Men who have sex with men (MSM) attending sexual health (SH) clinics are at high risk for HIV acquisition and are disproportionately affected by sexually transmitted infections (STIs). We collected standardised behavioural data from MSM attending clinics to characterise sexual behaviours and identify predictors for HIV and STIs. In 2012–2013, HIV-negative MSM attending five SH clinics in England reported sexual behaviours in the previous three months via a self-administered questionnaire. Behaviours were linked to the individual’s clinical records using national surveillance. The prevalence and incidence of bacterial STIs (gonorrhoea, Chlamydia, lymphogranuloma venereum and syphilis) and incidence of HIV were calculated. Adjusted odds ratios and hazard ratios with 95% confidence interval (CI) were reported for significant predictors. Of 1278 HIV-negative MSM, 54% were of white ethnicity and UK-born and 43% were 25–34 years old. Almost all men reported at least one partner in the last three months. Half reported condomless anal sex and 36% condomless receptive anal intercourse (CRAI). Incidence of bacterial STIs was 46/100 (95%CI 39–54) person years (py) and of HIV was 3.1/100 (95%CI 1.7–5.6) py. A STI at baseline and CRAI with increasing numbers of partners were associated with both incident infections. In this cohort of MSM high-risk behaviours and STIs were prevalent. Engagement in CRAI increased the likelihood of subsequent infection, while men diagnosed with a bacterial STI were at increased risk of a future STI. Clinical and behavioural risk assessments to determine an individual’s risk of infection could allow a more nuanced prevention approach that has greater success in reducing transmission.

ABSTRACT Triple-site testing (using pharyngeal, rectal, and urethral/first-void urine samples) for Neisseria gonorrhoeae and Chlamydia trachomatis using nucleic acid amplification tests detects greater numbers of infections among men who have sex with men (MSM). However, triple-site testing represents a cost pressure for services. MSM over 18 years of age were eligible if they requested testing for sexually transmitted infections (STIs), reported recent sexual contact with either C. trachomatis or N. gonorrhoeae , or had symptoms of an STI. Each patient underwent standard-of-care (SOC) triple-site testing, and swabs were taken to form a pooled sample (PS) (pharyngeal, rectal, and urine specimens). The PS was created using two methods during different periods at one clinic, but we analyzed the data in combination because the sensitivity of the two methods did not differ significantly for C. trachomatis ( P = 0.774) or N. gonorrhoeae ( P = 0.163). The sensitivity of PS testing (92%) was slightly lower than that of SOC testing (96%) for detecting C. trachomatis ( P = 0.167). For N. gonorrhoeae , the sensitivity of PS testing (90%) was significantly lower than that of SOC testing (99%) ( P < 0.001). When pharynx-only infections were excluded, the sensitivity of PS testing to detect N. gonorrhoeae infections increased to 94%. Our findings show that pooling of self-taken samples could be an effective and cost-saving method, with high negative predictive values. (Interim results of this study were presented at the BASHH 2013 summer meeting.)

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.

Background HIV testing can reduce undiagnosed and late HIV diagnosis. We examine trends between 2000–2013 of overall and undiagnosed HIV prevalence, HIV testing among men who have sex with men (MSM), and factors associated with undiagnosed HIV. Methods Repeat cross-sectional anonymous behavioural surveys with oral specimens for HIV antibody (Ab) testing were conducted in community venues in London. Participants were treated as undiagnosed HIV+ if they tested HIV Ab+, and had never tested for HIV, last tested or perceived themselves as HIV negative, or did not know their HIV status. Undiagnosed fraction is the proportion of undiagnosed HIV Ab+ results of the total number of HIV Ab+ results. Trends between 2000–2013 and factors associated with undiagnosed HIV (2011 and 2013 data) were examined using logistic regression. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. Results The majority of the 11876 participants included in the analysis were White, employed, and median age was 33 years. In 2013, overall and undiagnosed HIV prevalence was 13.6% (106/782) and 3.2% (25/782) respectively. Overall undiagnosed fraction remained unchanged: 34% (45/131) in 2000 and 24% (25/106) in 2013. Undiagnosed fraction among sexual health clinic non-attenders in last year remained unchanged: 62% (23/37) in 2000; 59% (10/17) in 2013. HIV testing in the last year increased: 26% (263/997) to 60% (467/777); among undiagnosed HIV+ men, it increased from 28.6% (10/35) to 66.7% (16/24). Compared to men aged >45, men aged 15–25 (AOR: 7.47, 95% CI: 1.56–35.74); compared to sexual health clinic attenders in the last year, non-sexual health clinic attenders (AOR: 4.39, 95% CI: 1.90–10.16) were more likely to have undiagnosed HIV. Conclusions HIV testing has increased yet undiagnosed HIV remains unchanged. Strategies to increase HIV testing among young MSM and in non-sexual health clinics should be developed and evaluated. Declaration of interest statement AMJ has been a Governor of the Wellcome Trust since 2011. The other authors declare that they have no conflicts of interest.

