OBJECTIVES:The 'Undetectable equals Untransmissible' (U=U) statement is based on robust evidence. Spreading this message aims to reduce HIV stigma, increase antiretroviral therapy (ART) adherence, and improve quality of life for people with HIV (PWH). Among PWH in the UK, we assessed the proportion believing U=U and its associations with HIV-related self-stigma, mental health, and sexual satisfaction. DESIGN:Positive Voices 2022 is the largest UK national survey of PWH (April 2022-March 2023). Participants self-completed a questionnaire on socio-demographic, HIV-related, health, and lifestyle factors. METHODS:We assessed associations of demographic, socioeconomic, and HIV-related factors with belief in U=U, and associations of belief in U=U with self-stigma, depression symptoms, anxiety symptoms, and sexual satisfaction (the latter among participants who had sex in the past 3 months) using logistic regression, unadjusted and adjusted for demographic group, age, and time on ART. RESULTS:Four thousand five hundred and fifty-three people on ART were included: 2671 (59%) gay or bisexual MSM (GBMSM), 1104 (24%) women, 646 (14%) heterosexual men; 1100 (24%) participants of Black ethnicity; median (IQR) age 52 years (44-60). 4192 (92%) had heard of U=U; fewer (2906, 64%) believed it. Lack of belief in U=U was more common among older participants, heterosexuals, those with less education, those with financial hardship, and those without knowledge of their last viral load level. Lack of belief in U=U was associated with HIV-related self-stigma [adjusted odds ratio (aOR) 1.88, 95% confidence interval (CI) 1.63-2.18], depression symptoms (aOR 1.33, 95% CI 1.13-1.56) anxiety symptoms (aOR 1.48, 95% CI 1.23-1.77), and less sexual satisfaction (physical pleasure: aOR 0.62, 95% CI 0.51-0.75; emotional satisfaction: aOR 0.72, 95% CI 0.60-0.87). With the exception of depression symptoms, these associations remained after additional adjustment for financial hardship. Patterns of association were similar among GBMSM compared to all other demographic groups combined. CONCLUSION:Despite high awareness of U=U among PWH in UK, belief remains inadequate, especially in disadvantaged groups. Promoting this message could help combat HIV-related stigma and improve mental health.

Background Disability is increasingly experienced by women ageing with HIV and multimorbidity. The Episodic Disability Questionnaire (EDQ) measures the presence, severity, and episodic nature of disability across six domains. We evaluated EDQ properties among women living with HIV in the United Kingdom.Methods Participants in the Positive Transitions Through the Menopause (PRIME) study completed the EDQ at two timepoints (1 week apart), criterion measures (WHODAS 2.0, EQ-5D-5L, Work and Social Adjustment Scale), and a demographic questionnaire. We evaluated internal consistency, test-retest reliability, measurement precision (Minimum Detectable Change (MDC) 95%), and construct validity. We assessed disability prevalence using WHODAS 2.0 (moderate threshold) and Equality Act Disability Definition (severe threshold).Results Of 104 participants (median age 56 years, 65% Black ethnicity), 93 (89%) completed the EDQ twice. Median duration since HIV diagnosis was 23 years; 98% had undetectable viral loads and 86% reported multimorbidity. Cronbach's alpha ranged from 0.83 (social domain) to 0.92 (daily activities domain). ICC ranged from 0.70 (physical domain) to 0.91 (daily activities domain). Precision varied, highest in daily activities (MDC95%: 6.10) and lowest in mental-emotional domains (MDC95%: 11.52). The EDQ met 80% (n = 47/59) of construct validity hypotheses. Disability prevalence was 79.81% (95%CI 70.57, 86.79) moderate and 41.75% (32.24, 51.88) severe.Conclusions The EDQ possesses internal consistency, test-retest reliability, and construct validity with varied precision among women living with HIV. Disability prevalence in this sample was higher than in the general population. The EDQ offers value for research, clinical practice, and national policy by enabling measurement and description of disability, supporting intervention evaluation, and informing priority-setting and healthcare service planning for women living with HIV in the UK.

