BACKGROUND:Current US guidelines recommend annual HCV screening among men who have sex with men (MSM) with HIV and MSM on pre-exposure prophylaxis against HIV (PrEP), but these recommendations were based largely on expert opinion using interferon-era assumptions. METHODS:We calibrated a dynamic economic model of HCV transmission among MSM to US data to determine the cost-effectiveness of HCV testing among MSM with HIV and/or using PrEP; and among MSM not using PrEP, compared to status quo HCV testing. Program costs and quality-adjusted life years (QALYs) were calculated to determine the mean incremental cost-effectiveness ratio (ICER) of each testing combination compared to its next least costly permutation. We defined the optimal strategy as that having the highest health benefits but with an ICER below a willingness-to-pay threshold of $100,000/QALY gained. RESULTS:Six testing strategies dominated the other combinations. Implementing recommended annual screening among MSM with HIV was cost-saving compared to current testing rates. However, the optimal strategy was testing MSM with HIV every 6 months, MSM using PrEP every 12 months, and MSM not using PrEP when tested for HIV (ICER $67,092/QALY gained). The optimal strategy did not change under sensitivity analyses. CONCLUSIONS:The optimal frequency of HCV testing to achieve maximum health benefit in a cost-effective manner for MSM in the US is higher in two subgroups, MSM with HIV, and MSM not using PrEP, than current US guidelines recommend. HCV testing is currently performed less frequently than optimal. Expanding testing is needed to improve HCV outcomes among MSM in the US.

Purpose Assessing risk factors and creating prediction models from real-world medical data is challenging, requiring numerous modelling decisions with clinical guidance. Logistic regression is a common model for such studies, for which we advocate the use of Bayesian methods that can jointly deliver probabilistic risk factor inference and prediction. As an exemplar, we compare Bayesian logistic regression with horseshoe priors and Projective Prediction variable selection with the established frequentist LASSO approach, to predict severe COVID-19 outcomes (death or ICU admittance) from demographic and laboratory biomarker data. Our study serves as guidance on data curation, variable selection, and performance assessment with cross-validation. Methods Our source data is based on a retrospective observational cohort design with records from three National Health Service (NHS) Trusts in southwest England, UK. Models were fit to predict severe outcomes within 28 days after admission to hospital (or a positive PCR result if already admitted) using demographic data and the first result from 30 biomarker tests collected within 3 days after admission (or testing positive if already admitted). Results Patients included hospitalized adults positive for COVID-19 from March to October 2020, 756 total patients: Mean age 71, 45% female, 31% (n=234) had a severe outcome, of whom 88% (n=206) died. Patients were split into training (n=534) and external validation groups (n=222). Using our Bayesian pipeline, we show a reduced variable model using Age, Urea, Prothrombin time (PT) C-reactive protein (CRP), and Neutrophil-Lymphocyte ratio (NLR) has better predictive performance (median external AUC: 0.71, 95% Quantile [0.7, 0.72]) relative to a GLM using all variables (external AUC: 0.67 [0.63, 0.71]). Conclusion Urea, PT, CRP, and NLR have been highlighted by other studies, and respectively suggest that hypovolemia, derangement of circulation via clotting, and inflammation are strong predictive risk factors of severity. This study provides guidance on conventional and Bayesian regression and prediction modelling with complex clinical data.

