Identifying missed opportunities for hepatitis C virus antenatal testing and diagnosis in England.

New case-finding opportunities are needed to achieve hepatitis C virus (HCV) elimination in England by the year 2030. HCV antenatal testing is not offered universally in England but is recommended for women with risk factors for HCV (e.g. injecting drug use, being born in a high-prevalence country). The aim of this analysis was to investigate the missed opportunities for HCV antenatal testing among women who had given birth and were subsequently diagnosed with HCV at some time after childbirth. By linking data on live births (2010-2020) to laboratory reports of HCV diagnoses (1995-2021), we identified all women who were diagnosed with HCV after the date of their first childbirth. This group was considered to potentially have experienced a missed opportunity for HCV antenatal testing; HCV-RNA testing and treatment outcomes were also obtained for these women. Of the 32,295 women who gave birth between 2010 and 2020 with a linked diagnosis of HCV (median age: 34 years, 72.1% UK-born), over half (n = 17,123) were diagnosed after childbirth. In multivariable analyses, the odds of being diagnosed with HCV after childbirth were higher in those of Asian Bangladeshi, Black African or Chinese ethnicity and among those born in Africa. Over four-fifths (3510/4260) of those eligible for treatment were linked to treatment, 30.7% (747/2435) of whom had a liver scarring level of at least moderate and 9.4% (228/2435) had cirrhosis. Given the potential opportunity to identify cases of HCV with targeted case-finding through antenatal services, universal opt-out testing should be considered in these settings.

Understanding current antenatal Hepatitis C testing and care in maternity services in England.

OBJECTIVES: Universal opt-out antenatal screening for Hepatitis C virus (HCV) is not currently recommened and it is recommended that maternity services offer risk-based testing. We aimed to investigate antenatal HCV testing and adherence to testing guidance. METHODS: A cross-sectional survey was circulated to maternity service providers between November-December 2020 which included testing policy, training for healthcare staff, and management of women found to be HCV positive. Descriptive data are presented. RESULTS: A total of 75 questionnaires were returned, representing 48 % of English maternity service providers. 87 % of providers reported offering antenatal HCV risk-based testing. Risk factors used to identify pregnant women for testing varied. Less than 15 % of respondents considered women that were ever homeless or with history of incarceraton or from higher HCV prevalence areas as high risk. CONCLUSIONS: Current antenatal HCV testing practices are inadequate and HCV infection likely goes undiagnosed in pregnancy, especially among vulnerable population groups. In the absence of universal antenatal screening, re-framing antenatal HCV risk-based testing and management as a quality improvement initiative and developing HCV specific pathway guidance for maternity units is required.

Investigating rates and risk factors for hepatitis C virus reinfection in people receiving antiviral treatment in England.

England has committed to the World Health Organization target to eliminate hepatitis C virus (HCV) as a public threat by the year 2030. Given successful treatments for HCV in recent years, it is unclear whether HCV reinfection will impact England's ability to achieve HCV elimination. We aimed to estimate the HCV reinfection rate among a cohort of patients receiving antiviral treatment using available surveillance data. Linkage between a treatment dataset from 2015 to 2019 and an HCV RNA testing dataset were used to identify people who experienced reinfection using three criteria. A Cox proportional hazards model was used to determine risk factors associated with HCV reinfection among a cohort who received treatment and had follow-up HCV RNA testing. The reinfection rate among those receiving HCV treatment was 7.91 per 100 person-years (PYs, 95% confidence interval (CI) 7.37-8.49) and highest among current injecting drug users (22.55 per 100 PYs, 95% CI 19.98-25.46) and people who had been in prison (20.42 per 100 PYs, 95% CI 17.21-24.24). In the adjusted model, women had a significantly reduced risk of reinfection. Being of younger age, current injecting drug users, and receipt of first treatment in prison were each significantly associated with increased risk of reinfection. Two-fifths of those with reinfection (43%, n = 329/767) were linked to treatment after reinfection, and of those starting treatment, three quarters (75%, n = 222/296) achieved a sustained virologic response. Guidance for testing groups at risk of reinfection and harm reduction strategies to minimize transmission should be implemented if England is to achieve HCV elimination targets.