Antiretroviral therapy (ART) has transformed HIV into a manageable health condition with normal life expectancy. However, people with HIV continue to have poorer mental health compared to background populations, which may be linked to stigma, lack of social support, or socioeconomic challenges. Personalised care aims to improve the outcomes of people with long-term health conditions and the National Health Service (NHS) Long Term Plan looks to implement this (including access to health coaching and social prescribing). The SPHERE trial aims to assess whether a health and well-being coaching and social prescribing intervention improves patient-reported health and well-being among people living with HIV who have psychosocial needs. SPHERE will be conducted across seven HIV outpatient clinics in England and is a pragmatic, two-arm, parallel group randomised controlled trial (RCT) embedding a routine assessment of psychosocial needs in HIV care. Eligibility criteria are people living with HIV aged 18 or older, available for the duration of study follow-up and scoring 16 or more on an assessment of psychosocial need: “Positive-Outcomes-11” (PO-11), covering physical, psychological, social and socioeconomic aspects of health and well-being. The RCT requires 568 participants who will be individually randomised in a 1:1 ratio to either a health and well-being coaching and social prescribing intervention or usual care. The intervention consists of up to eight coaching sessions that will be delivered by health professionals (e.g. HIV nurses) who have received specialist training to become health and well-being coaches. The trial will also include an internal pilot phase, process evaluation (to evaluate intervention feasibility, acceptability and mechanisms of action), economic evaluation (to assess the cost-effectiveness of the intervention and impact on NHS resource use) and parallel observational study (to assess subsequent development of psychosocial needs among those not initially eligible for the trial). The primary outcome is defined as achieving a reduction in PO-11 score of at least 40

OBJECTIVES:The average age of a person living with HIV in high-income countries is increasing, as are rates of multimorbidity and frailty. To meet these needs, existing services must adapt. This review aimed to identify the existing literature on what services are available to undertake long-term condition management (LTCM) for People with HIV in England. METHODS:A scoping review employing the Arksey & O'Malley's methodological framework was performed. Seven databases were searched most recently in October 2024 for studies describing services, interventions, or support for People with HIV in England to manage their overall health and wellbeing. Study inclusion was not limited by year of publication. Narrative reviews were excluded. Two reviewers independently performed data extraction using predetermined criteria, followed by a descriptive analysis. RESULTS:Forty publications were identified with six key areas where LTCM was addressed: HIV services, secondary care services, primary care, palliative care, peer support, self-management, and specialist services, suggesting that currently no service can undertake LTCM alone. CONCLUSIONS:If LTCM for People with HIV is to expand outside of HIV services, then additional HIV training is required for healthcare professionals with a focus on reducing stigma. Peer support should be at the forefront, and People with HIV should be involved in the assessment of need, design, and evaluation of services. There is a scarcity of high-level evidence, which justifies the need for further research and ongoing service evaluation to identify the optimal model(s) to ensure effective, equitable, and cost-effective care.

Increasingly, people attending HIV services are requesting long-acting injectable (LAI) antiretroviral treatment (ART). However, without HIV RNA resistance-associated mutation results, individuals are considered unsuitable for LAI ART. We present our experience of sequencing proviral HIV DNA in 30 individuals to inform suitability for LAI ART, of whom 23 were considered suitable. In conclusion, optimization of diagnostic tools such as proviral HIV DNA sequencing to confirm suitability for LAI ART would be a welcome addition.