Background: The prevalence of genital chlamydia and gonorrhoea is higher in the 16–24 years age group than those in other age group. With users, we developed the theory-based safetxt intervention to reduce sexually transmitted infections. Objectives: To establish the effect of the safetxt intervention on the incidence of chlamydia/gonorrhoea infection at 1 year. Design: A parallel-group, individual-level, randomised superiority trial in which care providers and outcome assessors were blinded to allocation. Setting: Recruitment was from 92 UK sexual health clinics. Participants: Inclusion criteria were a positive chlamydia or gonorrhoea test result, diagnosis of non-specific urethritis or treatment started for chlamydia/gonorrhoea/non-specific urethritis in the last 2 weeks; owning a personal mobile phone; and being aged 16–24 years. Allocation: Remote computer-based randomisation with an automated link to the messaging system delivering intervention or control group messages. Intervention: The safetxt intervention was designed to reduce sexually transmitted infection by increasing partner notification, condom use and sexually transmitted infection testing before sex with new partners. It employed educational, enabling and incentivising content delivered by 42–79 text messages over 1 year, tailored according to type of infection, gender and sexuality. Comparator: A monthly message regarding trial participation. Main outcomes: The primary outcome was the incidence of chlamydia and gonorrhoea infection at 12 months, assessed using nucleic acid amplification tests. Secondary outcomes at 1 and 12 months included self-reported partner notification, condom use and sexually transmitted infection testing prior to sex with new partner(s). Results: Between 1 April 2016 and 23 November 2018, we assessed 20,476 people for eligibility and consented and randomised 6248 participants, allocating 3123 to the safetxt intervention and 3125 to the control. Primary outcome data were available for 4675 (74.8%) participants. The incidence of chlamydia/gonorrhoea infection was 22.2% (693/3123) in the intervention group and 20.3% (633/3125) in the control group (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). There was no evidence of heterogeneity in any of the prespecified subgroups. Partner notification was 85.6% in the intervention group and 84.0% in the control group (odds ratio 1.14, 95% confidence interval 0.99 to 1.33). At 12 months, condom use at last sex was 33.8% in the intervention group and 31.2% in the control group (odds ratio 1.14, 95% confidence interval 1.01 to 1.28) and condom use at first sex with most recent new partner was 54.4% in the intervention group and 48.7% in the control group (odds ratio 1.27, 95% confidence interval 1.11 to 1.45). Testing before sex with a new partner was 39.5% in the intervention group and 40.9% in the control group (odds ratio 0.95, 95% confidence interval 0.82 to 1.10). Having two or more partners since joining the trial was 56.9% in the intervention group and 54.8% in the control group (odds ratio 1.11, 95% confidence interval 1.00 to 1.24) and having sex with someone new since joining the trial was 69.7% in the intervention group and 67.4% in the control group (odds ratio 1.13, 95% confidence interval 1.00 to 1.28). There were no differences in safety outcomes. Additional sensitivity and per-protocol analyses showed similar results. Limitations: Our understanding of the mechanism of action for the unanticipated effects is limited. Conclusions: The safetxt intervention did not reduce chlamydia and gonorrhoea infections, with slightly more infections in the intervention group. The intervention increased condom use but also increased the number of partners and new partners. Randomised controlled trials are essential for evaluating health communication interventions, which can have unanticipated effects. Future work: Randomised controlled trials evaluating novel interventions in this complex area are needed. Trial registration: This trial is registered as ISRCTN64390461. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

OBJECTIVE To quantify the effects of a series of text messages (safetxt) delivered in the community on incidence of chlamydia and gonorrhoea reinfection at one year in people aged 16-24 years. DESIGN Parallel group randomised controlled trial. SETTING 92 sexual health clinics in the United Kingdom. PARTICIPANTS People aged 16-24 years with a diagnosis of, or treatment for, chlamydia, gonorrhoea, or non-specific urethritis in the past two weeks who owned a mobile phone. INTERVENTIONS 3123 participants assigned to the safetxt intervention received a series of text messages to improve sex behaviours: four texts daily for days 1-3, one or two daily for days 4-28, two or three weekly for month 2, and 2-5 monthly for months 3-12. 3125 control participants received a monthly text message for one year asking for any change to postal or email address. It was hypothesised that safetxt would reduce the risk of chlamydia and gonorrhoea reinfection at one year by improving three key safer sex behaviours: partner notification at one month, condom use, and sexually transmitted infection testing before unprotected sex with a new partner. Care providers and outcome assessors were blind to allocation. MAIN OUTCOME MEASURES The primary outcome was the cumulative incidence of chlamydia or gonorrhoea reinfection at one year, assessed by nucleic acid amplification tests. Safety outcomes were self-reported road traffic incidents and partner violence. All analyses were by intention to treat. RESULTS 6248 of 20 476 people assessed for eligibility between 1 April 2016 and 23 November 2018 were randomised. Primary outcome data were available for 4675/6248 (74.8%). At one year, the cumulative incidence of chlamydia or gonorrhoea reinfection was 22.2% (693/3123) in the safetxt arm versus 20.3% (633/3125) in the control arm (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). The number needed to harm was 64 (95% confidence interval number needed to benefit 334 to 8 to number needed to harm 24). The risk of road traffic incidents and partner violence was similar between the groups. CONCLUSIONS The safetxt intervention did not reduce chlamydia and gonorrhoea reinfections at one year in people aged 16-24 years. More reinfections occurred in the safetxt group. The results highlight the need for rigorous evaluation of health communication interventions.

