Active recall to increase HIV and STI testing: a systematic review.

BACKGROUND: Active recall can improve reattendance rates and could increase retesting rates and detection of HIV and sexually transmitted infections (STIs), but the best strategy remains uncertain. METHODS: We conducted a systematic review and meta-analysis of active recall for HIV and/or STI testing. We searched six electronic databases using terms for HIV, STIs, tests and active recall (defined as a reminder to retest for HIV/STIs) for randomised, non-randomised and observational English-language studies published between 1983 and 2013. Outcomes included reattendance/retesting rate and STI diagnosis at follow-up. RESULTS: Of 5634 papers identified, 17 met the inclusion criteria. Of the 14 comparative studies, all but one demonstrated higher reattendance/retesting rates in the intervention group, but the range was wide (17.5-89%). Meta-analysis of nine RCTs found reattendance/retesting rates were significantly higher in the intervention versus control groups (pooled OR 2.42 (95% CI 1.84 to 3.19)). In a subgroup analysis, home sampling increased retesting compared with clinic testing (pooled OR 2.20 (95% CI 1.65 to 2.94)). In observational studies SMS reminders increased retesting compared with standard clinic care (pooled OR 2.19 (95% CI 1.46 to 3.29)), but study estimates were highly heterogeneous (I(2)=94%, p<0.001). CONCLUSIONS: Active recall interventions are associated with higher reattendance/retesting rates for HIV/STI. Although home sampling and SMS reminders were associated with higher reattendance/retesting rates in most studies, evidence is limited by the heterogeneity of interventions and control groups and the quality of studies. Further work is needed to explore which active recall modality is clinically cost-effective and acceptable for HIV/STI screening.

Who would use PrEP? Factors associated with intention to use among MSM in London: a community survey.

OBJECTIVE: To assess current and intended future use of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and characterise those attending sexual health clinics, the anticipated PrEP delivery setting. DESIGN: Cross-sectional study. METHODS: Self-administered survey of 842 HIV negative MSM recruited from social venues in London in 2011. RESULTS: One in 10 (10.2%, 83/814, 95% CI 8.2% to 12.5%) and one in 50 (2.1%, 17/809, 95% CI 1.2% to 3.3%) reported having ever used post-exposure prophylaxis (PEP) and PrEP respectively. Half reported they would be likely to use PrEP if it became available as a daily pill (50.3%, 386/786, 95% CI 46.7% to 53.9%). MSM were more likely to consider future PrEP use if they were <35 years (adjusted OR (AOR) 1.57, 95% CI 1.16 to 2.14), had unprotected anal intercourse with casual partners (AOR 1.70, 95% CI 1.13 to 2.56), and had previously used PEP (AOR 1.94, 95% CI 1.17 to 3.24). Over half of MSM (54.8% 457/834 95% CI 51.3 to 58.2) attended a sexual health clinic the previous year. Independent factors associated with attendance were age <35 (AOR 2.29, 95% CI 1.68 to 3.13), and ≥ 10 anal sex partners in the last year (AOR 2.49, 95% CI 1.77 to 3.52). CONCLUSIONS: The concept of PrEP for HIV prevention in the form of a daily pill is acceptable to half of sexually active MSM in London. MSM reporting higher risk behaviours attend sexual health clinics suggesting this is a suitable setting for PrEP delivery.

Audit of HIV testing frequency and behavioural interventions for men who have sex with men: policy and practice in sexual health clinics in England.

BACKGROUND: National guidance recommends targeted behavioural interventions and frequent HIV testing for men who have sex with men (MSM). We reviewed current policy and practice for HIV testing and behavioural interventions (BI) in England to determine adherence to guidance. METHODS: 25 sexual health clinics were surveyed using a semistructured audit asking about risk ascertainment for MSM, HIV testing and behavioural intervention policies. Practice was assessed by reviewing the notes of the first 40 HIV-negative MSM aged over 16 who attended from 1 June 2010, in a subset of 15 clinics. RESULTS: 24 clinics completed the survey: 18 (75%) defined risk for MSM and 17 used unprotected anal intercourse (UAI) as an indication of high risk. 21 (88%) offered one or more structured BI. Of 598 notes reviewed, 199 (33%) MSM reported any UAI. BI, including safer sex advice, was offered to and accepted by 251/598 (42%) men. A low proportion of all MSM (52/251: 21%) accepted a structured one-to-one BI as recommended by national guidance and uptake was still low among higher risk MSM (29/107: 27%). 92% (552/598) of men had one or more HIV test over a 1-year period. CONCLUSIONS: In 2010, the number of HIV tests performed met the national minimum standard but structured behavioural interventions were being offered to and accepted by only a small proportion of MSM, including those at a higher risk of infection. Reasons for not offering behavioural interventions to higher risk MSM, whether due to patient choice, a lack of staff training or resource shortage, need to be investigated and addressed.