The effectiveness of population-level intervention for HIV elimination is influenced by individual-level variation in sexual behaviour. We assess within-person changes in the frequency of condomless anal sex with two or more partners (CLS2+), estimate the transition probabilities and examine the predictors of transitions among a prospective cohort of HIV-negative gay, bisexual, and other men who have sex with men (GBMSM). Participants were recruited through one of three sexual health clinics in London and Brighton (July 2013 to April 2016) and self-completed a baseline paper questionnaire in the clinic. During follow-up, they were invited to complete four-monthly questionnaires twice a year and subsequent annual online questionnaires once a year (March 2015 to March 2018). We used Markov chain models to estimate transition probabilities from 'higher-risk' (CLS2+) to 'lower-risk' (no CLS2+) and vice versa, and to assess factors associated with transitions between different sexual risk levels. Among 1,162 men enrolled in the study, 622 (53.5%) completed at least one online questionnaire. Higher-risk behaviour was reported in 376/622 (60.4%) men during online follow-up. Overall, 1,665/3,277 (37.5%) baseline and follow-up questionnaires reported higher-risk behaviour. More than 60% of men (376/622) reported higher-risk behaviour at least one period during the follow-up, while 39.5% of men (246/622) never reported CLS2+ during the follow-up. In the next four months, the estimated probability of continuing higher-risk behaviour among men who reported higher-risk behaviour was 78%. Calendar time, recent HIV tests, PrEP and PEP use were the predictors of staying in higher-risk behaviour, while less stable housing status was associated with switching to lower-risk behaviour. Among men who reported lower-risk behaviour, the probability of engaging in the same behaviour was 88%. Recent HIV tests, PrEP and PEP use, recreational drugs, chemsex-associated drug and injection drugs, and bacterial STIs diagnosis were the predictors of switching to higher-risk behaviour. Our results indicate that at any one point in time, the majority of GBMSM are at low risk for HIV acquisition, although many experience short periods in which they are at higher risk. Markers of transitions can be utilized to identify which GBMSM are likely to increase or decrease their risk, thus helping the timing of HIV prevention interventions.

Objectives In England, infectious syphilis diagnoses have reached the highest annual number since 1948. Fifty per cent of syphilis testing is now provided through online postal self-sampling sexually transmitted infection (STI) testing services (OPSS). To reduce the burden of syphilis, we need to understand the syphilis prevalence and transition to treatment rates among service users of OPSS. This report aims to estimate syphilis prevalence among people accessing Sexual Health London (SHL), a regional, National Health Service (NHS)-funded OPSS. Methods Demographic, STI concurrency, sexual behaviour data and case outcomes were collected from SHL service users who received testing for syphilis between 8 March 2022 and 30 June 2023. Data were analysed to identify syphilis prevalence and transition to care rates. Results 458 520 syphilis tests were performed for 267 780 service users. 12 870 (2.8%) results were reactive. Their assigned case outcomes comprised: 10 048 (78.1%) past adequately treated syphilis; 971 (7.5%) treated for active syphilis; 1293 (10.1%) SHL results did not subsequently confirm and 558 (4.3%) had an unknown final outcome. Of unique users, 0.4% (940/267 780) received syphilis treatment at least once. They were: 89.3% aged >= 25 years, 87.3% male, 83.7% gay/bisexual. Co-infections identified were: chlamydia (14%), gonorrhoea (13.3%) and previously undiagnosed HIV (1.5%). 36.1% (339) took pre-exposure HIV prophylaxis, 30.1% engaged in sex parties/group sex and 26.8% had sex under the influence of drugs/alcohol. Individuals aged >= 35 years, of non-female gender, gay/bisexual, from indices of multiple deprivation (1-5) and from certain racially minoritised communities were statistically more likely to require treatment for syphilis than the overall testing population (p<0.05). Conclusion Estimated syphilis prevalence (0.4%) was comparable to rates within national sexual health clinics and the demographic characteristics of those most affected by syphilis were also similar. Further work is required to improve the integration between NHS OPSS and sexual health clinics and to enable OPSS to more accurately input data on treatment and diagnoses towards national surveillance statistics.

OBJECTIVES:Klick is a clinic-specific, digitally supported outpatient pathway of care for people living with HIV (PLWH). It involves a smartphone application (app) for PLWH to self-manage their care, navigate access to the clinic and communicate with their healthcare provider. We present a patient evaluation of Klick. METHODS:Patients use Klick to book/reschedule appointments, view laboratory results, request medication, access remote nurse-delivered consultations and communicate with clinicians. In October 2022, Klick was evaluated by PLWH through a questionnaire and interviews. RESULTS:Between August 2020 and April 2024, 5859 patients had registered to use Klick; during April 2024 alone, 2509 (43%) used Klick. In October 2022, 1661 PLWH were invited to complete surveys, of whom 362 (22%) responded. These respondents were 95% (340/358) male and 84% (298/354) white, and 63% (227/359) were in the age range 41-60 years. Respondents felt Klick was easy to use (average score 4.3/5), and 92% thought having a clinic-specific app was important/very important. Respondents valued the following app features as important/very important - online booking (93%); viewable results (94%); prescription requests (90%) - and rated their experience of using them highly - 91% for e-booking and 91% for viewable results. A total of 93% said they would recommend Klick to friends and 82% rated Klick as above average/excellent. CONCLUSIONS:PLWH reported high levels of satisfaction using a clinic-specific mHealth app to manage their HIV care and demonstrated sustained active use. Klick was rated easy to use, as helping to meet healthcare needs and as providing a superior experience for some aspects of care. Other HIV clinics or services managing chronic conditions could benefit from the adoption of personalized digital solutions to enhance patient care.