Objectives: To develop cross-validated prediction models for severe outcomes in COVID-19 using blood biomarker and demographic data; Demonstrate best practices for clinical data curation and statistical modelling decisions, with an emphasis on Bayesian methods. Design: Retrospective observational cohort study. Setting: Multicentre across National Health Service (NHS) trusts in Southwest region, England, UK. Participants: Hospitalised adult patients with a positive SARS-CoV 2 by PCR during the first wave (March - October 2020). 843 COVID-19 patients (mean age 71, 45% female, 32% died or needed ICU stay) split into training (n=590) and validation groups (n=253) along with observations on demographics, coinfections, and 30 laboratory blood biomarkers. Primary outcome measures: ICU admission or death within 28-days of admission to hospital for COVID-19 or a positive PCR result if already admitted. Results: Predictive regression models were fit to predict primary outcomes using demographic data and initial results from biomarker tests collected within 3 days of admission or testing positive if already admitted. Using all variables, a standard logistic regression yielded an internal validation median AUC of 0.7 (95% Interval [0.64,0.81]), and an external validation AUC of 0.67 [0.61, 0.71], a Bayesian logistic regression using a horseshoe prior yielded an internal validation median AUC of 0.78 [0.71, 0.85], and an external validation median AUC of 0.70 [0.68, 0.71]. Variable selection performed using Bayesian predictive projection determined a four variable model using Age, Urea, Prothrombin time and Neutrophil-Lymphocyte ratio, with a median AUC of 0.74 [0.67, 0.82], and external validation AUC of 0.70 [0.69, 0.71]. Conclusions: Our study reiterates the predictive value of previously identified biomarkers for COVID-19 severity assessment. Given the small data set, the full and reduced models have decent performance, but would require improved external validation for clinical application. The study highlights a variety of challenges present in complex medical data sets while maintaining best statistical practices with an emphasis on showcasing recent Bayesian methods.

One of the main goals of the 2016 Global Health Sector Strategy on viral hepatitis is the elimination of hepatitis C virus (HCV) as a public health problem by 2030, defined as an 80% reduction in incidence and 65% reduction in mortality relative to 2015. Although monitoring HCV incidence is key to validating HCV elimination, use of the gold-standard method, which involves prospective HCV retesting of people at risk, can be prohibitively resource-intensive. Additionally, few countries collected quality data in 2015 to enable an 80% decrease by 2030 to be calculated. Here, we first review different methods of monitoring HCV incidence and discuss their resource implications and applicability to various populations. Second, using mathematical models developed for various global settings, we assess whether trends in HCV chronic prevalence or HCV antibody prevalence or scale-up levels for HCV testing, treatment, and preventative interventions can be used as reliable alternative indicators to validate the HCV incidence target. Third, we discuss the advantages and disadvantages of an absolute HCV incidence target and suggest a suitable threshold. Finally, we propose three options that countries can use to validate the HCV incidence target, depending on the available surveillance infrastructure.

