Subjective cognitive symptoms (brain fog, memory problems) are common in menopause, but whether these self-reported symptoms correspond to measurable deficits in cognition remains unclear. In 14,234 females (aged 45–55) from the REACT-Long Covid Study, we examined self-reported cognitive symptoms and objective cognitive performance in premenopausal, perimenopausal, postmenopausal participants. Global cognitive performance was derived from eight online tasks (‘Cognitron’). Perimenopausal (OR = 1.31 [1.18, 1.35], p = 0.015) and postmenopausal participants (OR = 1.13 [1.08, 1.32], p = 0.014) had higher odds of reporting cognitive symptoms than premenopausal participants. Objective cognitive performance differed minimally across menopause status groups, with perimenopausal participants showing marginally higher accuracy than premenopausal and postmenopausal participants (0.03–0.06 SD, p < 0.023). Across all menopause status groups, cognitive symptoms were weakly associated with objective performance but moderately related to psychological symptoms. These findings underscore recognising cognitive symptoms as a key component of menopausal care and integrating patient-reported outcomes with objective and biological measures of cognitive health.

Objectives The rapid spread of SARS-CoV-2 infection caused high levels of hospitalisation and deaths in late 2020 and early 2021 during the second wave in England. COVID-19 disease during this period was associated with marked health inequalities across ethnic and sociodemographic subgroups. In this paper, we aim to investigate and quantify inequalities in the risk of SARS-CoV-2 infection across ethnic and sociodemographic subgroups during a key period before widespread vaccination, thereby identifying the populations that bore a disproportionate burden of risk.Methods We analysed risk factors for test-positivity for SARS-CoV-2, based on self-administered throat and nose swabs in the community during rounds 5-10 of the REal-time Assessment of Community Transmission-1 (REACT-1) study between 18 September 2020 and 30 March 2021.Results Compared with the White ethnicity, people of Asian and the Black ethnicity had a higher risk of infection during rounds 5-10, with odds of 1.45 (1.27, 1.66) and 1.34 (1.11, 1.63), respectively, adjusted for demographic factors including age, sex, region, key work status, ethnicity and deprivation. Among ethnic subgroups, the highest and the second-highest odds were found in Bangladeshi and Pakistani participants at 3.28 (2.24, 4.80) and 2.12 (1.70, 2.64), respectively, when compared with the White British participants. People in larger (compared with smaller) households had higher odds of infection. Healthcare workers with direct patient contact and care home workers showed higher odds of infection compared with other essential/key workers. Additionally, the odds of infection among participants in public-facing activities or settings were greater than among those not working in those activities or settings.Conclusion Our findings highlight the differences in the risk of SARS-CoV-2 infection in a global north population during a period when the risk of infection was high, and there were substantial levels of social mixing. Planning for future waves of severe respiratory pathogens should include policies to reduce inequality in the risk of infection by ethnicity, household size and occupational activity in order to reduce inequality in disease.

Black women are among the populations most underserved by HIV pre-exposure prophylaxis (PrEP) in England, despite higher risk of HIV acquisition. Previous research mostly focused on men who have sex with men (MSM), often neglecting Black women, and overfocused on patient-level barriers while overlooking provider and system-level factors. This study addresses these gaps by investigating barriers and facilitators to PrEP access by involving multiple stakeholders and exploring co-design strategies to tackle these barriers. The study used a structured two-phased qualitative approach. In Phase 1, focus groups (FG) were undertaken across three stakeholder streams: Black women, healthcare professionals (HCPs), and a group combining Black women and HCPs. FG allowed for consensus-building exercises on key barriers and facilitators to PrEP access, and their transcripts were analysed via thematic framework analysis using the Capability, Opportunity, Motivation and Behaviour model of behaviour change. In Phase 2, co-design workshops were conducted with the same stakeholder groups to develop interventions targeting the barrier identified as most important using the Behaviour Change Wheel framework. Interventions were evaluated against the APEASE criteria. Phase 1 identified six key barriers: HIV/PrEP knowledge gaps, restrictive policies, cultural stigma, healthcare system distrust, gendered relationship dynamics, and suboptimal PrEP use. Six facilitators emerged, including improved knowledge, increased accessibility, and addressing discrimination. All stakeholder groups voted for lack of awareness and knowledge as the priority barrier to address. All co-designed interventions consisted of a multimodal PrEP awareness campaign tailored to Black communities, with an emphasis on Black women’s involvement to foster trust and engagement. However, the workshops produced different approaches, with Black women focusing on community-led initiatives, and HCPs advocating for government-backed, broader strategies despite known distrust of institutions. This study highlights the importance of co-designing interventions with Black women to address multi-level barriers to PrEP access. It underscores the need for community education, healthcare system reforms, and the inclusion of Black women in decision-making processes to reduce PrEP equity gaps. The co-designed interventions provided a tailored, context-specific strategy that could improve PrEP uptake among Black women in England.