"Belt and braces approach; added benefit and extra reassurance": a multi-stakeholder examination of the challenges to effective provision of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Northern and Central England.

Pre-exposure prophylaxis (PrEP) involves HIV negative individuals taking antiretroviral drugs to reduce the probability of infection if exposed and is available through the IMPACT trial in England. This study aimed to explore men who have sex with men (MSM) and service provider (SP) perspectives on provision and accessibility of PrEP in Northern and Central England. Twenty MSM and 25 SPs from four Northern cities and one city in the West Midlands region were recruited for semi-structured interviews (December 2018 to October 2019). Interviews were analysed using Interpretative Phenomenological Analysis (IPA). Three key themes emerged: "Self-sourcing PrEP"; "Service delivery learnings"; and "Impact of using PrEP". Problems with equity of access and accessibility were noted, and recommendations for the future of PrEP programming and equitable service delivery were also presented. The study highlighted divergence in PrEP service experience from patients and providers, with results informing policy, practice and professional training.

Psychosocial and sexual characteristics associated with sexualised drug use and chemsex among men who have sex with men (MSM) in the UK.

OBJECTIVE: To understand how the emerging public health issue of chemsex relates to broader patterns of sexualised drug use (SDU) among men who have sex with men (MSM), which has been understudied. METHODS: Potential participants were invited to take part in an anonymous, cross-sectional online survey through Facebook advertising and community organisations' social media posts (April-June 2018). Multivariable logistic regression was used to compare MSM who engaged in recent SDU (past 12 months) with those who did not, and those who engaged in chemsex (γ-hydroxybutyrate/γ-butyrolactone, crystal methamphetamine, mephedrone, ketamine) with those who engaged in other SDU (eg, poppers, cocaine, cannabis). RESULTS: Of the 1648 MSM included, 41% reported recent SDU; 15% of these (6% of total, n=99) reported chemsex. Factors associated with SDU were recent STI diagnosis (aOR=2.44, 95% CI 1.58 to 3.76), sexual health clinic attendance (aOR=2.46, 95% CI 1.90 to 3.20), image and performance-enhancing drug use (aOR=3.82, 95% CI 1.87 to 7.82), greater number of condomless anal male partners, lower satisfaction with life and greater sexual satisfaction. Predictors of chemsex compared with other SDU were not being UK-born (aOR=2.02, 95% CI 1.05 to 3.86), living in a densely populated area (aOR=2.69, 95% CI 1.26 to 5.74), low sexual self-efficacy (aOR=4.52, 95% CI 2.18 to 9.40) and greater number of condomless anal male partners. Living with HIV, taking pre-exposure prophylaxis (PrEP), and experiencing or being unsure of experiencing sexual contact without consent were significantly associated with SDU and chemsex in bivariate analyses but not in the multivariable. CONCLUSION: Health and behavioural differences were observed between MSM engaging in chemsex, those engaging in SDU and those engaging in neither. While some MSM engaging in chemsex and SDU appeared content with these behaviours, the association with life satisfaction and sexual self-efficacy indicates psychosocial support is needed for some. The association with sexual risk and sexual consent also indicates the importance of promoting harm reduction among this population (eg, condoms, PrEP, drug knowledge).

What is the overlap between HIV and shigellosis epidemics in England: further evidence of MSM transmission?

