Decline in genital warts diagnoses among young women and young men since the introduction of the bivalent HPV (16/18) vaccination programme in England: an ecological analysis.

BACKGROUND: For several decades, diagnoses of genital warts at genitourinary medicine (GUM) clinics in England had been increasing. In 2008, a national human papillomavirus (HPV) vaccination programme was introduced using the bivalent vaccine (types 16 and 18 only). A decrease in genital warts was not anticipated. However, rates of genital warts in GUM clinics have declined significantly since the introduction of the vaccine. METHODS: Using data from GUM clinics across England, we analysed rates of genital warts by age, gender, sexual orientation and estimated vaccine coverage. RESULTS: The reduction in rates of genital warts diagnoses at GUM clinics between 2009 and 2014 was 30.6% among young women aged 15-19 years and 25.4% among same age heterosexual young men. Overall there was an association showing higher warts reduction with increasing vaccination coverage with the largest declines in warts diagnoses observed in young women aged 15 years (50.9%) with the highest vaccination coverage. No such declines were observed in men who have sex with men (MSM) of the same age. CONCLUSION: The results of these ecological analyses are strongly in keeping with the bivalent HPV vaccine providing modest protection against genital warts.

Ten-year follow-up of two cohorts with an increased risk of variant CJD: donors to individuals who later developed variant CJD and other recipients of these at-risk donors.

BACKGROUND: Transmission of variant Creutzfeldt-Jakob disease (vCJD) through blood transfusion is implicated in three deaths and one asymptomatic infection. Based on this evidence, individuals assessed to be at increased risk of vCJD through donating blood transfused to individuals who later developed vCJD, or through being other recipients of such donors, are followed up to further understand the risks of vCJD transmission through blood. OBJECTIVES: To provide a ten-year follow-up of these at-risk cohorts. METHODS: Blood donors to patients who later died from vCJD were identified by the Transfusion Medicine Epidemiological Review (TMER) study. A reverse risk probability assessment quantified the risk of blood transfusion or exposure through diet as the source of vCJD in the recipients. Donors to these recipients, and these donors' other recipients, with a probability risk above 1%, are classified as at increased risk of vCJD for public health purposes. These cohorts are monitored for any vCJD occurrences. RESULTS: A total of 112 donors and 33 other recipients of their donated blood have been classified as at increased risk. After 2397 and 492 vCJD-free years of follow-up, respectively, no deaths in either at-risk cohort were of vCJD-related causes. CONCLUSIONS: The at-risk cohorts have survived disease-free far longer than the estimated incubation time for dietary-acquired vCJD (donors) and transfusion-acquired disease (other recipients). However, due to our still limited understanding of, and a lack of a reliable test for, asymptomatic vCJD infection, public health follow-up is necessary for continued monitoring of at-risk cohorts.

High uptake of HPV immunisation in Scotland--perspectives on maximising uptake.

In September 2008, Scotland introduced a national human papillomavirus (HPV) immunisation programme with bivalent HPV vaccine, to prevent cervical cancer. This school-based programme routinely vaccinates girls aged between 12 and 13 years. A catch-up campaign, running over three years, also began at this time, offering vaccination to all girls aged 13 years to under 18 years old. The HPV immunisation campaign presented challenges due to this vaccine being targeted to girls in school and older girls who had left school. Following a long and comprehensive planning process, this campaign was successfully implemented across Scotland, delivering high vaccine uptake of 91.4% for three doses of vaccine in the first year (September 2008 to August 2009) for the routine cohort and 90.1% in the second year (September 2009 to August 2010) for the routine cohort. We describe the planning process, challenges and implementation strategies employed to achieve this high uptake.

HPV type-specific prevalence using a urine assay in unvaccinated male and female 11- to 18-year olds in Scotland.

BACKGROUND: We conducted a baseline prevalence survey of unvaccinated 11- to 18-year olds to inform effectiveness studies for the new human papillomavirus (HPV) immunisation programme in Scotland. METHODS: Participants were recruited from schools and colleges and invited to provide demographic data and an anonymous urine sample for type-specific HPV testing. RESULTS: Among females aged 11-14 years, the weighted prevalence was 1.1% overall; 0.9% for high-risk types and no infections were associated with types 16 and 18. Among 15- to 18-year old females, the weighted prevalence was 15.2% overall; 12.6% for high-risk types and 6.5% for types 16 and 18. Among females aged 16-18 years, infection was more frequently associated with attending college and rural schools, and showed a trend towards increasing prevalence with increasing social deprivation (P=0.045). Among males aged 11-14 years, the weighted prevalence was 1.4% overall; 1.0% for high-risk types and 0.7% for types 16 and 18. Among 15- to 18-year old males, the weighted prevalence was 3.9% overall; 2.4% for high-risk types and 0.7% for types 16 and 18. CONCLUSIONS: Human Papillomavirus prevalence is low among 11- to 14-year olds, which includes the age group targeted for routine vaccination. The prevalence in males and correlation with deprivation require further investigation.