We evaluated Klick, a nurse-led, digitally enabled model of HIV outpatient care, launched in 2020. Klick's smartphone app offers online booking, remote nurse-led consultations, and results. An audit of Klick nurse-led consultations was conducted against BHIVA monitoring guidelines, and nurses were interviewed about their experience. Of 40 Klick patients audited, 4 of 5 BHIVA standards were met: 100% had documented co-medications, smoking history, blood pressure, and viral load data, and 89% received a cardiovascular risk calculation (Targets 97%-90%-90%-90%-90%). Compared to national BHIVA audit findings, Klick performed better across 22 of 24 comparable measures. Nurses safely managed a cohort comprising some complexity (eg, co-morbidities, polypharmacy); no cases were escalated off the pathway, and all were virologically suppressed. Using a digitally supported model, nurses effectively provided safe care to HIV-positive patients with predominantly stable health, enabling consultants to focus on more complex caseloads. Care was comprehensive and person-centered and obtained better outcomes compared to previous national audits.

We describe 2 cases of infectious proctitis secondary to human monkeypox in patients presenting with rectal pain. These cases highlight the importance of multidisciplinary management of monkeypox and in expanding case definitions and enabling clinical recognition in patients presenting without skin rash.

Background: Biktarvy use is currently approved for HIV-1 infection in treatment-naïve and treatmentexperienced individuals after a series of successful investigator-sponsored phase III trials.However, studies on real-world evidence of its efficacy, safety, and tolerability are limited.Method: This review used the PRISMA extension for scoping reviews checklist as a framework.The final search strategy used was: (Bictegravir* OR biktarvy) AND (efficac* OR safe* OR effect* OR tolerab* OR "side effect*" OR "adverse effect*").The last search was performed on the 12th of August 2021.We included results from PubMed, EMBASE, EMCARE, Medline, CINAHL and BNL.Studies were eligible if they reported on the Efficacy, effectiveness, safety, or tolerability of bictegravir-based ART.Relevant conference abstracts under 24 months old were included in addition to full-text articles.Studies were excluded if Gilead Sciences sponsored them, if the total population taking B/F/TAF was <20, or if B/F/TAF was used off-label for other conditions.Review articles, meta-analyses, case reports, preclinical studies, and non-English publications were excluded.Results: After de-duplication, 333 studies were selected from peer-reviewed articles, and 27 were selected for fulltext assessment after reviewing their title and abstract.Seventeen studies fulfilled the inclusion criteria after a full-text review.We found that the efficacy of Biktarvy in clinical practice was comparable to phase III trials.However, adverse effects and discontinuation rates were found to be higher in the included real-world studies.Overall treatment discontinuation rates due to adverse effects ranged between 1.9 to 12%.Notably, discontinuation due to rash and weight gain was found to be higher than in approval trials. Conclusion:We conclude that further investigation of adverse effects and discontinuation rates is required, through large-scale prospective cohort studies.Further studies are needed on biktarvy-associated rash and weight gain specifically.Although the cohorts in the included realworld studies showed more demographic diversity when compared to the drug approval trials, further studies are still required on underrepresented groups such as women, pregnant people, ethnic minorities, and older adults.