Is the recall of men who have sex with men (MSM) diagnosed as having bacterial sexually transmitted infections (STIs) for re-screening a feasible and effective strategy?

OBJECTIVES: To assess the feasibility and outcomes of recalling men who have sex with men (MSM) diagnosed as having a bacterial sexually transmitted infection (STI) for re-screening. METHODS: This evaluation was conducted from December 2008 for a 9-month period. MSM diagnosed as having a bacterial STI in that period were offered recall for re-screening 3 months after their diagnosis. Re-screening rates and infection incidence were calculated. Differences in baseline characteristics by re-screening status and factors predictive of infection at re-screening were assessed using the Mann-Whitney test, χ(2) test and logistic regression. RESULTS: Of the 337 MSM diagnosed as having a bacterial STI, 301 were offered recall. Of these, 206 (68.4%) re-screened after 3 months, 30 (10%) declined and the remainder did not re-attend despite giving verbal consent. Compared with those not re-screening, those re-screening were less likely to be HIV positive (p=0.001), but there was no difference in baseline risk behaviours. There were 15 diagnoses of bacterial STIs at re-screening (29 per 100 person-year follow-up (pyfu); 95% CI 14.3 to 43.7) and five new HIV diagnoses of whom three had a negative test at baseline, one tested negative 6 months earlier and one never tested. Among those testing at both time points, the HIV incidence was 8.3 per 100 pyfu (95% CI 0.0 to 17.7). CONCLUSIONS: This evaluation demonstrates a 'recall for re-screening' strategy is feasible in terms of high re-screening rates and incidence of new infections diagnosed. Experimental evidence is needed to assess cost-effectiveness and whether it achieves its aim of reducing transmission of STIs and HIV.

The use of chaperones for intimate examinations: the patient perspective based on an anonymous questionnaire.

The objective of the study was to identify genitourinary (GU) medicine patients' opinions concerning the offer and provision of chaperones and to audit adherence to clinic policy. An anonymous questionnaire was completed by patients after their examination in two GU medicine clinics in central and north London. In total, 750 patients were given questionnaires, of which 627 (84%) were completed and returned. Less than half (45%) reported that they had been offered a chaperone. There was an association between patient gender/orientation and examiner gender/role for both offer and acceptance. Those likely to be offered (75%, 18/24) and accept (93%, 14/15) were women being examined by a man. Those least likely to be offered (27%, 32/120) or accept (3%, 1/31) were men who have sex with men. The offer of a chaperone was significantly greater for younger patients and those from Asian or black ethnic groups. Acceptance was highest among Asian patients. Most patients (88%, 530/602) did not want a chaperone for future examinations. Our conclusion was that most patients do not want a chaperone in the GU medicine clinic. Those who do would prefer for one to be offered, rather than for it to be routine. This supports the recommendation that all patients should be offered a chaperone for intimate examinations.

Sexual behaviours, HIV testing, and the proportion of men at risk of transmitting and acquiring HIV in London, UK, 2000-13: a serial cross-sectional study.