Background:Despite being vaccine-preventable, hepatitis A virus (HAV) outbreaks occur among men who have sex with men (MSM). We modelled the cost-effectiveness of vaccination strategies to prevent future outbreaks. Methods:A HAV transmission model was calibrated to HAV outbreak data for MSM in England over 2016-2018, producing estimates for the basic reproduction number (R0) and immunity levels (seroprevalence) post-outbreak. For a hypothetical outbreak in 2023 (same R0 and evolving immunity), the cost-effectiveness of pre-emptive (vaccination between outbreaks among MSM attending sexual health services (SHS)) and reactive (vaccination during outbreak among MSM attending SHS and primary care) vaccination strategies were modelled. Effectiveness in quality-adjusted life-years (QALYs) and costs were estimated (2017 UK pounds) from a societal perspective (10-year time horizon; 3% discount rate). The incremental cost-effectiveness ratio (ICER) was estimated. Findings:R0 for the 2016-2018 outbreak was 3·19 (95% credibility interval (95%CrI) 2·87-3·46); seroprevalence among MSM increased to 70·4% (95%CrI 67·3-72·8%) post-outbreak. For our hypothetical HAV outbreak in 2023, pre-emptively vaccinating MSM over the preceding five-years was cost-saving (compared to no vaccination) if the yearly vaccine coverage rate among MSM attending SHS was <9·1%. Reactive vaccination was also cost-saving compared to no vaccination, but was dominated by pre-emptive vaccination if the yearly vaccination rate was >8%. If the pre-emptive yearly vaccination rate fell below this threshold, it became cost-saving to add reactive vaccination to pre-emptive vaccination. Interpretation:Although highly transmissible, existing immunity limited the recent HAV outbreak among MSM in England. Pre-emptive vaccination between outbreaks, with reactive vaccination if indicated, is the best strategy for limiting future HAV outbreaks. Funding:NIHR.

Introduction The COVID-19 pandemic is impacting HIV care globally, with gaps in HIV treatment expected to increase HIV transmission and HIV-related mortality. We estimated how COVID-19-related disruptions could impact HIV transmission and mortality among men who have sex with men (MSM) in four cities in China, over a one- and five-year time horizon. Methods Regional data from China indicated that the number of MSM undergoing facility-based HIV testing reduced by 59% during the COVID-19 pandemic, alongside reductions in ART initiation (34%), numbers of all sexual partners (62%) and consistency of condom use (25%), but initial data indicated no change in viral suppression. A mathematical model of HIV transmission/treatment among MSM was used to estimate the impact of disruptions on HIV infections/HIV-related deaths. Disruption scenarios were assessed for their individual and combined impact over one and five years for 3/4/6-month disruption periods, starting from 1 January 2020. Results Our model predicted new HIV infections and HIV-related deaths would be increased most by disruptions to viral suppression, with 25% reductions (25% virally suppressed MSM stop taking ART) for a three-month period increasing HIV infections by 5% to 14% over one year and deaths by 7% to 12%. Observed reductions in condom use increased HIV infections by 5% to 14% but had minimal impact (<1%) on deaths. Smaller impacts on infections and deaths (<3%) were seen for disruptions to facility HIV testing and ART initiation, but reduced partner numbers resulted in 11% to 23% fewer infections and 0.4% to 1.0% fewer deaths. Longer disruption periods (4/6 months) amplified the impact of disruption scenarios. When realistic disruptions were modelled simultaneously, an overall decrease in new HIV infections occurred over one year (3% to 17%), but not for five years (1% increase to 4% decrease), whereas deaths mostly increased over one year (1% to 2%) and five years (1.2 increase to 0.3 decrease). Conclusions The overall impact of COVID-19 on new HIV infections and HIV-related deaths is dependent on the nature, scale and length of the various disruptions. Resources should be directed to ensuring levels of viral suppression and condom use are maintained to mitigate any adverse effects of COVID-19-related disruption on HIV transmission and control among MSM in China.

