BackgroundMpox, caused by monkeypox virus (MPXV), was considered a rare zoonotic disease before May 2022, when a global epidemic of cases in non-endemic countries led to the declaration of a Public Health Emergency of International Concern. Cases of mpox in Ireland, a country without previous mpox reports, could reflect extended local transmission or multiple epidemiological introductions.AimTo elucidate the origins and molecular characteristics of MPXV circulating in Ireland between May 2022 and October 2023.MethodsWhole genome sequencing of MPXV from 75% of all Irish mpox cases (182/242) was performed and compared to sequences retrieved from public databases (n = 3,362). Bayesian approaches were used to infer divergence time between sequences from different subclades and evaluate putative importation events from other countries.ResultsOf 242 detected mpox cases, 99% were males (median age: 35 years; range: 15-60). All 182 analysed genomes were assigned to Clade IIb and, presence of 12 distinguishable subclades suggests multiple introductions into Ireland. Estimation of time to divergence of subclades further supports the hypothesis for multiple importation events from numerous countries, indicative of extended and sustained international spread of mpox. Further analysis of sequences revealed that 92% of nucleotide mutations were from cytosine to thymine (or from guanine to adenine), leading to a high number of non-synonymous mutations across subclades; mutations associated with tecovirimat resistance were not observed.ConclusionWe provide insights into the international transmission dynamics supporting multiple introductions of MPXV into Ireland. Such information supported the implementation of evidence-informed public health control measures.

ObjectivesGay, bisexual and other men who have sex with men (gbMSM) have a higher risk of acquiring hepatitis A and B viruses (HAV and HBV) than the general population and are recommended for vaccination against both in Ireland. This study aims to determine the prevalence of self-reported HAV and HBV infection and vaccination among gbMSM in Ireland and explore factors associated with self-reported HAV and HBV vaccination among gbMSM. MethodsThis study analysed Irish data from the European MSM Internet Survey 2017 (EMIS-2017) to measure the prevalence of self-reported HAV and HBV infection and vaccination among gbMSM in Ireland. Multivariable logistic regression was used to explore the associations between sociodemographic, healthcare-related and behavioural factors and self-reported vaccination. ResultsThere were 2083 EMIS-2017 respondents in Ireland. Among HIV-negative gbMSM, 4.6% and 4.4% reported previous HAV and HBV infection, respectively, and 51% and 57% reported the receipt of one or more vaccine dose for HAV and HBV, respectively. In the multivariable analysis, HIV-negative gbMSM had lower odds of self-reported HAV vaccination if they lived outside the capital, Dublin (aOR 0.61, 95% CI: 0.48 to 0.78), had no third-level education (aOR 0.65, 95% CI: 0.45 to 0.92), were not tested for HIV in the last year (aOR 0.39, 95% CI: 0.31 to 0.50), had never tried to obtain pre-exposure prophylaxis (PrEP, aOR 0.60, 95% CI: 0.38 to 0.96) and had not been diagnosed with a sexually transmitted infection (STI) in the previous year (aOR 0.42, 95% CI: 0.28 to 0.63). Similar associations were observed for self-reported HBV vaccination. ConclusionsSelf-reported vaccination against HAV and HBV among gbMSM in Ireland is high, but the level of vaccination remains insufficient to protect against future HAV and HBV infections and outbreaks. Efforts to increase vaccination coverage among gbMSM should focus on men who live outside the capital, have lower educational attainment and do not engage with sexual health services.

INTRODUCTION:Antiretroviral therapy (ART) is integral to HIV prevention, including averting vertical transmission. The World Health Organization (WHO) recommends ART and breastfeeding for all women living with HIV for at least 12 months post-partum [1, 2]. Much of the data on HIV transmission through breastfeeding comes from low-resource settings, with a paucity of data on breastfeeding-related HIV transmission in women living with HIV in other settings. Women Against Viruses in Europe (WAVE), part of the European AIDS Clinical Society (EACS), aims to improve the standard of care for women living with HIV and sought to gain an understanding of breastfeeding guidelines and practice in women living with HIV across Europe. METHODS:A steering group convened by WAVE developed a survey to collate information on breastfeeding trends, practice, and guideline recommendations for women living with HIV in Europe and to establish interest in becoming involved in a collaborative breastfeeding network. The survey was disseminated to 31 countries in March 2022. RESULTS:In total, 25 eligible responses were received: 23/25 (92%) countries have HIV and pregnancy guidelines; 23/23 (100%) guidelines refer specifically to breastfeeding; 12/23 (52%) recommend against breastfeeding; 11/23 (48%) offer an option if certain criteria are met; 12/25 (48%) reported that the number of women living with HIV who breastfeed is increasing; 24/25 (96%) respondents were interested in joining a network on breastfeeding in women living with HIV. CONCLUSIONS:Recommendations vary, and nearly half of the guidelines recommend against breastfeeding. Many countries report an increase in breastfeeding. WAVE will establish a collaborative network to bridge data gaps, conduct research, and improve support for women living with HIV who choose to breastfeed.