Objective To determine how people in England changed their infection risk-related behaviours during the COVID-19 pandemic and in response to control measures, 19 June 2020 to 31 March 2022.Design Over 18 (of 19) rounds, randomly selected participants across England completed a questionnaire about risk-related behaviours, sociodemographics and symptoms.Participants Between 85 018 and 154 060 randomly selected participants per round, aged 5+ years, totalling 2 177 657 responses with relevant data.Main outcome measures Primary outcomes were self-reported shielding and/or taking specific precautions, not leaving home in the prior week, not being in close proximity with anyone outside their household the day before and wearing face coverings outside the home. Secondary community-level measures of mobility and public health policy stringency were compared with the primary outcomes to provide population-level context to the observed findings.Results Infection risk-related behaviours varied considerably over the nearly 2 years under study. Protective behaviours peaked in January 2021, during England’s winter wave, before widespread vaccination. At that time, the estimated proportion of self-reported shielding and/or taking specific precautions reached 21.6% (95% CI 21.4% to 21.8%), of self-reported not leaving home in the week prior to completing the questionnaire reached 7.99% (95% CI 7.85% to 8.13%) and of self-reported not having contact with anyone outside their household on the day before answering the questionnaire reached 89.2% (95% CI 89.1% to 89.4%). As self-reported vaccination rates increased and prevalence of infection decreased, protective behaviours decreased, although patterns varied by demographics. Protective behaviours were strongly correlated with community-level mobility data and the stringency of public health measures.Conclusions Individual-based data showed sizeable proportions of people undertook protective behaviours during the pandemic, especially during the second lockdown in January 2021, although there was evidence of ‘pandemic fatigue’ in the study’s later stages. Self-reported behaviours were closely aligned with community mobility data and the stringency of government policies, indicating policy-driven behavioural changes.

Background High response rates are needed in population-based studies, as nonresponse reduces effective sample size and bias affects accuracy and decreases the generalizability of the study findings. Objective We tested different strategies to improve response rate and reduce nonresponse bias in a national population–based COVID-19 surveillance program in England, United Kingdom. Methods Over 19 rounds, a random sample of individuals aged 5 years and older from the general population in England were invited by mail to complete a web-based questionnaire and return a swab for SARS-CoV-2 testing. We carried out several nested randomized controlled experiments to measure the impact on response rates of different interventions, including (1) variations in invitation and reminder letters and SMS text messages and (2) the offer of a conditional monetary incentive to return a swab, reporting absolute changes in response and relative response rate (95% CIs). Results Monetary incentives increased the response rate (completed swabs returned as a proportion of the number of individuals invited) across all age groups, sex at birth, and area deprivation with the biggest increase among the lowest responders, namely teenagers and young adults and those living in more deprived areas. With no monetary incentive, the response rate was 3.4% in participants aged 18‐22 years, increasing to 8.1% with a £10 (US $12.5) incentive, 11.9% with £20 (US $25.0), and 18.2% with £30 (US $37.5) (relative response rate 2.4 [95% CI 2.0-2.9], 3.5 [95% CI 3.0-4.2], and 5.4 [95% CI 4.4-6.7], respectively). Nonmonetary strategies had a modest, if any, impact on response rate. The largest effect was observed for sending an additional swab reminder (SMS text message or email). For example, those receiving an additional SMS text message were more likely to return a completed swab compared to those receiving the standard email-SMS approach, 73.3% versus 70.2%: percentage difference 3.1% (95% CI 2.2%-4.0%). Conclusions Conditional monetary incentives improved response rates to a web-based survey, which required the return of a swab test, particularly for younger age groups. Used in a selective way, incentives may be an effective strategy for improving sample response and representativeness in population-based studies.