Ongoing outbreak of mumps infection in Oban, Scotland, November 2010 to January 2011.

We report on an ongoing outbreak of 119 cases of mumps virus infection in the Oban area of Scotland,from 29 November 2010 to 31 January 2011. The median age of cases was 20 years, with the highest incidence in the 13-19-year-olds. A total of 53 cases had received two doses of measles-mumps-rubella (MMR) vaccine,in accordance with the United Kingdom vaccination schedule, while 33 had received only one dose and 30 had not been vaccinated.

Men who have sex with men who are born abroad and diagnosed with HIV in England and Wales: an epidemiological perspective.

Relatively little is known about the sexual health needs of men who have sex with men (MSM) born abroad who reside in the UK. We describe here the epidemiology of HIV among MSM born outside the UK and diagnosed with HIV in England and Wales. Reports of HIV diagnoses in England and Wales received at the Health Protection Agency Centre for Infections were analysed. Between 2000 and 2003, 6386 MSM were diagnosed with HIV in England and Wales. Country of birth was recorded for 3571 (56%). Of those with country of birth reported, 2598 (73%) were born in the UK and 973 (27%) abroad. Of those born abroad (973), 424 (44%) were born in Europe, 141 (15%) in Africa, 104 (11%) in South/Central America and the remainder in other regions. Where reported (949), 69% of MSM born abroad were White, 12% other/mixed, 9% Black Caribbean and 7% Black African. Probable country of infection was reported for 612 MSM born abroad: 52% were infected in the UK, 43% in their region of birth and 5% in another region. Men born abroad represent a significant proportion of HIV diagnoses among MSM in England and Wales. More than half probably acquired their HIV infection in the UK, strengthening the call for targeted HIV prevention and sexual health promotion among MSM who are not born in England and Wales.

The changing epidemiology of diagnosed prevalent HIV infections in England: greatest impact on the London environs.

Data from the 1997-2004 Surveys of Prevalent HIV Infections Diagnosed were analysed by three geographical areas of residence and treatment to describe the heterogeneous growth of the HIV epidemic in England and provide projections to 2007. Between 1997 and 2004, the number of diagnosed HIV-infected adults resident in England increased by 163% (14,223 to 37,459). Within the 'London environs' the increase was 360% (742 to 3411), within the rest of England 219% (4417 to 14,088) and within London 120% (9064 to 19,960). By 2004, the London environs had the largest proportion of infections acquired through heterosexual sex (and in particular women) and the most recently diagnosed population. Projections indicate over half of diagnosed HIV-infected adults will live outside London by 2007. The epidemiology of diagnosed HIV infection within the London environs is likely to be a predictor of future trends in England overall.

Late diagnosis of HIV infection among individuals with low, unrecognised or unacknowledged risks in England, Wales and Northern Ireland.

A small number of UK nationals who have a low, unrecognised or unacknowledged risk for HIV present late in the course of HIV infection; often after frequent attendances to primary care physicians. Information from in-depth interviews with individuals diagnosed with HIV in England, Wales and Northern Ireland (EW&NI) was analysed. Those diagnosed because of HIV-related symptoms (late diagnoses) were compared with those diagnosed for other reasons. Of the 286 individuals interviewed, 157 (55%) had HIV-related symptoms at the time of diagnosis, and 129 were tested for other reasons. A greater proportion of those diagnosed late were male and older. Of the 157 late diagnoses, 77 were considered to have acquired HIV heterosexually in the UK, 19 heterosexually abroad, 16 through 'high-risk' behaviours, 15 heterosexually by a 'high-risk' partner, four through blood transfusion and the remainder through an unusual or unknown route. A significantly higher proportion of those diagnosed late had had a long-standing relationship. None had been informed by a current or ex-partner of their HIV status. Primary care physicians should consider HIV as a possibility when patients without an apparent risk for HIV-infection present with symptoms indicative of possible immune suppression. Sensitive partner notification practices that enable a greater number of individuals to inform their partners should be explored.

Diagnoses of HIV-1 and HIV-2 in England, Wales, and Northern Ireland associated with west Africa.

