testing negative. 92% with symptoms were treated, only 23% testing positive. Of those asymptomatic contacts, 75% (9/12) were treated on the day, with 44% (4/9) negative. Discussion 52% (14/27) of these PNC were IV contacts, with 50% (7/14) positivity. 77% (10/13) of unverified contacts tested negative. IV attendances correlate positively with LSI within 14 days and chlamydia positivity. II For those PNC presenting over 14 days from LSI, the presence of symptoms did not correlate strongly with chlamydia positivity, and we will further may evaluate review the offer of epidemiological treatment to this group.

BackgroundEffectiveness of HIV postexposure prophylaxis (PEPSE) correlates with speed of uptake following HIV exposure. Time to first dose has not improved in the UK for over 10 years. On-demand pre-exposure prophylaxis (PrEP) has shown that people can self-start medication for HIV prevention.We hypothesised that advanced provision of PEPSE (HOME PEPSE) for men who have sex with men (MSM) to self- initiate would reduce time to first dose following HIV exposure.MethodsPhase IV, randomised, prospective, 48-week, open-label study was carried out. MSM at medium risk of acquiring HIV were randomised (1:1) to immediate or deferred standard of care (SOC) HOME PEPSE. Every 12 weeks, participants self-completed mental health/risk behaviour surveys and had HIV/sexually transmitted infection (STI) testing.HOME PEPSE comprised a 5-day pack of emtricitabine/tenofovir disoproxil fumarate/maraviroc 600 mg once daily initiated following potential exposure to HIV. If taken, participants completed a risk survey; PEPSE continuation was physician directed. Primary outcome was time from potential exposure to HIV to first PEPSE dose.Findings139 participants randomised 1:1; 69 to immediate HOME PEPSE and 70 to deferred HOME PEPSE. Median age 30 years (IQR 26–39), 75% white, 55% UK born and 72% university educated. 31 in HOME PEPSE and 15 in SOC arm initiated PEPSE. Uptake of HOME PEPSE was appropriate in 27/31 cases (87%, 95% CI: 71% to 95%). Median time from exposure to first dose was 7.3 hours (3.0, 20.9) for HOME PEPSE and 28.5 hours (17.3, 34.0) for SOC (p<0.01). HOME PEPSE was well tolerated with no discontinuations.No significant differences in missed opportunities for PEPSE uptake, sexual behaviour or bacterial STI infections between treatment arms.InterpretationHOME PEPSE reduced the time from exposure to first-dose PEPSE by 21+ hours, with no impact on safety. This significantly improves the efficacy of PEPSE and provides an option for people declining PrEP.

Introduction Between December 2021 and February 2022 six cases of ceftriaxone resistant gonorrhoea were identified in different regions of the UK. Most but not all, of these cases had links to travel from the Asia Pacific region. Whole genome sequencing was used to investigate the relationship of these cases to each other and to other international strains. Methods Neisseria gonorrhoeae isolates from all cases were tested for phenotypic susceptibility using gradient MIC strips (Biomerieux) and EUCAST breakpoints at the National reference laboratory. Genomic DNA was extracted using the Qiasymphony DSP DNA mini kit (Qiagen) and Illumina sequencing performed by Central Sequencing Laboratory (UKHSA) with analysis performed in PathogenWatch. Results Five of the six cases belonged to MLST ST8123 and carried the penA 60.001 allele associated with ceftriaxone resistance but the strains were not identical (Table 1). The sixth case belonged to MLST ST1901 which carried a penA allele with three of the five single nucleotide polymorphisms associated with cephalosporin resistance in penA allele 60.001 (Table 1). Discussion The ST8123 lineage has been commonly reported in China but not within the UK or Europe. This, coupled with reports of sustained transmission of the globally disseminated ceftriaxone-resistant FC428 clone associated with the penA 60.001 allele within China, supports that the FC428-related strains are more likely to have resulted from independent importation events with some limited onward transmission in the UK. The ST1901 lineage is disseminated within the UK and globally and can show multi-drug resistance but is more commonly associated with cefixime resistance and ceftriaxone susceptibility.