BACKGROUND: HIV incidence in men who have sex with men (MSM) in the UK has remained unchanged over the past decade despite increases in HIV testing and antiretroviral therapy (ART) coverage. In this study, we examine trends in sexual behaviours and HIV testing in MSM and explore the risk of transmitting and acquiring HIV. METHODS: In this serial cross-sectional study, we obtained data from ten cross-sectional surveys done between 2000 and 2013, consisting of anonymous self-administered questionnaires and oral HIV antibody testing in MSM recruited in gay social venues in London, UK. Data were collected between October and January for all survey years up to 2008 and between February and August thereafter. All men older than 16 years were eligible to take part and fieldworkers attempted to approach all MSM in each venue and recorded refusal rates. Data were collected on demographic and sexual behavioural characteristics. We analysed trends over time using linear, logistic, and quantile regression. FINDINGS: Of 13 861 questionnaires collected between 2000 and 2013, we excluded 1985 (124 had completed the survey previously or were heterosexual reporting no anal intercourse in the past year, and 1861 did not provide samples for antibody testing). Of the 11 876 eligible MSM recruited, 1512 (13%) were HIV positive, with no significant trend in HIV positivity over time. 35% (531 of 1505) of HIV-positive MSM had undiagnosed infection, which decreased non-linearly over time from 34% (45 of 131) to 24% (25 of 106; p=0·01), while recent HIV testing (ie, in the past year) increased from 26% (263 of 997) to 60% (467 of 777; p<0·0001). The increase in recent testing in undiagnosed men (from 29% to 67%, p<0·0001) and HIV-negative men (from 26% to 62%, p<0·0001) suggests that undiagnosed infection might increasingly be recently acquired infection. The proportion of MSM reporting unprotected anal intercourse (UAI) in the past year increased from 43% (513 of 1187) to 53% (394 of 749; p<0·0001) and serosorting (exclusively) increased from 18% (207 of 1132) to 28% (177 of 6369; p<0·0001). 268 (2%) of 11 570 participants had undiagnosed HIV and reported UAI in the past year were at risk of transmitting HIV. Additionally 259 (2%) had diagnosed infection and reported UAI and non-exclusive serosorting in the past year. Although we did not collect data on antiretroviral therapy or viral load, surveillance data suggests that a small proportion of men with diagnosed infection will have detectable viral load and hence might also be at risk of transmitting HIV. 2633 (25%) of 10 364 participants were at high risk of acquiring HIV (defined as HIV-negative MSM either reporting one or more casual UAI partners in the past year or not exclusively serosorting). The proportions of MSM at risk of transmission or acquisition changed little over time (p=0·96 for MSM potentially at risk of transmission and p=0·275 for MSM at high risk of acquiring HIV). Undiagnosed men reporting UAI and diagnosed men not exclusively serosorting had consistently higher partner numbers than did other MSM over the period (median ranged from one to three across surveys in undiagnosed men reporting UAI, two to ten in diagnosed men not exclusively serosorting, and none to two in other men). INTERPRETATION: An increasing proportion of undiagnosed HIV infections in MSM in London might have been recently acquired, which is when people are likely to be most infectious. High UAI partner numbers of MSM at risk of transmitting HIV and the absence of a significant decrease in the proportion of men at high risk of acquiring the infection might explain the sustained HIV incidence. Implementation of combination prevention interventions comprising both behavioural and biological interventions to reduce community-wide risk is crucial to move towards eradication of HIV. FUNDING: Public Health England.

A synthesis of convenience survey and other data to estimate undiagnosed HIV infection among men who have sex with men in England and Wales.

BACKGROUND: Hard-to-reach population subgroups are typically investigated using convenience sampling, which may give biased estimates. Combining information from such surveys, a probability survey and clinic surveillance, can potentially minimize the bias. We developed a methodology to estimate the prevalence of undiagnosed HIV infection among men who have sex with men (MSM) in England and Wales aged 16-44 years in 2003, making fuller use of the available data than earlier work. METHODS: We performed a synthesis of three data sources: genitourinary medicine clinic surveillance (11 380 tests), a venue-based convenience survey including anonymous HIV testing (3702 MSM) and a general population sexual behaviour survey (134 MSM). A logistic regression model to predict undiagnosed infection was fitted to the convenience survey data and then applied to the MSMs in the population survey to estimate the prevalence of undiagnosed infection in the general MSM population. This estimate was corrected for selection biases in the convenience survey using clinic surveillance data. A sensitivity analysis addressed uncertainty in our assumptions. RESULTS: The estimated prevalence of undiagnosed HIV in MSM was 2.4% [95% confidence interval (95% CI 1.7-3.0%)], and between 1.6% (95% CI 1.1-2.0%) and 3.3% (95% CI 2.4-4.1%) depending on assumptions; corresponding to 5500 (3390-7180), 3610 (2180-4740) and 7570 (4790-9840) men, and undiagnosed fractions of 33, 24 and 40%, respectively. CONCLUSIONS: Our estimates are consistent with earlier work that did not make full use of data sources. Reconciling data from multiple sources, including probability-, clinic- and venue-based convenience samples can reduce bias in estimates. This methodology could be applied in other settings to take full advantage of multiple imperfect data sources.

Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK.