There is currently no ‘gold standard’ for diagnosis of latent tuberculosis infection (LTBI), and both the tuberculin skin test and interferon-gamma release assays (IGRAs) are used for diagnosis; the latter have a higher sensitivity than tuberculin skin tests for diagnosis of LTBI in HIV-infected individuals with lower CD4 counts. No evidence base exists for selection of IGRA methodology to identify LTBI among human immunodeficiency virus-infected patients in the UK. We prospectively evaluated two commercially available IGRA methods (QuantiFERON-TB Gold In Tube [QFG] and T-SPOT.TB) for testing LTBI among HIV-infected patients potentially nosocomially exposed to an HIV-infected patient with ‘smear-positive’ pulmonary tuberculosis. Among the exposed patients median CD4 count was 550 cells/µL; 105 (90%) of 117 were receiving antiretroviral therapy, of who 104 (99%) had an undetectable plasma HIV load. IGRAs were positive in 12 patients (10.3%); QFG positive in 11 (9.4%) and T-SPOT.TB positive in six (5.1%); both IGRAs were positive in five patients (4.3%). There was one indeterminate QFG and one borderline T-SPOT.TB result. Concordance between the two IGRAs was moderate ( κ = 0.56, 95% confidence interval = 0.27–0.85). IGRAs were positive in only 4 (29%) of 14 patients with previous culture-proven tuberculosis. No patient developed tuberculosis during 20 months of follow-up.

Background Men who have sex with men (MSM) remain most at risk of acquiring HIV in the UK. While biomedical prevention methods, such as Pre-Exposure Prophylaxis (PrEP), present new prevention opportunities, questions remain over their acceptability and fit with existing prevention strategies and HIV risk management, including regular HIV testing. Here, we investigate the HIV testing behaviours and willingness to use PrEP among MSM in the UK. Methods Cross-sectional surveys of HIV-negative MSM in gay social venues in Edinburgh, Glasgow and London in 2011 (N = 2222). Results 53.2% (1177/2214) of participants had had an HIV test in the previous 12 months and 29.6% (642/2167) reported 4+ named HIV tests in the last two years. 48.2% (1070/2221) reported that their most recent HIV test was a regular test or sexual health check. Among men at higher risk of HIV infection (reporting unprotected anal intercourse [UAI] with multiple, casual or unknown/discordant partners), 40.2% (343/854) reported regular testing. Half of all participants would be willing to take PrEP on a daily basis (52.3%, 1133/2166). In all three cities, willingness to take PrEP was associated with younger age and higher levels of sexual risk behaviour (UAI with multiple, casual or unknown/discordant partners in Edinburgh and Glasgow and UAI with casual partners in London), but with testing for HIV or other sexually transmitted infections (STIs) in the previous 12 months in Edinburgh and Glasgow only. Conclusion PrEP could provide a new method of biomedical HIV prevention for men at high risk of acquiring infection, and there is a willingness to engage with this among MSM in the UK. However, this would require a level of frequent HIV testing beyond that currently reported by men at high risk. The potentially complex relationship between sexual risk behaviour, HIV testing, and PrEP use requires further research.

BackgroundAPTIMA Combo 2 (AC2) reliably detectsChlamydia trachomatis(CT) andNeisseria gonorrhoeae(NG) at extra-genital sites in men who have sex with men (MSM), but testing three separate samples (pharynx, urethra, rectum) is costly. Self-taken pharyngeal and rectal samples can be added to first-void urine (FVU) and tested as a single pooled sample (PS). We compared the sensitivity of PS with individual sample testing (SOC), and its acceptability to patients. In addition sample processing methods were compared (Method A: swabs and FVU into universal container to laboratory; Method B: APTIMA urine tube spiked with swabs to laboratory).MethodsMSM (symptomatic or CT/NG contacts) were recruited at two clinics. All were tested by PS and SOC; order of sampling was randomised. Demographics, sexual behaviour, symptoms, signs and acceptability were collected. Any positive AC2 test was considered a true positive. Each clinic used one processing method (not randomised).Results627/700 planned MSM recruited to date (43% HIV+); 65% symptomatic; 43% unprotected anal sex in the last month. 94 CT and 189 NG infections were detected (prevalence of CT and/or NG 46%; dual infection 6%). The sensitivity of PS and SOC to detect CT and NG was 92% and 96% respectively (p = 0.68). PS failed to detect 22 infections (CT = 6; 1 pharynx, 4 rectum, 1 urethra, and NG = 16; 11 pharynx, 4 rectum, 1 urethral).MethodA was used in 20/22 (91%) of missed cases; 21/22 (95%) were positive at a single site. SOC failed to detect 4 infections (CT = 3, NG = 1). 90% of MSM found self-taken sampling acceptable; 85% (n = 532) would be happy to take their own samples at home.ConclusionPS compares well with SOC. It offers the potential for significant cost savings and easier home testing. Missed infections may be due to the method of sample processing or low organism numbers.Abstract O18.2 Table 1Infection (N = 626)NG(Prevalence 15%, N = 94)CT(Prevalence 31%, N = 191)Overall Sensitivity % (95% CI)PS: 92 (87–93)SOC:99 (97–100)Overall Sensitivity % (95% CI)PS: 96 (90–98)SOC:98 (93–99)Method A%(95% CI%)N = 460PS: 90(82–93)SOC:99(96–100)Method A %(95% CI%)N = 460PS: 94 (86–98)SOC:97 (90–99)Method B % (95% CI%)N = 166PS: 96(87–99)SOC:100(93–100)Method B % (95% CI%)N = 166PS: 100(87–100)SOC:100(87–100)