We thank Kow et al. [1] for their response to the findings of the RECEDEC19 study on clinical outcomes between people living with and without HIV hospitalized with coronavirus disease 2019 (COVID19) [2]. The authors suggest the inclusion of antiretroviral therapy (ART) in the multivariable model, particularly those who received tenofovirbased ART, to investigate the effectiveness of these medications in patients with COVID19. As only five (7.4%) people living with HIV not receiving ART were included, this study was not powered to compare the effect of ART on clinical outcomes in hospitalized patients. Tenofovir disoproxil fumarate (TDF) is associated with renal and bone densityrelated adverse effects, and UK national guidelines [3] recommend avoiding TDF in people with impaired renal function or osteoporosis. As a result, the population receiving TDF is biased, and its inclusion in the multivariable model risks multicollinearity with the comorbidities, frailty and age factors that were already included. The small sample size and lack of a suitable denominator for people living with HIV across all clinics receiving tenofovirbased ART were other limitations in evaluating the effectiveness of tenofovir in the prevention of severe COVID19 hospitalisation outcomes. Therefore, we considered that inclusion of tenofovirbased ART in the multivariable model would be of limited value, and the antiretroviral data were presented descriptively to avoid overinterpretation in this paper. As the authors have summarized, tenofovir has been hypothesized to be potentially effective against severe acute respiratory syndrome coronavirus 2 (SARSCoV2); however, evidence to support the use of tenofovirbased strategies for the treatment or prevention of COVID19 remains sparse. Evidence from two openlabelled randomized trials have provided mixed results. Participants randomized to TDF/emtricitabine following a recent diagnosis (<7 days) of nonsevere COVID19 showed a mean realtime polymerase chain reaction cycle threshold difference of 2.9 (95% confidence interval [CI] 0.1– 5.2, p = 0.044) but no difference in time to symptom recovery, and the study was not powered to collect other clinical outcomes [4]. Although a larger pragmatic randomized trial of TDF/emtricitabine, rosuvastatin plus colchicine, or a combination of the four medications showed lower mortality in participants receiving all four medications (hazard ratio [HR] 0.53; 95% CI 0.29– 0.96; p = 0.038), TDF/emtricitabine alone was not associated with a reduction in 28day mortality in the TDF/emtricitabine arm compared with standard of care (HR 0.69; 95% CI 0.39– 1.20; p = 0.187) [5]. Two ongoing randomized controlled trials investigating TDF/emtricitabine as treatment for COVID19 are registered in the clinicaltrials.gov database at the time of writing (NCT04712357, NCT04890626). Effective treatments for COVID19 are available, but the search continues for effective, lower cost, alternative treatments and remains relevant, particularly for settings with limited resources and/or access to vaccines. However, we advise caution in the interpretation of the effectiveness of ART including tenofovir for the treatment of COVID19 from retrospective cohorts because of the contribution of confounding overlapping factors that may not be possible to adequately adjust for. The findings of the ongoing suitably powered and blinded randomized controlled trials are anticipated to provide more robust answers as to whether tenofovir is effective in the treatment of COVID19.

Objective To characterise the clinical features of monkeypox infection in humans. Design Descriptive case series. Setting A regional high consequences infectious disease centre with associated primary and secondary care referrals, and affiliated sexual health centres in south London between May and July 2022. Participants 197 patients with polymerase chain reaction confirmed monkeypox infection. Results The median age of participants was 38 years. All 197 participants were men, and 196 identified as gay, bisexual, or other men who have sex with men. All presented with mucocutaneous lesions, most commonly on the genitals (n=111 participants, 56.3%) or in the perianal area (n=82, 41.6%). 170 (86.3%) participants reported systemic illness. The most common systemic symptoms were fever (n=122, 61.9%), lymphadenopathy (114, 57.9%), and myalgia (n=62, 31.5%). 102/166 (61.5%) developed systemic features before the onset of mucocutaneous manifestations and 64 (38.5%) after (n=4 unknown). 27 (13.7%) presented exclusively with mucocutaneous manifestations without systemic features. 71 (36.0%) reported rectal pain, 33 (16.8%) sore throat, and 31 (15.7%) penile oedema. 27 (13.7%) had oral lesions and 9 (4.6%) had tonsillar signs. 70/195 (35.9%) participants had concomitant HIV infection. 56 (31.5%) of those screened for sexually transmitted infections had a concomitant sexually transmitted infection. Overall, 20 (10.2%) participants were admitted to hospital for the management of symptoms, most commonly rectal pain and penile swelling. Conclusions These findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries. A variable temporal association was observed between mucocutaneous and systemic features, suggesting a new clinical course to the disease. New clinical presentations of monkeypox infection were identified, including rectal pain and penile oedema. These presentations should be included in public health messaging to aid early diagnosis and reduce onward transmission.

Disruption to sexual health services during the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2; coronavirus disease 2019 [COVID‐19]) pandemic may have adversely affected the provision of HIV post‐exposure prophylaxis (PEP), possibly leading to increased HIV transmission. Globally, services have reported a reduction in the number of PEP prescriptions dispensed during lockdowns, although it is unclear why. Our primary objective was to describe the temporal change in weekly HIV PEP dispensed at six English sexual health clinics in 2020.