BACKGROUND:Due to rising numbers of STI diagnosis and increasing prevalence of antimicrobial resistance, we explored trends in STI testing frequency and diagnoses, alongside sexual decision making and attitudes concerning condom use and HIV pre-exposure prophylaxis (PrEP) at a large urban UK sexual health clinic. METHODS:We examined 66 528 electronic patient records covering 40 321 attendees between 2016 and 2019, 3977 of whom were men who have sex with men or trans persons who have sex with men (MSM/TPSM). We also explored responses from MSM/TPSM attendees sent an electronic questionnaire between November 2018 and 2019 (n=1975) examining behaviours/attitudes towards PrEP. We measured trends in STI diagnoses and sexual behaviours including condomless anal intercourse (CAI), using linear and logistic regression analyses. RESULTS:Tests resulting in gonorrhoea, chlamydia or syphilis diagnoses increased among MSM/TPSM from 13.5% to 18.5% between 2016 and 2019 (p<0.001). The average MSM/TPSM STI testing frequency increased from 1.5/person/year to 2.1/person/year (p=0.017). Gay MSM/TPSM had the highest proportions of attendances resulting in diagnoses, increasing from 15.1% to 19.6% between 2016 and 2019 (p<0.001) compared with bisexual/other MSM/TPSM increasing from 6.9% to 14.5% (p<0.001), alongside smaller but significant increases in non-MSM/TPSM from 5.9% to 7.7% (p<0.001).The proportion of MSM/TPSM clinic attendees reporting CAI in the previous 3 months prior to at least one appointment in a given year increased significantly from 40.6% to 45.5% between 2016 and 2019 (p<0.0001) and average number of partners from 3.8 to 4.5 (p=0.002). Of 617 eligible questionnaire responses, 339/578 (58.7%) HIV-negative and 29/39 (74.4%) HIV-positive MSM/TPSM indicated they would be more likely to have CAI with someone on PrEP versus not on PrEP. 358/578 (61.9%) HIV-negative respondents said that PrEP use would make them more likely to have CAI with HIV-negative partners. CONCLUSION:Rising numbers of STI diagnoses among MSM/TPSM are not attributable to increased testing alone. Increased CAI and number of partners may be attributable to evolving sexual decision making among PrEP users and their partners. Proportionally, bisexual/other MSM/TPSM have the steepest increase in STI diagnoses.

Background People who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed. Methods In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I-2 statistic and p value for heterogeneity. Findings We identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1.55 [95% CI 1.23-1.95; p=0.0002]; I-2 = 62.7%; n=17) and HCV (1.65 [1.44-1.90; p<0.0001]; I-2 = 44.8%; n=28]) among PWID compared with those who were not homeless or were stably housed. Associations for both HIV and HCV persisted when pooling adjusted estimates (adjusted relative risk for HIV: 1.39 [95% CI 1.06-1.84; p=0.019]; I-2 = 65.5%; n=9; and for HCV: 1.64 [1.43-1.89; p<0.0001]; I-2 = 9.6%; n=14). For risk of HIV acquisition, the association for unstable housing (cRR 1.82 [1.13-2.95; p=0.014]; n=5) was higher than for homelessness (1.44 [1.13-1.83; p=0.0036]; n=12), whereas no difference was seen between these outcomes for risk of HCV acquisition (1.72 [1.48-1.99; p<0.0001] for unstable housing, 1.66 [1.37-2.00; p<0.0001] for homelessness). Interpretation Homelessness and unstable housing are associated with increased risk of HIV and HCV acquisition among PWID. Our findings support the development of interventions that simultaneously address homelessness and unstable housing and HIV and HCV transmission in this population. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.