Objectives HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP. Methods Aggregated numbers of people receiving >= 1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England. Results PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning. Conclusions Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.

An outbreak of SARS-CoV-2 (1 March to 10 May 2021) with an attack rate of 26.5% among approximately 1150 workers at a storage and distribution centre in England prompted a multidisciplinary outbreak investigation (5 May to 6 August 2021), with the aim of better understanding worker- and workplace-related risk factors for viral transmission in the warehousing sector. Overall, environmental factors (e.g., ventilation, humidity and temperature) were assessed to be appropriate at the facility. Nevertheless, 39 (51.3%) surface samples from across the site tested positive for low/ very low levels of SARS-CoV-2 RNA (Ct value ≥ 32.0 for all). Among the study participants, of whom 35.6% were confirmed or suspected cases, 95.5% reported having received COVID-19 prevention training, 100.0% reported handwashing, and 80.0% reported use of face coverings at work. Notably, 43.9% and 19.0% reported working with a symptomatic and a positive contact respectively. Furthermore, 80.5% and 46.3% had concerns regarding reduction in their income and future unemployment, respectively, due to self-isolation. The findings of this study suggest that, in addition to targeted workplace infection control measures and tailored work area specific risk assessments, an enhanced and equitable sick leave policy may help limit presenteeism and viral transmission in large workplaces.

Genomic surveillance for SARS-CoV-2 lineages informs our understanding of possible future changes in transmissibility and vaccine efficacy and will be a high priority for public health for the foreseeable future. However, small changes in the frequency of one lineage over another are often difficult to interpret because surveillance samples are obtained using a variety of methods all of which are known to contain biases. As a case study, using an approach which is largely free of biases, we here describe lineage dynamics and phylogenetic relationships of the Alpha and Beta variant in England during the first 3 months of 2021 using sequences obtained from a random community sample who provided a throat and nose swab for rt-PCR as part of the REal-time Assessment of Community Transmission-1 (REACT-1) study. Overall, diversity decreased during the first quarter of 2021, with the Alpha variant (first identified in Kent) becoming predominant, driven by a reproduction number 0.3 higher than for the prior wild-type. During January, positive samples were more likely to be Alpha in those aged 18 to 54 years old. Although individuals infected with the Alpha variant were no more likely to report one or more classic COVID-19 symptoms compared to those infected with wild-type, they were more likely to be antibody-positive 6 weeks after infection. Further, viral load was higher in those infected with the Alpha variant as measured by cycle threshold (Ct) values. The presence of infections with non-imported Beta variant (first identified in South Africa) during January, but not during February or March, suggests initial establishment in the community followed by fade-out. However, this occurred during a period of stringent social distancing. These results highlight how sequence data from representative community surveys such as REACT-1 can augment routine genomic surveillance during periods of lineage diversity.

OBJECTIVES:HIV pre-exposure prophylaxis (PrEP) delivery in the UK is inequitable; over 95% of PrEP users were men who have sex with men (MSM) despite making up less than 50% of new HIV diagnoses. We conducted a systematic review to identify modifiable barriers and facilitators to PrEP delivery in the UK among underserved populations. METHODS:We searched bibliographic/conference databases using the terms HIV, PrEP, barriers, facilitators, underserved populations, and UK. Modifiable factors were mapped along the PrEP Care Continuum (PCC) to identify targets for interventions. RESULTS:In total, 44 studies were eligible: 29 quantitative, 12 qualitative and three mixed-methods studies. Over half (n = 24 [54.5%]) exclusively recruited MSM, whereas 11 were in mixed populations (all included MSM as a sub-population) and the other nine were in other underserved populations (gender and ethnicity minorities, women, and people who inject drugs). Of the 15 modifiable factors identified, two-thirds were at the PrEP contemplation and PrEParation steps of the PCC. The most reported barriers were lack of PrEP awareness (n = 16), knowledge (n = 19), willingness (n = 16), and access to a PrEP provider (n = 16), whereas the more reported facilitators were prior HIV testing (n = 8), agency and self-care (n = 8). All but three identified factors were at the patient rather than provider or structural level. CONCLUSIONS:This review highlights that the bulk of the scientific literature focuses on MSM and on patient-level factors. Future research needs to ensure underserved populations are included and prioritized (e.g. ethnicity and gender minorities, people who inject drugs) and provider and structural factors are investigated.