OBJECTIVES: To describe HIV diagnoses, including those of HIV-2 infection, made in England, Wales, and Northern Ireland (E,W&NI) among those probably infected in west Africa, and to consider whether there is evidence for ongoing heterosexual transmission within the United Kingdom. METHODS: Reports of new HIV diagnoses received at the Communicable Disease Surveillance Centre were analysed. Individuals probably infected in west Africa and those infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa were included. RESULTS: Between 1985 and 2003 inclusive, 1324 individuals diagnosed and reported with HIV had probably been infected in west Africa, with 222 diagnoses made in 2003. 917 (69%) were HIV-1 infected and 52 (6%) HIV-2 or HIV-1/HIV-2 co-infected. For 355 (27%) the HIV type was not reported. The proportion of HIV-2 and HIV-1/HIV-2 infections varied by country of infection (p<0.001): ranging from the Gambia (11.7%-15.2%) to Nigeria (0.7%-1.0%). A further 130 individuals were probably infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa. 89 (68%) were HIV-1 infected and three (2%) HIV-2 infected or HIV-1/HIV-2 co-infected. For 38 (29%) HIV type was not reported. CONCLUSION: The number of people infected with HIV in west Africa and diagnosed in E,W&NI has increased in recent years, and there is evidence of heterosexual transmission within the United Kingdom from people infected in west Africa. While numbers of HIV-2 diagnoses remain relatively low, an appreciable proportion of people infected in some west African countries and diagnosed in the United Kingdom may be HIV-2 positive, with implications for prognosis and treatment.

The changing epidemiology of prevalent diagnosed HIV infections in England, Wales, and Northern Ireland, 1997 to 2003.

OBJECTIVES: To present the current epidemiology of prevalent diagnosed HIV infections in England, Wales, and Northern Ireland (E, W, & NI) and describe trends over time. METHODS: Descriptive analyses of the annual national Survey of Prevalent HIV Infections Diagnosed (SOPHID) for the period 1997 to 2003. RESULTS: In 2003, 34 251 adults (15 years of age or over) were seen for HIV related care in E, W, & NI, representing a 17% increase in the prevalence of diagnosed HIV infections compared with 2002 and a 132% increase compared with 1997. Between 1997 and 2003, as a proportion of total prevalent cases, adults who acquired their infection through heterosexual sex increased from 26% to 49%; black African adults increased from 15% to 35% and diagnosed adults resident in London fell from 62% to 55% of the total. The male to female ratio declined from 5:1 to 2:1. The proportion of adults receiving combination antiretroviral therapy increased from 53% in 1998 to 64% in 2003. CONCLUSION: There has been a large increase in the number of adults with diagnosed HIV infection seen for care in E, W, & NI since 1997. Changes in the epidemiology of prevalent diagnosed HIV were seen by sex, route of infection, ethnicity, level of antiretroviral therapy, and areas of residence and treatment. In 2003, for the first time, prevalent diagnosed infections acquired through heterosexual sex over-took those acquired through sex between men. These increases have serious implications for the planning and financing of HIV services in the United Kingdom.

Epidemiology of HIV among black and minority ethnic men who have sex with men in England and Wales.

OBJECTIVES: To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (E&W). METHODS: Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth. RESULTS: Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in E&W were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p<0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%. CONCLUSIONS: Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in E & W; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in E&W was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in E&W.

Evaluation of the de-selection of men who have had sex with men from blood donation in England.

BACKGROUND AND OBJECTIVES: The Blood Services of the UK permanently de-select men who have had sex with men (MSM) from donating blood. The rationale for this has been questioned. This article attempts to evaluate whether this selection criterion does contribute to blood safety. MATERIALS AND METHODS: Data about transfusion-transmissible infections, in particular about human immunodeficiency virus (HIV) infection, were used to evaluate whether de-selection of MSM meets the aims of donor selection. Models were constructed to estimate the risk of HIV-infectious donations entering the blood supply should this criterion be changed. RESULTS: Many assumptions were required to generate estimates of the risk of HIV infection entering the blood supply. The accuracy of the estimates is therefore uncertain and the probable ranges around the estimates were wide. However, by using the most probable assumptions, our models suggested that de-selection of MSM for 12 months since the last sexual contact, or complete removal of this selection criterion, would be expected to increase the risk of HIV-infectious donations entering the blood supply in England by approximately 60% (from the current risk of 0.45 per year to 0.75 per year) and 500% (to 2.5 per year), respectively. The increase in numbers of non-infected donations would be relatively small--less than 2% of donations. The probability of a relatively high frequency of other sexually transmissible blood-borne infections also currently favours maintaining permanent de-selection of MSM, irrespective of the risk of HIV-infectious donations. Current compliance with this selection criteria was estimated to be 95%. CONCLUSIONS: Based on current knowledge, accepting blood donations from MSM would probably increase the risk of transfusion-transmission of HIV and of other blood-borne infections. Good compliance with this criterion has contributed greatly to the safety of blood transfusions in England. Better communication about donor selection, to maintain and improve compliance with this and other selection criteria, is recommended. Other risk groups are gaining in relative importance for the risk of transfusion-transmitted HIV infection, and ongoing evaluation of all donor-selection criteria is also recommended.