Askari, Ara iBMedSci, MBBSa; Nashier, Chhavi iBScb; Ghelani, Rahul iBSc, MBBSa; Vargas Zhang, Adrianb; Ng, Meganb; Karagozlu, Zekiyeb; Bracchi, Margherita MDa; Moyle, Graeme MDa; Asboe, David MBBSa; Boffito, Marta MD, PhDa,b Author Information

Getting to Zero is a commonly cited strategic aim to reduce mortality due to both HIV and avoidable deaths among people with HIV. However, no clear definitions are attached to these aims with regard to what constitutes HIV-related or preventable mortality, and their ambition is limited. This Position Paper presents consensus recommendations to define preventable HIV-related mortality for a pragmatic approach to public health monitoring by use of national HIV surveillance data. These recommendations were informed by a comprehensive literature review and agreed by 42 international experts, including clinicians, public health professionals, researchers, commissioners, and community representatives. By applying the recommendations to 2019 national HIV surveillance data from the UK, we show that 30% of deaths among people with HIV were HIV-related or possibly HIV-related, and at least 63% of these deaths were preventable or potentially preventable. The application of these recommendations by health authorities will ensure consistent monitoring of HIV elimination targets and allow for the identification of inequalities and areas for intervention.

Background Chemsex (the use of psychoactive drugs in sexual contexts) has been associated with HIV acquisition and other STIs, so there is benefit in identifying those most likely to start chemsex to offer risk reduction interventions such as pre-exposure prophylaxis (PrEP). To date, there have been no data from a longitudinal study analysing factors most associated with starting and stopping chemsex. Methods The prospective cohort study, Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2), collected 4 monthly and annual online questionnaire data from men who have sex with men (MSM) from 2015 to 2018. We investigate the association of sociodemographic factors, sexual behaviours and drug use with starting and stopping chemsex among 622 men who completed at least one follow-up questionnaire. Poisson models with generalised estimating equations were used to produce risk ratios (RRs) accounting for multiple starting or stopping episodes from the same individual. Multivariable analysis was adjusted for age group, ethnicity, sexual identity and university education. Findings In the multivariable analysis, the under 40 age group was significantly more likely to start chemsex by the next assessment (RR 1.79, 95% CI 1.12 to 2.86). Other factors which showed significant association with starting chemsex were unemployment (RR 2.10, 95% CI 1.02 to 4.35), smoking (RR 2.49, 95% CI 1.63 to 3.79), recent condomless sex (CLS), recent STI and postexposure prophylaxis (PEP) use in the past year (RR 2.10, 95% CI 1.33 to 3.30). Age over 40 (RR 0.71, 95% CI 0.51 to 0.99), CLS, and use of PEP (RR 0.64, 95% CI 0.47 to 0.86) and PrEP (RR 0.47, 95% CI 0.29 to 0.78) were associated with lower likelihood of stopping chemsex by the next assessment. Interpretation Knowledge of these results allows us to identify men most likely to start chemsex, thus providing an opportunity for sexual health services to intervene with a package of risk mitigation measures, especially PrEP use.

Introduction Part of the UKHSA strategy for Mpox control focusses on vaccination. We describe the roll-out of Mpox vaccination within a large London sexual health service (SHS). Methods In the initial phase, individuals at high-risk of Mpox acquisition (defined by risk factors including recent STI, PrEP use, GBMSM) were invited by SMS to attend scheduled vaccine clinics delivered within SHS. Subsequently, staff from the Trust’s Flu/COVID vaccine service were seconded to support vaccine delivery outside of SHS. In the second phase, we moved to routine delivery of opportunistic vaccination within SHS, supported by outreach events. Results To date, 17 860 vaccines have been given, of which 13 190 were first doses (see figure 1). Doses administered in scheduled clinics totalled 13 198, and opportunistic doses totalled 4662. Outreach events delivered 26 vaccine doses. The majority of doses (74%) have been delivered via the Flu/COVID vaccine team outside of SHS. Delivering vaccines within SHS had significant service impacts, with a reduction in clinical capacity of 50% in July-August 2022. Delivery by the Flu/COVID team necessitated ≥2 bank staff working additional hours (with pharmacy and administrative staff), supported financially by the vaccine tariff. Discussion Identification of at-risk individuals, SMS invitations and rapid deployment of dedicated clinics facilitated the delivery of mass vaccination within at-risk populations, albeit with significant SHS service impacts during the initial phase of roll-out. Financially supported partnership working with the Trust’s vaccination team latterly lessened the impact on SHS, and delivered significant numbers of doses, demonstrating the need for adequately remunerated activity.