BACKGROUND:A SARS-CoV-2 outbreak with an attack rate of 14.3% was reported at a plastics manufacturing plant in England.METHODS:Between 23rd March and 13th May 2021, the COVID-OUT team undertook a comprehensive outbreak investigation, including environmental assessment, surface sampling, molecular and serological testing, and detailed questionnaires, to identify potential SARS-CoV-2 transmission routes, and workplace- and worker-related risk factors.RESULTS:While ventilation, indicated using real-time CO2 proxy measures, was generally adequate on-site, the technical office with the highest localized attack rate (21.4%) frequently reached peaks in CO2 of 2100ppm. SARS-CoV-2 RNA was found in low levels (Ct ≥35) in surface samples collected across the site. High noise levels (79dB) were recorded in the main production area, and study participants reported having close work contacts (73.1%) and sharing tools (75.5%). Only 20.0% of participants reported using a surgical mask and/or FFP2/FFP3 respirator at least half the time and 71.0% expressed concerns regarding potential pay decreases and/or unemployment due to self-isolation or workplace closure.CONCLUSIONS:The findings reinforce the importance of enhanced infection control measures in manufacturing sectors, including improved ventilation with possible consideration of CO2 monitoring, utilising air cleaning interventions in enclosed environments, and provision of good-quality face masks (i.e., surgical masks or FFP2/FFP3 respirators) especially when social distancing cannot be maintained. Further research on the impacts of job security-related concerns is warranted.

The value of SARS-CoV-2 lateral flow immunoassay (LFIA) tests for estimating individual disease risk is unclear. The REACT-2 study in England, UK, obtained self-administered SARS-CoV-2 LFIA test results from 361,801 adults in January-May 2021. Here, we link to routine data on subsequent hospitalisation (to September 2021), and death (to December 2021). Among those who had received one or more vaccines, a negative LFIA is associated with increased risk of hospitalisation with COVID-19 (HR: 2.73 [95% confidence interval: 1.15,6.48]), death (all-cause) (HR: 1.59, 95% CI:1.07, 2.37), and death with COVID-19 as underlying cause (20.6 [1.83,232]). For people designated at high risk from COVID-19, who had received one or more vaccines, there is an additional risk of all-cause mortality of 1.9 per 1000 for those testing antibody negative compared to positive. However, the LFIA does not provide substantial predictive information over and above that which is available from detailed sociodemographic and health-related variables. Nonetheless, this simple test provides a marker which could be a valuable addition to understanding population and individual-level risk.

Data System. The REal-time Assessment of Community Transmission-1 (REACT-1) Study was funded by the Department of Health and Social Care in England to provide reliable and timely estimates of prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection over time, by person and place. Data Collection/Processing. The study team (researchers from Imperial College London and its logistics partner Ipsos) wrote to named individuals aged 5 years and older in random cross-sections of the population of England, using the National Health Service list of patients registered with a general practitioner (near-universal coverage) as a sampling frame. We collected data over 2 to 3 weeks approximately every month across 19 rounds of data collection from May 1, 2020, to March 31, 2022. Data Analysis/Dissemination. We have disseminated the data and study materials widely via the study Web site, preprints, publications in peer-reviewed journals, and the media. We make available data tabulations, suitably anonymized to protect participant confidentiality, on request to the study’s data access committee. Public Health Implications. The study provided inter alia real-time data on SARS-CoV-2 prevalence over time, by area, and by sociodemographic variables; estimates of vaccine effectiveness; and symptom profiles, and detected emergence of new variants based on viral genome sequencing. (Am J Public Health. 2023;113(5):545–554. https://doi.org/10.2105/AJPH.2023.307230 )