National assessment of prevalent diagnosed HIV infections.

HIV infection is associated with high treatment and care costs and subject to large differences in prevalence between health districts. Equitable distribution of resources requires information provided by an annual national survey of prevalent diagnosed HIV infections (SOPHID). This measures HIV caseloads by health district of residence throughout England, Wales, and Northern Ireland and is used to inform local public health professionals and to improve allocation of government funding for HIV prevention and care. Survey totals are adjusted by underreporting and non-attendance factors to produce a more accurate assessment of the total caseloads. On average the combined adjustments increase the reported caseload by 14.7% annually. Adjusted prevalence estimates ranged from 14,164 in 1995 to 18,460 in 1998, an increase of 30%.

An estimate of the contribution of HIV infection to the recent rise in tuberculosis in England and Wales.

BACKGROUND: The number of patients with tuberculosis has been increasing slowly in England and Wales since the late 1980s. HIV infection has been a contributory factor to increases in tuberculosis in a number of comparable industrialised countries. This study investigated the extent of tuberculosis and HIV co-infection in England and Wales in 1993 and 1998, and estimated its contribution to the increase in tuberculosis observed during this period. METHODS: Patients aged 16-54 years old at diagnosis on the 1993 and 1998 National Tuberculosis Survey databases were matched with those on the HIV/AIDS patient database. A coded process maintained patient confidentiality. Primary outcome measures were the increase between 1993 and 1998 in the numbers with both infections reported and an estimate of the proportion of the increase in tuberculosis during this period attributable to HIV co-infection. RESULTS: In 1993 61 (2.2%) tuberculosis patients aged 16-54 years matched with patients reported to the HIV database, increasing to 112 (3.3%) in 1998 (p=0.08; OR 1.35; 95% CI 0.97 to 1.87). Patients co-infected with HIV contributed an estimated 8.5% of the increase in number of tuberculosis patients between 1993 and 1998 nationwide (11% in London). In both years prevalence of co-infection was greatest in London and in patients of white and black African ethnic groups. CONCLUSIONS: In 1998 the number of tuberculosis patients co-infected with HIV in England and Wales, though still small, had nearly doubled since 1993, with most of the increase occurring in London. As HIV infection may be undiagnosed in patients with tuberculosis, and tuberculosis may be unreported in patients with diagnosed HIV infection, the true extent of co-infection will have been underestimated by this study. In addition, constraints in coded matching make it inevitable that some reported co-infections are missed. Routine HIV testing of all patients with tuberculosis should now be considered, particularly in patients of white or black African ethnic origin under 55 years of age.

Numbers of adults with diagnosed HIV infection 1996-2005--adjusted totals and extrapolations for England, Wales and Northern Ireland.

Using data from the annual surveys of individuals receiving HIV related treatment or other care from 1996 to 2000, trends in prevalent numbers of diagnosed HIV infections have been extrapolated to the years 2001-05. Results show that the adjusted prevalent number for 1996 was 14,205 and that this has increased by 62% by the end of 2000, and will have increased by 139% by the end of 2005. The drivers for this increase have been the sustained rise in diagnoses in infections heterosexually acquired in sub-Saharan Africa and the continuing numbers of new diagnoses in men who have sex with men.

Survival after diagnosis of AIDS among adults resident in the United Kingdom in the era of multiple therapies.

The epidemiology of HIV and AIDS in the United Kingdom (UK) has changed markedly since highly active antiretroviral therapy (HAART) was introduced in 1996. HAART including protease inhibitors has considerably improved survival from AIDS diagnosis. The number of deaths of individuals with HIV infection in the UK, reported within 12 months of the end of the year of death, have decreased between 1995 and 1998. Concurrently AIDS diagnoses, reported within 12 months of the end of the year of diagnosis, have declined whilst diagnoses of HIV infection, similarly reported, have risen. Data from 13,689 adult AIDS cases diagnosed up to the end of 1996 were analysed. The overall median survival from AIDS diagnosis to death was 19.3 months. Over 50% of the cases diagnosed in 1996 were alive at the end of the survey therefore median survival exceeds 24 months, the maximum follow up time for the cohort. The opportunity for receiving HAART was modelled in three time periods: pre-multiple therapies (before September 1995), multiple reverse-transcriptase inhibitor therapy available (September 1995 to March 1996), and multiple therapy including protease inhibitors available (April 1996 onwards). Survival rates improved significantly among female heterosexuals and men who have sex with men when multiple therapy including protease inhibitors became available.