IntroductionIn the last decade diagnoses of most STIs have risen among men who have sex with men (MSM). Although a significant proportion of this is likely due to increased STI screening, understanding the role of behavioural drivers remains critical. We measure the associations between stimulant use to enhance and prolong sexual experiences (chemsex) and bacterial STI diagnoses in UK MSM, individually considering HIV-diagnosed MSM, pre-exposure prophylaxis (PrEP) users and other MSM.MethodsWe used the UK 2017–2018 European MSM Internet Survey data (n=9375). We constructed causal inference models using multivariable logistic regression, calculating adjusted OR (aOR) and 95% CI of the associations between participation in recent (≤12 months) exclusively dyadic or multipartner chemsex versus no chemsex and recent self-reported diagnoses of syphilis, gonorrhoea and chlamydia.ResultsAmong MSM with an HIV diagnosis, 25% of users indicated recent multipartner chemsex, vs 28% of PrEP users and 5% of other MSM. Adjusting for age, ethnicity, UK birth, cis-trans status, sexual identity, education, settlement size and relationship status, participation in recent multipartner chemsex versus no chemsex was associated with greater odds of recent syphilis, gonorrhoea and chlamydia diagnosis. aORs for recent syphilis, gonorrhoea and chlamydia diagnoses were 2.6 (95% CI 1.7 to 4.1), 3.9 (95% CI 2.6 to 5.8) and 2.9 (95% CI 1.9 to 4.3), respectively, in HIV-diagnosed MSM; 1.9 (95% CI 1.1 to 3.3), 2.9 (95% CI 2.0 to 4.2) and 1.9 (95% CI 1.3 to 2.8), respectively, in PrEP users; and 4.0 (95% CI 2.3 to 6.9), 2.7 (95% CI 1.9 to 3.8) and 2.3 (95% CI 1.6 to 3.4), respectively, in other MSM. Conversely, exclusively dyadic chemsex had no significant associations with bacterial STI diagnoses among HIV-diagnosed MSM, only gonorrhoea (aOR 2.4, 95% CI 1.2 to 4.7) among PrEP users and syphilis (aOR 2.8, 95% CI 1.4 to 5.6) among other MSM.DiscussionMultipartner chemsex may drive the association between chemsex and bacterial STI diagnoses and thus should be the focus of future tailored chemsex interventions. Additionally, PrEP acceptability among MSM and particularly chemsex participants has generated an emergent group suitable for such interventions.

Background Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has helped reduce new HIV infections. However, bacterial sexually transmitted infections (STIs) have increased among PrEP users. We examined PrEP knowledge, access, and risk perceptions in an age of antimicrobial resistance (AMR). Methods An online anonymous survey was distributed to all cisgender men/transpersons who have sex with men attending a sexual health clinic in Bristol, United Kingdom (October 2018 to November 2019). Interviews with a sample identified at increased risk of HIV were analyzed thematically and integrated with survey data. Results Five hundred and seventy-eight (95%) of 617 cisgender men/transpersons who have sex with men survey respondents were HIV-negative/unknown, of these, 202 (34.9%) had ever used PrEP. Interviewees (n = 24) reported widespread awareness of and enthusiasm for PrEP. Among nonusers, 39% (146/376) were unaware how to access PrEP, and 27% (103/376) could not access PrEP through the national “impact” trial of whom 79% (81/103) were eligible. The PrEP was described as “life-changing,” but expense was the main barrier to use. Sixty-two percent (358/578) of HIV-negative/unknown respondents on PrEP were more likely to have condomless anal intercourse with someone they thought was HIV-negative. Interviewees used PrEP with other risk-reduction strategies. Sexually transmitted infections were seen as “curable” and AMR rarely influenced risk perception or sexual decision making. Conclusions The PrEP awareness was high, but purchase cost limited access. PrEP may increase condomless anal intercourse, but interviewees used PrEP as one of many risk-reduction tools. Reduced fear of HIV transmission and testing was highly valued. Sexually transmitted infection AMR was not seen as an immediate threat and did not influence risk perception or sexual decision making.