Objective To estimate the prevalence of, and associated risk factors for, persistent symptoms post-COVID-19 among children aged 5–17 years in England. Design Serial cross-sectional study. Setting Rounds 10–19 (March 2021 to March 2022) of the REal-time Assessment of Community Transmission-1 study (monthly cross-sectional surveys of random samples of the population in England). Study population Children aged 5–17 years in the community. Predictors Age, sex, ethnicity, presence of a pre-existing health condition, index of multiple deprivation, COVID-19 vaccination status and dominant UK circulating SARS-CoV-2 variant at time of symptom onset. Main outcome measures Prevalence of persistent symptoms, reported as those lasting ≥3 months post-COVID-19. Results Overall, 4.4% (95% CI 3.7 to 5.1) of 3173 5–11 year-olds and 13.3% (95% CI 12.5 to 14.1) of 6886 12–17 year-olds with prior symptomatic infection reported at least one symptom lasting ≥3 months post-COVID-19, of whom 13.5% (95% CI 8.4 to 20.9) and 10.9% (95% CI 9.0 to 13.2), respectively, reported their ability to carry out day-to-day activities was reduced ‘a lot’ due to their symptoms. The most common symptoms among participants with persistent symptoms were persistent coughing (27.4%) and headaches (25.4%) in children aged 5–11 years and loss or change of sense of smell (52.2%) and taste (40.7%) in participants aged 12–17 years. Higher age and having a pre-existing health condition were associated with higher odds of reporting persistent symptoms. Conclusions One in 23 5–11 year-olds and one in eight 12–17 year-olds post-COVID-19 report persistent symptoms lasting ≥3 months, of which one in nine report a large impact on performing day-to-day activities.

Background Long COVID is a patient-made term describing new or persistent symptoms experienced following SARS-CoV-2 infection. The Real-time Assessment of Community Transmission-Long COVID (REACT-LC) study aims to understand variation in experiences following infection, and to identify biological, social, and environmental factors associated with Long COVID. We undertook a pilot interview study to inform the design, recruitment approach, and topic guide for the REACT-LC qualitative study. We sought to gain initial insights into the experience and attribution of new or persistent symptoms and the awareness or perceived applicability of the term Long COVID. Methods People were invited to REACT-LC assessment centres if they had taken part in REACT, a random community-based prevalence study, and had a documented history of SARS-CoV-2 infection. We invited people from REACT-LC assessment centres who had reported experiencing persistent symptoms for more than 12 weeks to take part in an interview. We conducted face to face and online semi-structured interviews which were transcribed and analysed using Thematic Analysis. Results We interviewed 13 participants (6 female, 7 male, median age 31). Participants reported a wide variation in both new and persistent symptoms which were often fluctuating or unpredictable in nature. Some participants were confident about the link between their persistent symptoms and COVID-19; however, others were unclear about the underlying cause of symptoms or felt that the impact of public health measures (such as lockdowns) played a role. We found differences in awareness and perceived applicability of the term Long COVID. Conclusion This pilot has informed the design, recruitment approach and topic guide for our qualitative study. It offers preliminary insights into the varied experiences of people living with persistent symptoms including differences in symptom attribution and perceived applicability of the term Long COVID. This variation shows the value of recruiting from a nationally representative sample of participants who are experiencing persistent symptoms.

ABSTRACT Background The COVID-19 pandemic is having a lasting impact on health and well-being. We compare current self-reported health, quality of life and symptom profiles for people with ongoing symptoms following COVID-19 to those who have never had COVID-19 or have recovered. Methods A cohort study was established with participants from the REACT programme. A sample (N=800,000) of adults were contacted between August and December 2022 to complete a questionnaire about their current health and COVID-19 history. We used logistic regression to identify predictors of persistent symptoms lasting ≥12 weeks following COVID-19. We fitted Accelerated Failure Time models to assess factors associated with rate of recovery from persistent symptoms. Findings Overall, 276,840/800,000 (34.6%) of invited participants completed the questionnaire. Median duration of COVID-related symptoms (N=130,251) was 1.3 weeks (inter-quartile range 6 days to 2 weeks), with 7.5% and 5.2% reporting ongoing symptoms ≥12 weeks and ≥52 weeks respectively. Female sex, having ≥1 comorbidity, more severe symptoms at time of COVID-19 and being infected when Wild-type variant was dominant were associated with higher probability of symptoms lasting ≥12 weeks. Longer time to recovery in those with persistent symptoms was found for females, people with comorbidities, living in more deprived areas, current smokers and for Wild-type compared to later variants. Mental health and health-related quality of life were significantly worse among participants with ongoing persistent COVID-19 symptoms compared with those who had never had COVID-19 or had recovered. Interpretation Although COVID-19 is usually of short duration, some adults experience persistent and burdensome illness. Funding This work is independent research funded by the National Institute for Health and Care Research (NIHR) (REACT Long COVID (REACT-LC) (COV-LT-0040)). This research is part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation (UKRI) (MC_PC_20029). The views expressed in this publication are those of the author(s) and not necessarily those of NIHR or UKRI.

ABSTRACTBackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody lateral flow immunoassays (LFIA) can be carried out in the home and have been used as an affordable and practical approach to large-scale antibody prevalence studies. However, assay performance differs from that of high-throughput laboratory-based assays which can be highly sensitive. We explore LFIA performance under field conditions compared to laboratory-based ELISA and assess the potential of LFIAs to identify people who lack functional antibodies following infection or vaccination.MethodsField evaluation of a self-administered LFIA test (Fortress, NI) among 3758 participants from the REal-time Assessment of Community Transmission-2 (REACT-2) study in England selected based on vaccination history and previous LFIA result to ensure a range of antibody titres. In July 2021, participants performed, at home, a self-administered LFIA on finger-prick blood, reported and submitted a photograph of the result, and provided a self-collected capillary blood sample (Tasso-SST) for serological assessment of IgG antibodies to the spike protein using the Roche Elecsys® Anti-SARS-CoV-2 assay. We compared the self-administered and reported LFIA result to the quantitative Roche assay and checked the reading of the LFIA result with an automated image analysis (ALFA). In a subsample of 250 participants, we compared the results to live virus neutralisation.ResultsAlmost all participants (3593/3758, 95.6%) had been vaccinated or reported prior infection, with most having received one (862, 22.9%) or two (2430, 64.7%) COVID-19 vaccine doses. Overall, 2777/3758 (73.9%) were positive on self-reported LFIA, 2811/3457 (81.3%) positive by LFIA when ALFA-reported, and 3622/3758 (96.4%) positive on Roche anti-S (using the manufacturer reference standard threshold for positivity of 0.8 U ml-1). Live virus neutralisation was detected in 169 of 250 randomly selected samples (67.6%); 133/169 were positive with self-reported LFIA (sensitivity 78.7%; 95% CI 71.8, 84.6), 142/155 (91.6%; 86.1, 95.5) with ALFA, and 169 (100%; 97.8, 100.0) with Roche anti-S. There were 81 samples with no detectable virus neutralisation; 47/81 were negative with self-reported LFIA (specificity 58.0%; 95% CI 46.5, 68.9), 34/75 (45.3%; 33.8, 57.3) with ALFA, and 0/81 (0%; 0.0, 4.5) with Roche anti-S. All 250 samples remained positive with Roche anti-S when the threshold was increased to 1000U ml-1.ConclusionsSelf-administered LFIA can provide insights into population patterns of infection and vaccine response, and sensitivity can be improved with automated reading of the result. The LFIA is less sensitive than a quantitative antibody test, but the positivity in LFIA correlates better than the quantitative ELISA with virus neutralisation.