Objectives For the last 10 years there has been an epidemic of hepatitis C virus (HCV) infection in men who have sex with men (MSM) in Europe, North America and Australia. The majority of those infected are also HIV-positive and it is unclear to what extent HIV-negative MSM are also at increased risk of infection with HCV. This study provides the first examination of the association between HIV and hepatitis C serostatus in a sample of MSM recruited in community settings.Methods A total of 1121 participants completed a short questionnaire in 2008/2009 giving demographic and behavioural data, and donated a sample of oral fluid that was subsequently tested for antibodies to selected pathogens (HIV, syphilis and HCV).Results The seroprevalence of hepatitis C antibody was 2.1% [95% confidence interval (CI) 1.4-3.2%]. It was more common in those with HIV infection [7.7% (95% CI 4.2-12.9%) vs. 1.2% (95% CI 0.6-2.1%) in those without HIV infection; P<0.001], those with a history of syphilis [12.2% (95% CI 4.6-24.8%) vs. 1.7% (95% CI 1.0-2.6%) in those without such a history; P<0.001] and those who reported casual unprotected anal intercourse in the previous year [4.1% (95% CI 2.0-7.4%) vs. 1.2% (95% CI 0.5-2.2%) in those who did not report such intercourse; P=0.01]. There was no relationship between hepatitis C antibody (anti-HCV) status and other demographic variables (age, ethnicity, employment status or education).Conclusions The seroprevalence of anti-HCV in HIV-negative MSM (1.2%) was higher, but not significantly higher, than that in the general population (0.67%). The prevalence was significantly higher in those infected with HIV or with previous syphilis infection and in those reporting unprotected anal intercourse. Our findings support current British Association for Sexual Health and HIV guidelines recommending the provision of selective HCV testing in MSM according to individual risk profile.

Background APTIMA Combo 2 (AC2) performs well for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) from extra-genital sites in high prevalence groups such as men who have sex with men (MSM), but testing three samples (pharynx, urethra and rectum) is a significant cost pressure for services. Aims To determine the; (1) Performance of AC2 to detect CT and NG from a pooled specimen: self-taken pharyngeal and rectal samples added to first-void urine (PS) compared with standard of care testing from individual sites (SOC). (2) Acceptability of pooling among MSM. Methods MSM (symptomatic or contacts of CT/NG) attending two London sexual health services were recruited. Information about demographics, sexual behaviour, symptoms, signs and acceptability of pooling was collected. PS and SOC sampling order was randomised and results compared. Results Of the planned 1400 MSM, 99 (53 HIV+) have been recruited. Two equivocal results were excluded from analysis. Some of the questionnaire data were missing. 80%(73/91) were symptomatic and 60% (57/96) reported unprotected anal sex in the last month. The prevalence of CT and/or NG infection was 35% (95% CI 26% to 45%), CT alone 14% (95% CI 8% to 23%) and NG alone 21% (95% CI 13% to 30%). The sensitivity and specificity of PS vs SOC to detect CT/NG is 88% (95% CI 72% to 96%) and 100% (95% CI 93% to 100%), respectively (abstract P98 table 1). PS failed to detect four NG cases (3 pharynx, 1 rectum). MSM reported confidence (n=74, 86%) and willingness (n=75, 88%) to take their own samples (see abstract P98 table 1). Abstract P98 Table 1 Sensitivity and specificity of pooled samples according to test Number positive (%) SOC testing [95% CI] Number positive (%) PS testing Sensitivity % [95% CI] Specificity % [95% CI] CT &/ or NG* (*CT&NG, n=4) 34 (35) [26 to 45] 30 (88) 88 [72 to 96] 100 [93 to 100] CT 14 (14) [8 to 23] 14 (100) 100 [73 to 100] 100 [95 to 100] NG 20 (21) [13 to 30] 16 (80) 80 [56 to 93] 100 [94 to 100] Discussion Pooling specimens in MSM offers the potential for significant savings and improved access to testing. Missed infections may be due to sampling error or low organism load. The evaluation of this strategy continues.