Modelling suggests hepatitis C virus (HCV) elimination is possible among men who have sex with men (MSM), with key screening groups including HIV‐diagnosed MSM and MSM using pre‐exposure prophylaxis (PrEP). Mathematical modelling was used to determine the cost‐effectiveness of HCV case‐finding strategies among MSM from the provider perspective, and to determine which interventions could achieve a 90% reduction in HCV incidence over 2015–2030. At baseline, we assumed symptomatic screening in HIV‐negative MSM (including PrEP users) and 12‐monthly screening among HIV‐diagnosed MSM. Improved case‐finding strategies included screening alongside HIV testing in HIV‐negative MSM not using PrEP (PrEP non‐users); 12/6/3‐monthly screening in PrEP users; and 6‐monthly screening in HIV‐diagnosed MSM, with the cost‐effectiveness being compared incrementally. Costs (GBP) and quality‐adjusted life years (QALYs) were assessed to estimate the mean incremental cost‐effectiveness ratio (ICER) with a time horizon to 2050, compared to a willingness‐to‐pay threshold of £20,000/QALY. From the baseline, the most incrementally cost‐effective strategy is to firstly undertake: (1) 12‐monthly HCV screening of PrEP users (gaining 6715 QALYs with ICER £1760/QALY), followed by (2) HCV screening among PrEP non‐users alongside HIV testing (gaining 7048 QALYs with ICER £4972/QALY). Compared to the baseline, this combined strategy would cost £46.9 (95%CrI £25.3–£66.9) million and achieve the HCV elimination target in 100% of model runs. Additional screening incurs ICERs >£20,000/QALY compared to this combined strategy. In conclusion, HCV elimination can be achieved cost‐effectively among UK MSM. Policymakers should consider scaling‐up HCV screening in HIV‐negative MSM, especially PrEP users, for achieving this target.

MacGregor, L; Martin, NK; Mukandavire, C; Hickson, F; Weatherburn, P; Hickman, M; Vickerman, P; (2017) Behavioural, not biological, factors drive the HCV epidemic among HIV-positive MSM: HCV and HIV modelling analysis including HCV treatment-as-prevention impact. International journal of epidemiology. ISSN 0300-5771 DOI: https://doi.org/10.1093/ije/dyx075 Downloaded from: http://researchonline.lshtm.ac.uk/3962340/ DOI: https://doi.org/10.1093/ije/dyx075

Background Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown. Methods An HCV/HIV transmission model was calibrated to UK prevalence of HIV (5·9%) and chronic HCV infection among HIV-positive MSM (10·0%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the impact on HCV incidence (2018–2030) of HCV screening every 12/6/3-months (and completing treatment within 6 months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We then estimated the additional screening required among HIV-negative non-PrEP users to achieve a 90% reduction in overall incidence by 2025/2030. The effect of a 50% reduction in condom use among PrEP users (risk compensation) was estimated. Results Without risk compensation, PrEP scale-up decreases HCV incidence by 9·5% by 2030, whereas it increases by 26·5% with risk compensation. Screening and treating PrEP users for HCV every 12/6/3-months decreases HCV incidence by 41/46/48%, respectively, increasing to 74/81/83% if HIV-diagnosed MSM are also screened at the same frequencies. Risk compensation reduces these latter projections by <5%. To achieve a 90% reduction in HCV incidence by 2030 (values in bracket are with risk compensation), HIV-negative MSM not on PrEP require screening every 5·2 (4·5) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, decreasing to every 2·6 (2·3) years for the 2025 target. For 25% PrEP coverage, then the 2030 HCV elimination target may be reached without screening HIV-negative MSM not on PrEP. Conclusion Increased screening of all MSM (particularly HIV-diagnosed MSM and MSM on PrEP) is required to achieve the WHO HCV-elimination targets for MSM in the UK. Disclosure No significant relationships.

