Background Widely accessible, acceptable, equitable, HIV pre-exposure prophylaxis (PrEP) services are central to HIV transmission elimination. Multi-stakeholder collaboration, activism and government support enabled Scotland to implement a publicly-funded national PrEP programme delivered through sexual health services from 2017. Although innovations in PrEP implementation occur, they are rarely analysed or consolidated. We address this gap in Scotland by: 1) examining diverse perspectives on barriers and facilitators to the key steps of PrEP implementation (i.e., awareness, access, uptake, initiation, adherence and retention in care) and 2) using implementation science theories to systematically specify transferable ways to improve these steps. Method Semi-structured interviews and focus groups (2018–2019) with geographically and demographically diverse sexual health clinic patients seeking/using/declining or stopping PrEP (n=39), sexual healthcare professionals (n= 54), community-based organisation (CBO) service users (n=9) and staff (n=15). Thematic analysis identifying barriers and facilitators to implementing PrEP was complemented by analyses using the Behaviour Change Wheel to specify detailed recommendations for enhancing PrEP implementation. Results Barriers and Facilitators to the key steps ranged from: macrosocial (political will, competitive dynamics in the service ecology, structural racism); mesosocial (effective monitoring systems and reporting); to microsocial (staff skills and self-efficacy, low HIV literacy). Enhancing implementation across the key steps included: incentivising organisations to share expertise (funding mechanisms, equitable partnership work); targeted culturally sensitive, normalising and awareness-raising interventions; co-production of nationally co-ordinated training and patient resources (e.g. for managing side-effects, adherence support, improving cultural competencies); guidance for correct use of event-based PrEP; supporting PrEP provision in diverse settings to reach underserved communities. Conclusion Systematic analysis of what had and had not worked, and why has enabled development of wide-ranging but specific recommendations for policy-makers, clinicians, CBOs and individuals to optimise PrEP awareness, access, uptake, initiation, adherence and retention in care. These recommendations could be used to improve all PrEP services.

The objectives of this study were to describe the findings of anal cytology screening during the first year of a unit protocol offering yearly screening to all HIV-positive men who have sex with men (MSM). Of 285 patients seen, 75% were offered anal cytology screening. Sixty-two percent of patients offered screening accepted and 21% of anal smears performed were reported as abnormal. Anal cytology screening may lead to earlier detection of anal intraepithelial neoplasia allowing for treatment before progression to cancer. This study revealed potential difficulties in follow-up of patients with high-grade precancerous disease and highlighted potential resource implications of implementing a routine screening programme.

BackgroundThe effectiveness of condoms in preventing sexually transmitted infections (STI) including HIV depends on consistent and correct use.AimsTo examine associations between demographics, STI risk, condom proficiency, condom problems and STI acquisition among MSM and to direct discussion and debate towards thinking about how and why it might be important to improve condom use skills.MethodsCross-sectional surveys of MSM were conducted in GUM clinics and commercial gay venues in Summer 2010. The self-completed, anonymous questionnaires recorded data on socio-demographic variables, numbers of unprotected anal intercourse (UAI) partners in the preceding year, STIs diagnosed over the previous year and self-reported condom problems and condom proficiency.Results792 respondents provided data with an overall response rate of 70% (n=459 clinic sample, n=333 community). Number of UAI partners was the strongest predictor of self-reported STI acquisition over the previous 12 months. Demographic characteristics were not associated with self-reported STI diagnosis. However, condom proficiency score was associated with self-reported STI acquisition in the previous 12 months. Condom problem score was also associated with self-reported STI diagnosis in the clinic but not community sample. Condom problem score remained associated with STI diagnosis after adjusting for number of UAI partners with logistic regression.DiscussionThis study identified a measure of condom use associated with likelihood of STI diagnosis when controlling for number of UAI partners. Targeting those who experience condom problems may improve overall frequency and consistency of condom use among MSM; in turn reducing likelihood of STI acquisition. This could involve developing condom problem scales into screening tools for STI risk. Accordingly we encourage further research to determine the value of condom use training as a potential intervention to improve sexual health among MSM.

A national audit of practice performance against the key performance indicators in the British Association for Sexual Health and HIV (BASHH) and HIV Medical Foundation for AIDS Sexual Health Standards for the Management of Sexually Transmitted Infections (STIs) was conducted in 2011. Approximately 60% and 8% of level 3 and level 2 services, respectively, participated. Excluding partner notification performance, the five lowest areas of performance for level 3 clinics were the STI/HIV risk assessment, care pathways linking care in level 2 clinics to local level 3 services, HIV test offer to patients with concern about STIs, information governance and receipt of chlamydial test results by clinicians within seven working days (the worst area of performance). The five lowest areas of performance for level 2 clinics were participating in audit, having an audit plan for the management of STIs for 2009–2010, the STI/HIV risk assessment, HIV test offer to patients with concern about STIs and information governance. The results are discussed with regard to the importance of adoption of the standards by commissioners of services because of their relevance to other national quality assurance drivers, and the need for development of a national system of STI management quality assurance measurement and reporting.

In 2004, the British Association for Sexual Health and HIV Scottish Branch audited HIV testing in new attendees diagnosed with a sexually transmitted infection at genitourinary medicine clinics in Scotland. In 2008 the audit loop was completed. Large increases were seen in rates of test offer and uptake, particularly in health boards with low baseline levels of testing. Overall rates of testing remain below those recommended and wide variability between boards persists.

Peripheral neuropathy (PN) is common in the setting of antiretroviral (ARV) programmes in resource-limited settings and poses significant challenges in assessment and management. A retrospective analysis was undertaken of prevalence and management of PN in a cohort of 3341 patients on highly active antiretroviral therapy. A first line ARV regimen containing stavudine (D4T) is used for clinically eligible patients. Amitriptyline is prescribed for symptom relief and in cases of persistent or escalating symptoms zidovudine (AZT) is substituted for D4T. Leg pain or numbness was reported in 1173 patients (35%). However, only 428 (13%) were given a diagnosis of PN, 228 (7%) were prescribed amitriptyline and 200 (6%) were switched to AZT. A recent pharmokinetic study in this population showed a high C max of D4T with the generic combination triomune (D4T 40 mg). This could account for the high prevalence of PN. The optimum time for switch to a non-D4T containing regimen is unknown.

Genitourinary medicine clinic attendees who were newly diagnosed as HIV antibody positive in a population with low overall HIV prevalence were compared with HIV-ve control groups in a retrospective study. Demographics and clinical data from the clinic attendance at which the HIV test was performed were analysed. Of 25,627 HIV tests, 113 were positive. Seventy-eight percent had an identified risk factor for HIV and more than half had symptoms of, or were contacts of, a sexually transmitted infection (STI) or HIV. Only eight clients testing HIV+ve had attended for routine STI testing and only two of these had no identified risk factor. Groups shown to be at higher HIV risk included attendees with past history of STI, men-who-have-sex-with-men (MSM) and those requesting HIV test without an STI screen. MSM testing HIV-ve had high rates of HIV risk behaviour.