Background Gay, bisexual, and other men who have sex with men (gbMSM) report a higher prevalence of drug use in comparison to the general male population. However, in Ireland, there is a paucity of literature regarding the prevalence of drug use and its determinants among gbMSM. Aims/Objectives To quantify the prevalence of (i) recreational drug use (RDU) and (ii) sexualised drug use (SDU) among gbMSM in Ireland, and to identify the factors associated with these drug use practices. Methods The European MSM Internet Survey (EMIS) 2017 was an online, anonymous, internationally-promoted questionnaire. Two binary outcomes were included in our analyses: (1) RDU and (2) SDU in the previous year. Multivariable-adjusted logistic regression explored factors associated with these outcomes, and all independent covariates were adjusted for one another. Results Among gbMSM without HIV (n = 1,898), 40.9% and 13.1% engaged in RDU and SDU in the previous year, respectively. Among diagnosed-positive gbMSM (n = 141), the past-year respective prevalence estimates were 51.8% and 26.2%. Increased odds of RDU were observed among gbMSM who were younger (vs. 40+ years) (18–24 years; AOR 2.96, 95% CI 2.05–4.28, 25–39 years; AOR 1.66, 95% CI 1.27–2.16), lived in Dublin (vs. elsewhere) (AOR 1.47, 95% CI 1.17–1.83), and engaged in condomless anal intercourse (CAI) in the previous year (vs. none) (1–2 partners; AOR 1.79, 95% CI 1.34–2.38, 6+ partners; AOR 1.79, 95% CI 1.18–2.71). Greater odds of SDU were identified among those who lived in Dublin (vs. elsewhere) (AOR 1.50, 95% CI 1.07–2.10), and engaged in CAI (vs. none) (1–2 partners; AOR 3.16, 95% CI 2.05–4.88, 3–5 partners; AOR 2.50, 95% CI 1.47–4.26, and 6+ partners; AOR 3.79, 95% CI 2.23–6.43). Conclusion GbMSM report a high prevalence of drug use in Ireland. Targeted interventions, including harm reduction campaigns, may be needed to support healthier drug use choices among this community.

Aims The national PrEP programme launched in Ireland in November 2019 with tenofovir/emtricitabine free to those meeting eligibility criteria. We assessed the impact of the first year of the PrEP programme on new HIV diagnoses in the largest sexual health and HIV service in Ireland. Methods A free PrEP service was established in November 2019. We reviewed the number of new diagnoses of HIV between November 2018-2019, before the introduction of the national PrEP programme and compared this with the number of new HIV diagnosis between November 2019-2020. Results There were 95 new HIV diagnoses (63.3% MSM) between November 2018 and 2019 and 73 new HIV diagnoses (65.7% MSM) between November 2019 and 2020. There was a statistically significant decline in new HIV diagnoses between the 2 years (P = 0.0003). 546 patients were prescribed PrEP as of December 2020.106 patients (19.4%) changed their PrEP dosing regimen due to lockdown. 178 individuals (32.6%) had a rectal infection diagnosed. Conclusion There has been a reduction in new HIV diagnoses in our cohort (although this has occurred during a global pandemic). It is too early to say if PrEP reduces late presentations of HIV based on our findings. A significant number of rectal infections were identified in the PrEP clinic suggesting ongoing risk despite pandemic restrictions. Further research into sexual practices during COVID-19 is needed to assess if this had an impact on the lower rates of HIV acquisition.