BACKGROUND: Evidence suggests that sexual transmission between men has replaced foreign travel as the predominant mode of Shigella transmission in England. However, sexuality and HIV status are not routinely recorded for laboratory-reported Shigella, and the role of HIV in the Shigella epidemic is not well understood. METHODS: The Modular Open Laboratory Information System containing all Shigella cases reported to Public Health England (PHE) and the PHE HIV and AIDS Reporting System holding all adults living with diagnosed HIV in England were matched using a combination of Soundex code, date of birth and gender. RESULTS: From 2004 to 2015, 88 664 patients were living with HIV, and 10 269 Shigella cases were reported in England; 9% (873/10 269) of Shigella cases were diagnosed with HIV, of which 93% (815/873) were in men. Shigella cases without reported travel history were more likely to be living with HIV than those who had travelled (14% (751/5427) vs 3% (134/4854); p<0.01). From 2004 to 2015, the incidence of Shigella in men with HIV rose from 47/100 000 to 226/100 000 (p<0.01) peaking in 2014 at 265/100 000, but remained low in women throughout the study period (0-24/100 000). Among Shigella cases without travel and with HIV, 91% (657/720) were men who have sex with men (MSM). HIV preceded Shigella diagnosis in 86% (610/720), and 65% (237/362) had an undetectable viral load (<50 copies/mL). DISCUSSION: We observed a sustained increase in the national rate of shigellosis in MSM with HIV, who may experience more serious clinical disease. Sexual history, HIV status and STI risk might require sensitive investigation in men presenting with gastroenteritis.

Anti-Hepatitis C (HCV) test positivity and new HCV diagnoses among women tested in antenatal services in England between 2015-2019.

OBJECTIVE: To determine associations with hepatitis C virus (HCV) positivity, new HCV diagnoses and subsequent linkage to HCV treatment services among pregnant women in England. METHOD: A retrospective cohort using routine laboratory tests for HCV-specific antibody (anti-HCV) and HCV-RNA undertaken during antenatal attendances England. All women receiving at least one anti-HCV test during an antenatal clinic attendance between 2015 and 2019 were included. Multivariable logistic regression was used to investigate sociodemographic associations with anti-HCV test positivity among pregnant women who did (PWIDs) and did not (non-PWIDs) inject drugs, as well as to identify sociodemographic factors associated with being newly diagnosed during pregnancy. Linkage to antiviral treatment services and treatment outcomes were determined for those women who tested HCV-RNA positive. RESULTS: 32,088 women (median age 32 years, 19,664 (61 %) UK-born, 337 (1.1 %) PWID) received an anti-HCV test among whom 814 (2.5 %) had a positive anti-HCV test (95 % confidence interval [2.4-2.7 %]). Anti-HCV test positivity was 2.1 % [2.0-2.3 %] among non-PWIDs and 40 % [35-46 %] among PWIDs. In multivariable analyses among non-PWIDs, anti-HCV test positivity was associated with older age, living in more deprived areas, and varied by ethnicity and country of birth. Among PWIDs, anti-HCV test positivity was associated with older age only. Three hundred and twenty (39 %) of the women testing anti-HCV positive were new diagnoses; those who were newly diagnosed were younger and lived in less deprived than those with a prior diagnosis whereas PWIDs were less likely to be newly diagnosed. HCV-RNA positivity was 52 % (n = 330/640, 95 %CI[47.6-55.5 %]) among those with an HCV-RNA test within 30 days, and 75 % (n = 220/293, 95 %CI[69.7-79.9 %]) of those eligible for treatment had engaged in HCV treatment services after antenatal testing. CONCLUSIONS: Antenatal testing for HCV provides an opportunity for new case findings and engagement with treatment services where needed. Therefore, universal opt-out testing for HCV antenatally should be reconsidered.

A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people.