BACKGROUND:The introduction of antiretrovirals has resulted in a demographic shift with an increasing proportion of people living with HIV older than 50 years and a change in the spectrum of diseases affecting this population. A specialised clinical service dedicated to older people living with HIV was implemented at Chelsea and Westminster Hospital, London, UK in 2009, following training of health-care providers in HIV, ageing, comorbidity, and polypharmacy management. We report the results of a service evaluation reviewing 10 years of activity of this specialised clinic, including lessons to be applied in routine practice.METHODS:We estimated the prevalence of multimorbidity and polypharmacy and described algorithms devised for use across our HIV outpatient services following implementation of the specialised clinical pathway. The service evaluation was approved by our local clinical governance system and data relative to the period 2009-19 were collected on a secured trust database.FINDINGS:Dedicated time was created for senior and junior doctors, a nurse, and a pharmacy to create clinical appointments for older people living with HIV referred by all service care providers. The team would review different clinical scenarios, book follow-up appointments to review results, refer to different specialists or to complex multidisciplinary teams when necessary. 744 people with HIV aged 50 years and older attended our services (93% [691] male, 7·1% [53] female; mean age 56·5 years [SD 5·5]; 84·2% [622] White, 7·5% [56] Black, 0·9% [7] Asian, 7·5% [56] other race or ethnicity). The prevalence of multimorbidity was 69·3% and of polypharmacy was 46·6%. The most common comorbidities were vitamin D deficiency (428 of 690, 62%), dyslipidaemia (373, 50·1%), hypertension (157, 21·5%), depressive or anxious disorders (117, 15·8%), osteoporosis (91, 12·2%), obesity (98, 13·2%), chronic kidney disease (56, 7·5%), and diabetes (43, 5·7%). Patients with dyslipidaemia, osteoporosis, and metabolic disorders were referred to a live well pathway clinic focusing on targeted lifestyle interventions, including diet and physical exercise, under the supervision of a dietician and a physiotherapist.INTERPRETATION:We have described how our HIV over-50 clinic was organised and implemented, and we reported data showing high rates of comorbidities and polypharmacy, which led to the establishment of a specialised care pathway for all HIV care providers and to the implementation of further joint HIV and specialty clinics (cardiology, metabolic, menopause, nephrology, neurology, and geriatric).FUNDING:None.

Heskin J, et al. Sex Transm Infect March 2023 Vol 99 No 2 Rapid reconfiguration of sexual health services in response to UK autochthonous transmission of mpox (monkeypox) Joseph Heskin , Molly Dickinson, Nicklas Brown, Nicolo Girometti, Margaret Feeney, James Hardie, Ceri Evans, Alan McOwan, Christopher Higgs, Sheena Basnayake, Gary W Davies, Paul Randell, Margherita Bracchi, Marta Boffito, David Asboe, Luke SP Moore, Michael Rayment , Nabeela Mughal, Ruth Byrne, Rachael Jones

INTRODUCTION:This short report describes the results of a survey that was developed by Public Health England (PHE), the British HIV Association (BHIVA) and the Children's HIV Association (CHIVA) and circulated to all UK national health service HIV providers in the UK following the first wave of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; coronavirus disease 2019 [COVID-19]) pandemic to assess the impact of the pandemic on HIV clinics.METHODS:The survey was created by BHIVA/CHIVA and PHE and was piloted prior to circulation to all HIV clinics within the UK on 3 July 2020. The survey questions were designed to assess the impact of the first wave of COVID-19 on HIV clinics and lead/senior HIV clinicians. Clinicians' responses were collected between 3 July 2020 and 17 September 2020. The survey responses were collated, and non-statistical analysis was performed.RESULTS:The results of the survey confirmed that services had undergone substantial changes, including a shift from face-to-face consults to predominantly virtual consultations. Some clinicians' responses suggested that the first wave had many negative effects on people living with HIV, including their ability to access mental health services.CONCLUSION:The first wave of COVID-19 caused significant changes to HIV services within the UK. There was a shift toward the use of technology in healthcare, and results from subsequent clinician surveys carried out since the first wave of COVID-19 will reflect the ongoing transformation of care towards a more virtual service.