Introduction In England, 96% of PrEP Impact Trial (2017–2020) participants were men who have sex with men, despite accounting for <50% of new HIV diagnoses. The PrEP-to-need ratio (PnR; no. PrEP users divided by new HIV diagnoses) has been used elsewhere to explore PrEP use inequity. We used this ecological metric to investigate whether PrEP access equity improved following expanded commissioning in 2020. Method We requested the number of people receiving ≥1 NHS PrEP prescription from GUMCAD (combined with Impact database pre-commissioning), and non-late new HIV diagnoses (epidemiological proxy for PrEP need) from HARS. We calculated the PnR across socio-demographic factors during Impact (Oct-2017 to Feb-2020) and post-commissioning PrEP era (2021) in England. Results The overall PnR increased >11-fold pre-commissioning (PnR=3.0) to 2021 (PnR=34.2) as new HIV diagnoses dropped 4-fold while PrEP users increased 3-fold. However, while the PnR increased 12-fold (from 3.9 to 46.1) amongst all men, it increased <6-fold (0.4 to 2.3) in women (Table 1). This increasing gender equity gap was observed across age, ethnicity, and region of residence: White men had the highest PnR across periods and increased 14-fold (5.3 to 75.0) as 2.7 times as many used PrEP in 2021; meanwhile, Black African women consistently had the lowest PnR across time; doubling (0.1 to 0.2) as 1.1 times as many used PrEP in 2021 i.e. White men’s PnR was 53-fold higher than Black women’s pre-commissioning, increasing to 375-fold post-commissioning. Discussion HIV combination prevention should be guided by equity metrics relative to the HIV epidemic. While there is no set PrEP use threshold required to achieve targets of HIV incidence reduction, we demonstrated large PrEP equity gaps across gender and ethnicity pre- to post-commissioning, similarly to other HIV prevention and treatment outcomes. The PnR can support the optimisation of combination prevention to reach the Government’s aim to stop HIV transmissions by 2030.

The COVID-19 pandemic is having a lasting impact on health and well-being. We compare current self-reported health, quality of life and symptom profiles for people with ongoing symptoms following COVID-19 to those who have never tested positive for SARS-CoV-2 infection and those who have recovered from COVID-19. Overall, 276,840/800,000 (34·6%) of invited participants took part. Mental health and health-related quality of life were worse among participants with ongoing persistent symptoms post-COVID compared with those who had never had COVID-19 or had recovered. In this study, median duration of COVID-related symptoms (N = 130,251) was 1·3 weeks (inter-quartile range 6 days to 2 weeks), with 7·5% and 5·2% reporting ongoing symptoms ≥12 weeks and ≥52 weeks respectively. Female sex, ≥1 comorbidity and being infected when Wild-type variant was dominant were associated with higher probability of symptoms lasting ≥12 weeks and longer recovery time in those with persistent symptoms. Although COVID-19 is usually of short duration, some adults experience persistent and burdensome illness.

The relationship between prevalence of infection and severe outcomes such as hospitalisation and death changed over the course of the COVID-19 pandemic. Reliable estimates of the infection fatality ratio (IFR) and infection hospitalisation ratio (IHR) along with the time-delay between infection and hospitalisation/death can inform forecasts of the numbers/timing of severe outcomes and allow healthcare services to better prepare for periods of increased demand. The REal-time Assessment of Community Transmission-1 (REACT-1) study estimated swab positivity for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in England approximately monthly from May 2020 to March 2022. Here, we analyse the changing relationship between prevalence of swab positivity and the IFR and IHR over this period in England, using publicly available data for the daily number of deaths and hospitalisations, REACT-1 swab positivity data, time-delay models, and Bayesian P-spline models. We analyse data for all age groups together, as well as in 2 subgroups: those aged 65 and over and those aged 64 and under. Additionally, we analysed the relationship between swab positivity and daily case numbers to estimate the case ascertainment rate of England's mass testing programme. During 2020, we estimated the IFR to be 0.67% and the IHR to be 2.6%. By late 2021/early 2022, the IFR and IHR had both decreased to 0.097% and 0.76%, respectively. The average case ascertainment rate over the entire duration of the study was estimated to be 36.1%, but there was some significant variation in continuous estimates of the case ascertainment rate. Continuous estimates of the IFR and IHR of the virus were observed to increase during the periods of Alpha and Delta's emergence. During periods of vaccination rollout, and the emergence of the Omicron variant, the IFR and IHR decreased. During 2020, we estimated a time-lag of 19 days between hospitalisation and swab positivity, and 26 days between deaths and swab positivity. By late 2021/early 2022, these time-lags had decreased to 7 days for hospitalisations and 18 days for deaths. Even though many populations have high levels of immunity to SARS-CoV-2 from vaccination and natural infection, waning of immunity and variant emergence will continue to be an upwards pressure on the IHR and IFR. As investments in community surveillance of SARS-CoV-2 infection are scaled back, alternative methods are required to accurately track the ever-changing relationship between infection, hospitalisation, and death and hence provide vital information for healthcare provision and utilisation.