Pre-exposure prophylaxis (PrEP) for HIV prevention is recommended by WHO as part of a comprehensive HIV prevention package for people at substantial risk of HIV infection. 1 WHOGuidelines on when to start anti-retroviral therapy and on pre-exposure prophylaxis for HIV. https://apps.who.int/iris/bitstream/handle/10665/186275/9789241509565_eng.pdf?sequence=1Date: September 2015 Date accessed: September 20, 2018 Google Scholar PrEP is effective at preventing HIV acquisition, as is shown by high efficacy in placebo-controlled trials and demonstration projects, and increased PrEP coverage is associated with substantial decreases in HIV incidence across the population of men who have sex with men in high-income settings. 2 Grulich A, Guy RJ, Amin J, et al. Rapid reduction in HIV diagnoses after targeted PrEP implementation in NSW, Australia. 25th Conference on Retroviruses and Opportunistic Infections; Boston, MA, USA; March 4–7, 2018 (abstr 88). Google Scholar , 3 Fonner VA Dalglish SL Kennedy CE et al. Effectiveness and safety of oral HIV pre-exposure prophylaxis for all populations. AIDS. 2016; 30: 1973-1983 Crossref PubMed Scopus (402) Google Scholar , 4 Nwokolo N Hill A McOwan A Poznak A Rapidly declining HIV infection in MSM in central London. Lancet HIV. 2017; 4: e482-e483 Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar

BACKGROUND:Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.METHODS:An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.RESULTS:Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.INTERPRETATION:At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

Background There is currently considerable interest the complex relationship between PrEP and STI incidence. Our Challenges and Opportunities of PrEP (CHOP) study uses qualitative and quantitative methods to ascertain the changes in behaviour and STI rates in high risk men/transgender/nonbinary persons who have sex with men (MSM/TPSM) before and after commencement of the PrEP Impact trial (‘Impact’) in our clinic (01/12/2017). Methods We performed retrospective data analysis of clinic and laboratory records for MSM/TPSM attendees who attended a British sexual health clinic in a large urban area between 01/12/2016 and 28/02/2019. We used logistic regression to compare STI diagnoses (chlamydia, gonorrhoea and syphilis at any site) and sexual risk score in two time periods (1: 01/12/2016 – 31/11/17 and 2: 01/12/2017 to 28/02/2019). Results Of 72,667 attendances, 10,918 were MSM/TPSM and, excluding duplicate entries (164) and those who were already HIV positive (236), this left 3,407 individuals with 10,518 attendances: 4,378 (period 1) and 6,140 (period 2). Mean HIV acquisition risk score at first visit in period 1 was 5.8 and 5.4 in period 2. In period 1 at first visit 13.5% (266/1,975) had one or more STI compared with 20.2% (289/1143) in period 2, a rise of 6.7%. Logistic regression showed OR1.6 (p<0.001, 95%CI 1.35–1.95). STI diagnoses for subsequent visits in period 1, 6.3% (151/2403) attendances had one or more STIs diagnosed, and in period 2 10.9% (513/4708). This is a rise of 4.6% (OR 1.8 (p<0.001 95%CI 1.51–2.20). Conclusion Although risk score was similar during both time periods, STI rates were significantly higher both at first visit and at subsequent visits. The qualitative aspect of this study will explore whether this reflects attracting more high risk MSM/TPSM into the service or whether use of PrEP increases risk-taking behaviour. Disclosure No significant relationships.

Background People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I (2) statistic and the P-value for heterogeneity. Findings We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1.81, 95% CI 1.40-2.34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I-2=63.5%; p=0.001), and a 62% (RR 1.62, 95% CI 1.28-2.05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I-2=57.3%; p=0.002). Past incarceration was associated with a 25% increase in HIV (RR 1.25, 95% CI 0.94-1.65) and a 21% increase in HCV (1.21, 1.02-1.43) acquisition risk. Interpretation Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID. Copyright (c) 2018 The Author(s). Published by Elsevier Ltd.