Background/PurposeIn March 2020 the World Health Organisation declared Covid-19 a global pandemic. Ireland responded by shutting all non-essential shops, businesses and schools. Our healthcare system had to adapt and rapid adaptations were made to ambulatory HIV care.ApproachRecords were virtually reviewed and triaged using existing electronic patient records(EPR) prior to appointments. Antiretrovirals(ARVs) were pre-prescribed and prepared by pharmacy for those anticipated to remain on the same ARVs. We determined those for whom routine phlebotomy could be diverted. We paused cervical, STI screening and vaccination programme in the initial phase, reopening in a more streamlined manner as the pandemic went out of each wave and adapting again as it went back into a new wave. We undertook a staff survey to assess their views on the new service delivery.Outcomes/ImpactWe conducted a survey of our staff members across all disciplines. There were 34 responses out of 53 staff members. 76.47% agreed that pre reviewing EPR was better for patient care, 88.24% believed that patient flow was improved, 76.47% believed that patients time in the department was reduced due to the virtual reviews and that covid-19 risk was reduced. 80% of doctors felt that doing the virtual reviews was a valuable training experience. 50% believed that there was more time available to deal with complex cases.Innovation and SignificancePre prescribing medications has led to better patient flow and social distancing during clinic. Complex issues, in many cases can be addressed prior to clinic and discussed with senior providers. Stricter adherence to appointment times is more convenient for patients and staff. This system has allowed us to identify patients with complex medical needs and presented opportunity for education and training between senior and junior providers, whilst decreasing Covid-19 risk to provider and patient.

In the midst of the COVID-19 pandemic, health care providers have had to rapidly change how they deliver care to patients. We discuss how we are delivering a virtual HIV pre-exposure prophylaxis (PrEP) service during this time; challenges faced; challenges expected and goals for the coming months.

We describe the successful use of isavuconazole for treatment of an HIV-positive patient with cryptococcal meningitis following induction therapy with liposomal amphotericin B and flucytosine. Because the Cryptococcus neoformans isolate from cerebrospinal fluid had a borderline minimum inhibitory concentration of 8 mg/L, initial consolidation therapy was given with a daily dose of fluconazole 1200 mg based on area under the curve to minimum inhibitory concentration modelling data. Toxicity, and the radiological emergence of a cryptococcoma in the setting of immune reconstitution inflammatory syndrome, prompted a therapeutic switch to isavuconazole. Subsequent imaging after 19 weeks of isavuconazole shows a significant reduction in cryptococcoma size from 11 mm to complete resolution. The patient remains well after 210 days of therapy with a view to completion of treatment after 1 year.

Untreated syphilis results in significant fetal/neonatal morbidity and death. Increases in infectious syphilis rates worldwide, in particular in the United States, UK and Ireland, necessitates continued diligence in antenatal management. Universal antenatal screening is standard care worldwide. In Ireland management follows the ‘Prevention of Perinatal Transmission’ guidelines. A retrospective cohort study of T.Pallidum seropositive antenatal patients attending three tertiary maternity hospitals in Dublin, Ireland from 01/August/2015 to 31/August/2018 was completed . Ethical approval was granted. Data included demographics, syphilis serology, co-infections, treatment, infant follow-up and adherence to national guidelines. 98 seropositive women with 104 pregnancies were identified, representing 0.14% of livebirths in the study period (n≈66700). 87.5%(n=91) did not speak English as their first language, and 36%(n=37) reported no prior treatment. 91% (n=95) attended a syphilis specialist. Baseline RPR was positive in 31 pregnancies (neat=17, 1:2=6, 1:4=5, 1:16=1, 1:32=2). Treatment was indicated in 40 pregnancies: 85%(n=34) completed Benzathine Penicillin-G (BPG) treatment >4 weeks before delivery; two did not complete BPG treatment; two initiated BPG treatment late in pregnancy and two received Erythromycin. There were 98(94%) liveborn infants, 4 miscarriages and 2 terminations. 28 infants received stat dose BPG on day 1 of life. Two infants received a ten-day course of penicillin. One case of congenital syphilis was identified, with neurological and radiological findings of syphilis infection. Minority ethnic groups comprised the majority in this study. For most, treatment was completed prior to delivery. One in 10 requiring treatment either failed to attend or initiated treatment very late in pregnancy. We highlight a need for continued cohesive multidisciplinary care, focussing on supporting women from minority ethnic communities to access comprehensive maternal and infant care.

Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the white matter central nervous system occurring in immunocompromised patients particularly those with T cell deficiency such as in HIV, haematological and solid organ malignancies and those taking immunomodulatory medications. PML is caused by JC virus however in rare cases BK virus has been isolated in the cerebral spinal fluid of patients presenting with PML. In this case we describe a 49 year old man who presented to the emergency department with a 2 week history of progressive right sided weakness and dysarthria. His background history included HIV diagnosed in 2005, he had not engaged with care in the past 2 years and had not been taking anti-retroviral therapy (ART). Other past medical history included untreated hepatitis C. His CD4 count was 90 (11%) cells/mm3 on admission and his HIV viral load VL) was 141,000 copies/ml. Magnetic resonance imaging(MRI) showed a hypointense lesion on T1, hyperintense on T2 and FLAIR without diffusion restriction and without mass effect. A lumbar puncture was performed which confirmed JC virus was positive (PCR <50 copies/ml) and also revealed BK virus was positive (PCR 46,511 copies/ml). The patient was commenced on tenofovir alafenamide fumarate/emtricitabine/darunavir/cobicistat in combination with dolutegravir 50mg twice daily. On day 40 post commencement of ART the patient was readmitted with worsening of his right arm weakness and dysarthria. A repeat MRI was performed which showed the hyperdense lesion on T2 and FLAIR appeared slightly larger with some slight enhancement with gadolinium contrast but no other features suggesting PML immune reconstitution inflammatory syndrome (IRIS). The CD4 count had increased to 141(17%) and HIV VL had decreased to 85 copies/ml. A clinical diagnosis of PML IRIS was made and the patient was commenced on prednisolone 30mg BD which lead to an initial improvement in symptoms. Interestingly in this case, both JC virus and BK virus were detected in the CSF of this patient with the level of JC virus being too low to quantify. BK virus was not detectable on peripheral serum sampling suggesting that BK virus is replicating in the CNS independent of other body sites. There have been 5 case reports in the literature of BK virus as the cause of PML. Testing for BK virus should be considered in patients presenting with signs and symptoms of PML and encephalitis particularly when no other cause is found.

This paper examines ideas, concepts, and theories, in relation to the revival of the Irish language as a transatlantic venture c.1857-1887 focusing on print media and cultural organisations in the United States. The study of these forums in the context of the Irish language revival allows us to assess theories and methodologies relating to the media's role in a transatlantic context. It demonstrates the transcending of the Irish language across transnational borders, the creation of debate and discussion in a hybrid community public sphere, and the role print media, and media events, played in constructing this transatlantic and transnational community, highlighting that movements in the US and Ireland influenced one another in the context of ideology, methodology and organisation.

Syphilis remains a disease of public health importance, with considerable health effects if not treated. Concurrent infection with syphilis and untreated HIV facilitates HIV transmission. The incidence of syphilis in Europe has been increasing, particularly among men who have sex with men (MSM) and in MSM with HIV. However, there is heterogeneity among countries in the case definition used for syphilis and in reported syphilis notification rates. In Ireland, we have undertaken a number of refinements of the national syphilis surveillance system since 2014, including refinement of the laboratory thresholds for notification (rapid plasma reagin 1:16 and/or positive IgM). This article outlines the steps taken and some of the challenges we faced. Our current case definition now accurately reflects the epidemiology of syphilis in Ireland and our current surveillance provides timely information for action, while not reducing the sensitivity of the system too much. For countries where surveillance is driven mainly by laboratory reporting and where obtaining clinical details is challenging, these thresholds for notification may be a pragmatic solution.

Can the campaign Undetectable=Untransmittable (U=U), established for the sexual transmission of HIV, be applied to the transmission of HIV through breastfeeding? European AIDS Clinical Society and, to some extent, American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring. This Viewpoint summarises existing evidence on transmission of HIV through breastfeeding, differences in HIV dynamics and viral load between breastmilk and plasma, and the effects of antiretroviral therapy on infants. At present, insufficient evidence exists to make clear recommendations for the required frequency of clinical and virological monitoring for mother and infant in a breastfeeding relationship or for the action to be taken in the event of viral rebound. We propose a roadmap for collaborative research to provide the missing evidence required to enable mothers who wish to breastfeed to make a fully informed choice.