INTRODUCTION: Chemsex is a specific form of sexualised drug use (SDU) that is an emerging public health issue among men who have sex with men (MSM). Although the recent focus on chemsex is a reflection of the associated harms it is important to understand SDU more broadly and its associations with risk behaviours. Additionally, some of the reasons suggested for MSM engagement in SDU are also likely to apply to women who have sex with women (WSW) and trans people. The aim of this review was to investigate SDU, including chemsex, among lesbian, gay, bisexual and trans (LGBT) people internationally in relation to sexual health outcomes (HIV status, STI diagnosis, condom use). METHODS: Papers that were published between January 2010 and June 2020 reporting SDU in MSM, WSW, or trans people were identified through Medline, PsycINFO, CINAHL Plus and Web of Science. Results were synthesised using a narrative approach. RESULTS: The search identified 2,710 publications, of which 75 were included in the final synthesis. The majority of studies measured SDU among MSM (n = 71), and four studies measured SDU among trans people. Research into SDU had been conducted in 55 countries and 32 countries had recorded the use of a chemsex drug among MSM, although the drugs used to define chemsex varied. Among studies that researched MSM, SDU was most commonly investigated in relation to condomless anal intercourse (n = 42), followed by HIV prevalence (n = 35), and then STI diagnoses (n = 27). Drug use was generally associated with sexual health outcomes, but particularly in chemsex studies. CONCLUSIONS: SDU research is lacking among WSW and trans people, despite trans women having a high HIV prevalence. Among MSM, most drugs were associated with sexual health outcomes, and therefore it is important to include both chemsex drugs and other drugs in SDU research.

Image and performance enhancing drug use among men who have sex with men and women who have sex with women in the UK.

BACKGROUND: The use of image and performance enhancing drugs (IPEDs) among men who have sex with men (MSM) and women who have sex with women (WSW) is rarely studied, with most of this research focused on anabolic androgenic steroid use among MSM. To address this gap, the extent of recent IPED use and the associated factors are explored in a community-recruited sample of MSM and WSW METHODS: Data from the UK LGBT Sex and Lifestyles Survey was used, which recruited through social-media advertising and community organisations (April-June 2018). Participants were asked if they had taken any IPEDs (e.g. anabolic steroids, growth hormone, hCG, Melanotan, non-prescribed diet pills) in the past 12 months. Factors associated with recent (in past 12 months) IPED use among MSM and WSW were investigated using stepwise binary logistic regression. RESULTS: 1,658 MSM and 1,507 WSW were included in the analysis. Among MSM, 3.4% (n = 57) had recently taken IPEDs, 60% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among MSM was associated with psychoactive drug use, Viagra use, higher body dissatisfaction, and lower sexual satisfaction. Among WSW, 4.1% (n = 62) had recently taken IPEDs, and 50% of those taking IPEDs had used psychoactive drugs. In the multivariable analysis, IPED use among WSW was associated with being aged 45 years and over, recent STI diagnosis, recent sexual contact without consent, and higher body dissatisfaction. CONCLUSION: IPED use was reported by around 1-in-25 MSM and WSW, and was associated with a number of health and psychological problems. Research to better understand the drivers and impacts of IPED use among MSM and WSW, and how this compares to use among heterosexual people is needed.

Service provision and barriers to care for men who have sex with men engaging in chemsex and sexualised drug use in England.

BACKGROUND: Chemsex and sexualised drug use (SDU) among men who have sex with men (MSM) has become a public health issue because of its associated sexual risks. Some MSM engaging in SDU require further help and support, but it is not clear if this need is being met. This research seeks to understand MSM and service provider (SP) perspectives of the current standard of service provision for MSM engaging in SDU. METHOD: Semi-structured interviews were conducted with 13 MSM and 16 SPs in England (January-December 2019). MSM who reported taking one of ten substances for sex in the past 12 months were recruited from a mailing list or a community organisation providing chemsex support. Potential SP participants were recruited via an email sent from their local healthcare NHS Trust. Data for MSM and SPs were analysed separately using thematic analysis. RESULTS: MSM participants had a median age of 34 years (range 23-66).The majority of SPs recruited were genitourinary medicine (GUM) consultants. We found that the main reason for engagement in SDU was because of the enhanced sexual experience. Most MSM recruited were satisfied with their sexual health service provision, but barriers to care were highlighted by both MSM and SPs. Four themes relating to barriers to care were identified: accessibility of sexual health services, funding of services, SP's attitudes towards MSM who engage in SDU, and services outside sexual healthcare. CONCLUSION: SPs appeared to have adopted a harm reduction approach to MSM engaging in SDU, but for MSM wanting further help and assistance in relation to their SDU additional barriers to care existed. Training healthcare providers outside of sexual health services regarding chemsex and SDU may reduce some of these barriers, but funding for sexual health services needs to be improved to maintain and further develop services.