OBJECTIVES: Undiagnosed infection presents a potential risk for the onward transmission of HIV and denies men early interventions for their health. Little is known about the differences between men who are, and are not, aware of their HIV status in the UK. METHODS: Cross-sectional surveys of men in commercial gay venues in London, Brighton, Manchester, Glasgow, and Edinburgh (2003-2005). Anonymous, self-completion questionnaires, and oral fluid samples (tested for HIV antibodies) were obtained from 3672 men (61% response rate). RESULTS: Of 3501 men with a confirmed positive or negative oral fluid result, 318 were HIV positive (9.1%). Of these, 131 (41.2%) were undiagnosed; 81.1% of men with undiagnosed HIV had previously tested (92.2% tested negative; the remainder did not know the result); 62.3% still thought that they were negative. Undiagnosed and diagnosed men reported greater sexual risk and sexually transmitted infections than HIV-negative men. Compared with HIV-negative men, the adjusted odds ratio of unprotected anal intercourse with two or more partners was higher among undiagnosed men (odds ratio 2.21, 95% confidence interval 1.17-4.20), but highest among diagnosed men (odds ratio 6.80, 95% confidence interval 4.39-10.52). CONCLUSION: A high proportion of the HIV-positive men were undiagnosed and not receiving benefits of clinical care, but sexual risk and sexually transmitted infections were highest among men who were aware of their HIV-positive status. Clinics should proactively offer testing to reduce undiagnosed HIV, target repeat testing at high-risk men who have previously tested negative, and initiate evidence-based behavioural interventions to reduce sexual risk among men living with diagnosed HIV as well as those testing negative.

A tale of three cities: persisting high HIV prevalence, risk behaviour and undiagnosed infection in community samples of men who have sex with men.

OBJECTIVES: To examine the geographical variations in HIV prevalence (diagnosed and undiagnosed), use of sexual health services, sexually transmitted infections and sexual behaviour in a community sample of men who have sex with men in three cities in England, specifically London, Brighton and Manchester. METHODS: Cross-sectional surveys of men visiting gay community venues in three large cities in England. Men self-completed a questionnaire and provided an anonymous oral fluid sample for HIV antibody testing. RESULTS: HIV prevalence ranged from 8.6% to 13.7% in the three cities. Over one-third of HIV infection remained undiagnosed in all sites despite 69% of HIV-positive men reporting attending a genitourinary medicine clinic in the last year. Similar and high levels of risk behaviour were reported in all three cities. 18% of HIV-negative men and 37% of HIV-positive men reported unprotected anal intercourse with more than one partner in the last year. 20% of negative men and 41% of positive men reported an STI in the last year. CONCLUSIONS: Across all cities, despite widespread availability of anti-retroviral treatment and national policy to promote HIV testing, many HIV infections remain undiagnosed. Data from this community sample demonstrate high levels of risk behaviour and STI incidence, especially among those who are HIV positive. Renewed efforts are needed to increase diagnosis and to reduce risk behaviour to stem the continuing transmission of HIV.

Increases in HIV-related sexual risk behavior among community samples of gay men in London and Glasgow: how do they compare?

OBJECTIVE: In this paper, we compare trends in sexual risk among gay men in the largest city in England (London) and the largest city in Scotland (Glasgow). METHODS: Self-complete questionnaires administered to representative samples of men visiting the commercial gay scenes in London and Glasgow in 1996, 1999, and 2002 (N = 8247). RESULTS: Multivariate logistic regression was used to assess the trends in unprotected anal intercourse (UAI), UAI with partners of unknown/discordant HIV status, and UAI with more than 1 partner. Each increased significantly in 1999 and 2002 in London, but only in 2002 in Glasgow. Testing for HIV also increased significantly in London, but not in Glasgow. Overall, HIV testing levels were considerably lower in Glasgow (in 2002, 49.1% vs. 74.6% in London). Overall, sexual risk was higher in London, but UAI with partners of unknown/discordant HIV status was higher in Glasgow (in 2002, 27.4% vs. 21.3%). CONCLUSIONS: Although the same pattern of increase in HIV-related sexual risk behavior was apparent in the cities, differences in HIV testing and nonconcordant UAI suggest different HIV prevention needs and that targeted health promotion interventions are required in London and Glasgow. City-specific factors should be considered in the development of appropriate sexual health interventions.

Pregnant women with HIV infection can expect healthy survival: three-year follow-up.