In Ireland, men who have sex with men (MSM) have increased HIV risk. Pre-exposure prophylaxis (PrEP), combined with safe sex practices, can reduce HIV acquisition. We estimated MSM numbers likely to present for PrEP by applying French PrEP criteria to Irish MSM behavioural survey data. We adjusted for survey bias, calculated proportions accessing testing services and those likely to take PrEP. We estimated 1-3% of MSM in Ireland were likely to present for PrEP.

IntroductionIn Ireland, HIV infection predominantly occurs among men who have sex with men (MSM). Combination prevention approaches, including pre-exposure prophylaxis (PrEP), are recommended to reduce the risk of acquiring HIV. We used the 2015 MSM Internet Survey Ireland (MISI), a large-scale community survey among adult MSM in Ireland, to estimate the proportion of MISI respondents eligible for PrEP.MethodsWe applied PrEP eligibility criteria from France to MISI variables. Where exact criteria could not be applied, the most similar form was used. French PrEP eligibility criteria include HIV negative MSM or transgender adults who had at least one of the following: condomless anal sex (CAI) with ≥2 different partners in the past six months; episodes of STIs in the past 12 months; used multiple post-exposure prophylaxis (PEP) treatment(s) or used drugs during sex.ResultsMISI included 3,045 MSM aged 18–64 years; 2,870(94%) were HIV negative or never HIV tested. In the past 12 months, 370(12%) reported CAI with ≥2 non-steady partners; 243(8%) reported an STI diagnosis and 181(6%) used drugs associated with chemsex. Four percent (n=119) were treated with PEP. Overall, 23% [95%CI(22–25)] of MISI respondents are eligible for PrEP.DiscussionAn estimated one in four MISI respondents met French PrEP eligibility criteria. Applying this estimate to the MSM population in Ireland, taking study limitations, those engaged in services and assumed PrEP uptake into account, would enable calculation of the number of MSM eligible for PrEP. This estimate will be useful for informing PrEP policy in Ireland.

Post-exposure prophylaxis (PEP) is an important aspect of HIV prevention following potential exposure. We conducted a survey to assess knowledge of HIV PEP, and awareness of HIV PEP resources, among key healthcare professionals, using an anonymous online questionnaire. Twelve (18%) of 68 respondents answered five or more of six knowledge questions correctly; 49 (72%) cited the Emergency Management of Injuries (EMI) toolkit as a resource. Although most respondents were aware of the EMI Toolkit for HIV PEP, the low number of respondents correctly answering knowledge questions suggests a need for training to avoid potential suboptimal HIV PEP use.

IntroductionThe ultimate goal of HSV management in pregnancy is to prevent perinatal transmission and, where possible, to facilitate vaginal delivery.MethodsData was collected from antenatal charts of 107 women who reported a history of HSV or who had a documented outbreak during that pregnancy. Descriptive column statistics were used in excel for data analysis.ResultsFrom May 2013 to Feb 2017, 107 Women were seen in the clinic for management of HSV in 108 pregnancies. Median gestation at referral (82/108) was 23/40 (range 2–39/40). Mean age 33yr (range 18–45). 91 (85%) European. 9(8%) HIV+. 82 (76%) reported prior history. 96 (89%) had type-specific serology sent of which 89 (92%) HSV IgG +ve. 28 (31%) HSV 1 & 2 positive, 47 (52%) Type I positive only, 12 (13%) Type 2 positive only, 2 were weak + and not typed. 69 (63%) had STI testing, 100% negative. 4 of the 107 (80%) had primary HSV in that pregnancy. 67 received HSV prophylaxis; 66 valaciclovir; 1 aciclovir. Mean gestation starting prophylaxis was 36/40 (range 20 – 39). Data on mode of delivery on 82 of 107 (76%) pregnancies; 59 (71%) vaginal, 24 (29%) lower segment caesarean sections, none for HSV. Median gestation at delivery of 84 pregnancies 39/40 (range 29 – 41). To date no cases of perinatal HSV transmission have been reported.DiscussionThere is good compliance with Irish guidelines on HSV management in pregnancy. HSV2 remains an issue. This combined clinic facilitates good compliance with standard guidelines for HSV management in pregnancy. This model of care should be available across all antenatal settings.