Psychosocial and sexual factors associated with recent sexual health clinic attendance and HIV testing among trans people in the UK.

OBJECTIVES: Trans people remain an understudied population in the UK, with unmet sexual health needs. The aim of this research was to identify possible barriers and facilitators for sexual health clinic attendance and HIV testing among trans people. METHODS: Lesbian, gay, bisexual and transgender (LGBT) participants from across the UK were invited to take part in a cross-sectional online survey through Facebook advertising (April-June 2018). Psychosocial and sexual factors associated with recent sexual health clinic attendance, and ever having an HIV test were examined using multivariate logistic regression. RESULTS: A total of 3007 cisgender and 500 trans participants completed the survey. Trans participants were less likely to attend a sexual health clinic than cisgender participants (27% vs 36%, p<0.001) and report ever having an HIV test (49% vs 64%, p<0.001). One trans participant reported living with HIV and three reported currently taking pre-exposure prophylaxis. Factors associated with trans sexual health clinic attendance were: living in London, having a relationship with multiple partners, engaging in condomless anal intercourse, greater life satisfaction, and having alcohol and/or drugs before sex. Being a person of colour, aged 25-49 years, in a relationship with multiple partners, condomless anal intercourse, lower body dissatisfaction, and having drugs before sex were associated with ever having an HIV test among trans participants. CONCLUSIONS: Trans people were less likely to attend sexual health services than cisgender people, and half of trans participants who reported condomless anal intercourse had never had an HIV test. Further research is needed to understand and improve uptake of sexual health services among trans people.

Associations with drug use and sexualised drug use among women who have sex with women (WSW) in the UK: Findings from the LGBT Sex and Lifestyles Survey.

INTRODUCTION: Studies indicate that women who have sex with women (WSW) report greater levels of drug use than heterosexual women, but globally few studies have looked at sexualised drug use among WSW. This study investigated the factors associated with drug use and sexualised drug use (SDU) among WSW. METHODS: Potential participants across the UK were invited to take part in a cross-sectional anonymous online survey between April-June 2018. The LGBT Sex and Lifestyles Survey recruited participants through Facebook advertising and social media posts from community organisations. Multivariate logistic regression was used to compare WSW who had engaged in any drug use in the past 12 months with those who had not, and those who engaged in sexualised drug use in the past 12 months with those who engaged in other drug use. RESULTS: 1501 WSW could be included in the analyses (mean age = 28.9, 97% white ethnicity). Any drug use was reported by 39% of WSW (n = 583), 44% of which (17% of total, n = 258) reported SDU. Factors associated with drug use were identifying as queer (aOR = 1.86, 95%CI 1.08, 3.23), younger age (aOR = 0.96, 95%CI 0.95, 0.98), being born outside the UK (aOR = 1.75, 95%CI 1.15, 2.66), recent sexual assault (aOR = 2.35, 95%CI 1.43, 3.86), > = 5 female sexual partners (aOR = 3.81, 95%CI 1.81, 8.01), and psychological distress (aOR = 1.75, 95%CI 1.15, 2.67). SDU was associated with identifying as bisexual (aOR = 2.55, 95%CI 1.69, 3.86), > = 5 female sexual partners (aOR = 4.50, 95%CI 1.91, 10.59), and highest education achieved at 16 or lower (aOR = 2.46, 95%CI 1.24, 4.90). CONCLUSIONS: Some WSW may have negative experiences in relation to drug use and SDU. Harm reduction and health services that provide services for WSW should be aware of potentially compounding factors related to drug use, such as sexual assault and psychological distress, providing a safe and LGBT-friendly environment to discuss these issues.