OBJECTIVES: To document postpartum disease-free survival of HIV-infected women taking antiretroviral therapy (ART) during pregnancy. METHODS: Laboratory and clinical data were collected on all HIV-infected pregnant women delivering from 1998 to 2002 and followed up until September 2004 at 6 hospitals in London. Mothers were grouped according to receipt of zidovudine monotherapy (ZDVm), highly active antiretroviral therapy (HAART) given during and continued after pregnancy (cHAART), and short-term HAART given during pregnancy and discontinued on delivery (START). RESULTS: Eight-five women took ZDVm, 155 took cHAART, and 71 took START. The mean follow-up for all mothers was 33 months, with a total of 847 person-years. At the first antenatal clinic (ANC) visit, 72% of women were in Centers for Disease Control and Prevention (CDC) stage A, 85% were treatment naive, and the ZDVm group had a median HIV viral load (VL) 10-fold less than those mothers who started HAART during pregnancy. At last follow-up, 1 patient had died and 6 (1.9%) had progressed to CDC stage C; 62% of all women, including a quarter of the ZDVm group, were receiving HAART for their own health; and 83% of all mothers had a VL <50 HIV RNA copies/mL of plasma regardless of whether they were on treatment or not. CONCLUSIONS: The median-term postpartum prognosis of HIV-infected pregnant women with access to HAART is good. Exposure to short-course ZDVm or START during pregnancy did not jeopardize their response to subsequent therapy.

Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire.

BACKGROUND: A new model of comprehensive care nurse-led clinics has enabled experienced genitourinary medicine nurses to co-ordinate the first-line, comprehensive care of female patients presenting with sexually transmitted infections and other sexual health conditions and issues. AIM: This paper describes the development of a patient satisfaction questionnaire to compare the satisfaction of women attending nurse-led or doctor-led clinics at a central London genitourinary medicine clinic. METHODS: A previously validated questionnaire was adapted using the findings of qualitative interviews exploring patient expectations of the service. The draft questionnaire was tested for internal consistency, sub-scale homogeneity, construct validity and stability. The final version consisted of a 34 item, five-point Likert scale, which was found to be both reliable (Cronbach's alpha 0.91) and stable (test-retest 0.95). There was some evidence of construct validity. The questionnaire was then distributed to a convenience sample of 132 women attending a nurse-led clinic and 150 seen at a doctor-led clinic. RESULTS: There was a 90% response rate. The median total satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups, respectively (P = 0.05). Significantly higher scores on the sub-scales measuring quality and competence of technical care (P < 0.001), provision of information (P = 0.01) and overall satisfaction (P = 0.01) were seen for the nurse-led group. No significant differences were found in the sub-scales measuring service attributes and specific attributes of interpersonal relationships. CONCLUSION: The rigorous development, piloting and testing phases of this satisfaction questionnaire led to reliable and valid results. This study demonstrated that nurse-led clinics within this service are an acceptable alternative to the existing doctor-led clinics.

Predictors of immunological failure after initial response to highly active antiretroviral therapy in HIV-1-infected adults: a EuroSIDA study.

BACKGROUND: Factors that determine the immunological response to highly active antiretroviral therapy (HAART) are poorly defined. OBJECTIVE: Our aim was to investigate predictors of immunological failure after initial CD4(+) response. METHODS: Data were from EuroSIDA, a prospective, international, observational human immunodeficiency virus (HIV) type 1 cohort. RESULTS: Of 2347 patients with an increase in CD4(+) cell count >or=100 cells/microL within 6-12 months of the initiation of HAART, 550 (23%) subsequently experienced immunological failure (CD4(+) count less than or equal to the pre-HAART value). The incidence of failure was 11.6 incidences/100 person-years of follow-up (95% confidence interval [CI], 10.2-13.4) during the first 12 months and decreased significantly over time (P<.0001). Independent predictors of immunological failure were pre-HAART CD4(+) cell count (per 50% higher; relative hazard [RH], 2.05; 95% CI, 1.83-2.31; P<.0001), time-updated virus load (per 1 log(10) higher; RH, 1.77; 95% CI, 1.64-1.92; P<.0001), and HIV-1 risk behavior (P=.047 for a global comparison of risk groups). CONCLUSION: The risk of immunological failure in patients with an immunological response to HAART diminishes with a longer time receiving treatment and is associated with pretreatment CD4(+) cell count, ongoing viral replication, and intravenous drug use.