PrEP use and unmet PrEP-need among men who have sex with men in London prior to the implementation of a national PrEP programme, a cross-sectional study from June to August 2019.

BACKGROUND: Access to prevention options, including HIV pre-exposure prophylaxis (PrEP), remains a public health priority for gay, bisexual, and other men who have sex with men (MSM), especially in London. We describe PrEP use in a London community sample of MSM before the introduction of a national PrEP programme in October 2020. METHODS: From June-August 2019, MSM aged ≥ 18 recruited from London commercial venues were asked to self-complete a sexual health questionnaire and provide an oral fluid sample for anonymous HIV antibody testing. Descriptive analyses of demographic characteristics, service engagement and outcomes, as well as sexual risk and prevention behaviours were examined in the survey population and in those reporting current PrEP use. We performed sequential, multivariate analyses examining current PrEP use in MSM of self-perceived HIV-negative/unknown status with identified PrEP-need defined as the report of condomless anal sex (CAS) in the last three months, or the report of CAS (in the last year) with an HIV-positive/unknown status partner not known to be on HIV treatment, in reflection of UK PrEP guidelines. RESULTS: One thousand five hundred and thirty-fifth questionnaires were completed across 34 venues, where 1408 were analysed. One in five MSM of self-perceived HIV-negative/unknown status reported current PrEP use (19.7%, 242/1230). In men with PrEP-need, 68.2% (431/632) did not report current use. Current PrEP use was associated with age (aOR: 3.52, 95% CI: 1.76-7.02 in men aged 40-44 vs men aged 18-25) and education (aOR: 1.72, 95% CI: 1.01-2.92 in men with ≥ 2 years/still full-time vs no/ < 2 years of education since age 16). CONCLUSION: Among MSM in London, PrEP use is high but there is indication of unmet PrEP-need in men of younger age and lower levels of post-16 education. National programme monitoring and evaluation will require continued community monitoring to guide interventions ensuring equitable PrEP access and uptake in those who could most benefit from PrEP.

Patterns of sexualised recreational drug use and its association with risk behaviours and sexual health outcomes in men who have sex with men in London, UK: a comparison of cross-sectional studies conducted in 2013 and 2016.

OBJECTIVE: London has one of the highest identified prevalence of chemsex (sexualised recreational drug use) among men who have sex with men (MSM) in Europe. We examine MSM's patterns of chemsex and its association with HIV/STI risk behaviours, STI diagnoses and sexual healthcare-seeking behaviours, including if HIV testing behaviour met UK national guidelines (three monthly if engaging in chemsex). METHODS: Cross-sectional survey data from 2013 (n=905) and 2016 (n=739) were collected using anonymous, self-administered questionnaires from MSM recruited in commercial gay venues in London, UK. Descriptive and multivariable analyses, stratified by self-reported HIV status, were conducted. Adjusted prevalence ratios (aPR) with 95% CIs were calculated. RESULTS: Comparing the 2013 and 2016 surveys, chemsex prevalence in the past year remained stable, in both HIV-negative/unknown-status MSM (20.9% in 2013 vs 18.7% in 2016, p=0.301) and HIV-positive MSM (41.6% in 2013 vs 41.7% in 2016, p=0.992). Combined 2013-2016 data showed that compared with other MSM, those reporting chemsex were more likely to report HIV/STI risk behaviours, including condomless anal intercourse with serodifferent HIV-status partners (HIV-negative/unknown-status men: aPR 2.36, 95% CI 1.68 to 3.30; HIV-positive men: aPR 4.19, 95% CI 1.85 to 9.50), and STI diagnoses in the past year (HIV-negative/unknown-status men: aPR 2.10, 95% CI 1.64 to 2.69; HIV-positive men: aPR 2.56, 95% CI 1.57 to 4.20). 68.6% of HIV-negative/unknown-status men reporting chemsex attended sexual health clinics and 47.6% had tested for HIV more than once in the past year. CONCLUSIONS: Chemsex in London MSM remained stable but high, particularly among HIV-positive men. Irrespective of HIV status, chemsex was associated with engagement in HIV/STI risk behaviours. Frequency of HIV testing in the past year among HIV-negative/unknown-status men was below national recommendations. Promoting combination prevention strategies, including three monthly HIV/STI testing, access to pre-exposure prophylaxis/antiretroviral treatment and behavioural interventions among MSM reporting chemsex, remains vital to address sexual health inequalities in MSM.

Recruiting and Engaging Heterosexual-Identified Men Who have Sex with Men: A Brief Report of Considerations for Sex Researchers.

Heterosexual-identified men who have sex with men (H-MSM) are a unique population difficult to identify and recruit for research and practice. Yet, engaging H-MSM remains a top research priority to learn more about this population's health needs. A scoping review was conducted to develop a stronger understanding of recruitment patterns involving H-MSM in research. The search and screening procedures yielded 160 total articles included in the present study. Most studies relied on venue-based and internet-based recruitment strategies. Thematic analysis was then used to identify three themes. Locations of H-MSM's sexual encounters related to where sex researchers may recruit participants; sociocultural backgrounds of H-MSM related to important characteristics researchers should acknowledge and consider when working with H-MSM; and engagement with health services related to how H-MSM interact with or avoid HIV/STI testing and treatment and other public health services. Findings suggest H-MSM have sex with other men in a variety of venues (e.g. bathhouses, saunas) but tend to avoid gay-centric venues. H-MSM also are diverse, and these unique identities should be accounted for when engaging them. Finally, H-MSM are less likely to access healthcare services than other MSM, highlighting the need for targeted advertisements and interventions specific for H-MSM.

Household structure and its association with sexual risk behaviours and sexual health outcomes: evidence from a British probability sample survey.

OBJECTIVES: Economic and social changes over the last 20 years have led to changes in the living situations of young people in Britain. A person's home-life context might influence their sexual behaviour, with implications for their sexual healthcare needs; we investigated this hypothesis. METHODS: Britain's third National Survey of Sexual Attitudes and Lifestyles, a probability sample survey undertaken in 2010-2012, interviewed 15 162 men and women aged 16-74 years in Britain (with 3869 aged 16-24 years). We examined household structure by gender and age group. We then focused on sexually experienced young people (aged 16-24 years), and used multivariable models to explore associations between household structure, sexual risk behaviours and sexual health outcomes, independent of confounders including age, relationship status, employment and area of residence. RESULTS: Young people were most likely to be living with parents (women 57.1% (95% CI 54.5% to 59.6%) and men 68.7% (95% CI 65.4% to 71.8%)) or non-relatives (women 10.5% (95% CI 8.5% to 12.9%) and men 12.6% (95% CI 10.1% to 15.6%)). Among the 81.3% of young people who were sexually experienced, compared with young women living with parents (reference category), young women living alone or with non-relatives had a higher likelihood of reporting ≥2 sexual partners (adjusted OR 1.54 (95% CI 1.03 to 2.31); 1.76 (95% CI 1.03 to 3.00), respectively). Women living alone were also more likely to have had unsafe sex (2.04 (95% CI 1.38 to 3.02)). Despite these differences in sexually transmitted infection (STI) risk, there was no difference in sexual healthcare-seeking behaviour. Young men and women living with partners reported lower levels of sexual risk behaviours. CONCLUSIONS: Our study suggests household structure may influence the sexual behaviour of young people in Britain. Given changes in their living arrangements, the role of household structure in sexual health research should be further investigated, and also considered as a possible marker for STI risk in clinical consultations.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review.

BACKGROUND: Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model. METHODS: Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma). CONCLUSIONS: This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed. TRIAL REGISTRATION: PROSPERO CRD42016041786.