Demand for pre-exposure prophylaxis for HIV and the impact on clinical services: Scottish men who have sex with men perspectives.

There is a lack of data on ability and willingness of men who have sex with men (MSM) to self-fund HIV pre-exposure prophylaxis (PrEP). We aimed to explore how many eligible (PROUD study criteria) men may want PrEP and how many lower-risk MSM would be willing and able to self-fund this intervention. A self-completed anonymous questionnaire was distributed to MSM populations attending services. Of 377 participants, 81.5% were aware of PrEP. Fifty-three (15.5 %) were eligible, of whom 43 (81%) were very/extremely likely to want it. Of those ineligible, 229 (80%) were aware of PrEP and 106 (37.3%) were very/extremely likely to want it. Of eligible respondents 23% would be willing and able to pay at least £50 a month for PrEP. Of ineligible respondents this proportion was 21%. Our survey revealed high levels of awareness, understanding and willingness to take PrEP among MSM at high and lower risk of HIV acquisition. It indicated that over 70% of high-risk men would be unwilling or unable to self-fund PrEP, should it not be available on the NHS. For lower-risk MSM we estimated that capacity requirements for monitoring self-funded PrEP will be 50% higher than numbers eligible for PrEP. These factors will need to be taken into account when planning services.

British Association for Sexual Health and HIV Scottish investigation 2010-2011: reasons for non-attendance in individuals lost to follow-up for HIV care for more than 12 months in Scotland.

As of 31 March 2011, 6696 HIV diagnoses had ever been reported in Scotland; of these, 1791 individuals had died, 3339 were attending specialist services, but the remainder had defaulted from specialist care; an investigation into their reasons for non-attendance, and the efforts of services to re-engage, was undertaken by British Association for Sexual Health and HIV Scottish branch using a web-based survey questionnaire. Twelve of the 13 Scottish HIV services returned information for 424 of 579 eligible cases; 112 of these 424 individuals were identified as genuine non-attendees. Findings indicate that the epidemiology of these non-attendees is similar to that of the whole Scottish HIV cohort. Three-quarters of individuals failed to attend a booked appointment following their last known attendance and very few attempts to contact non-attending individuals were successful. This survey has refocused attention on those lost to follow-up, while quality of the national data-set has improved, providing a clearer epidemiological picture of people living with HIV in Scotland.

Strongyloides stercoralis: highlighting an imported case of the neglected parasite.

Travel-related strongyloidiasis is described in an HIV-infected individual who previously tested positive for schistosomiasis. This report illustrates that a positive serological result for schistosomiasis may represent a co-infection but may potentially occur as a result of cross-reactivity. Routine testing for schistosomiasis but not for strongyloidiasis in HIV-infected individuals who have spent more than one month in sub-Saharan Africa is recommended in recent UK HIV care guidelines. Therefore we recommend that further consideration should be given to routine investigations for other parasites including Strongyloides species in these circumstances.

Anal cytology screening in HIV-positive men who have sex with men: experience in a city centre HIV clinic.

The objectives of this study were to describe the findings of anal cytology screening during the first year of a unit protocol offering yearly screening to all HIV-positive men who have sex with men (MSM). Of 285 patients seen, 75% were offered anal cytology screening. Sixty-two percent of patients offered screening accepted and 21% of anal smears performed were reported as abnormal. Anal cytology screening may lead to earlier detection of anal intraepithelial neoplasia allowing for treatment before progression to cancer. This study revealed potential difficulties in follow-up of patients with high-grade precancerous disease and highlighted potential resource implications of implementing a routine screening programme.

UK national audit against the key performance indicators in the British Association for Sexual Health and HIV Medical Foundation for AIDS and Sexual Health Sexually Transmitted Infections Management Standards.

A national audit of practice performance against the key performance indicators in the British Association for Sexual Health and HIV (BASHH) and HIV Medical Foundation for AIDS Sexual Health Standards for the Management of Sexually Transmitted Infections (STIs) was conducted in 2011. Approximately 60% and 8% of level 3 and level 2 services, respectively, participated. Excluding partner notification performance, the five lowest areas of performance for level 3 clinics were the STI/HIV risk assessment, care pathways linking care in level 2 clinics to local level 3 services, HIV test offer to patients with concern about STIs, information governance and receipt of chlamydial test results by clinicians within seven working days (the worst area of performance). The five lowest areas of performance for level 2 clinics were participating in audit, having an audit plan for the management of STIs for 2009-2010, the STI/HIV risk assessment, HIV test offer to patients with concern about STIs and information governance. The results are discussed with regard to the importance of adoption of the standards by commissioners of services because of their relevance to other national quality assurance drivers, and the need for development of a national system of STI management quality assurance measurement and reporting.

UK national guideline on safer sex advice.

This guideline provides evidence-based guidance on the content of safer sex advice and the provision of brief behaviour change interventions deliverable in genitourinary (GU) medicine clinics. Much of the advice is applicable to other healthcare settings including general practice and clinics providing HIV care. Advice on condom use and effectiveness, oral sex and other sexual practices, testing for sexually transmitted infections (STI) and partner reduction is provided. Advice specific to the transmission of HIV infection including seroadaptive behaviours and negotiated safety is also included. An accompanying review of the evidence supporting the guideline with a complete reference list is available online. A patient information leaflet based on the advice statements developed is also available through the BASHH website.

BASHH Scotland/Scottish HIV and AIDS group national audit 2009-2010: sexual health care for people living with HIV.

A national Scottish audit of 282 patients with HIV infection attending 11 clinics showed the following levels of performance against quality improvement Scotland Sexual Health Services Standards: syphilis serology was offered in the previous six months to 55% of patients (range: 12-97% of patients in individual clinics), sexual history documented within four weeks of initial HIV diagnosis in 67% (12-100%) and offer of tests for sexually transmitted infections (STIs) documented within four weeks of HIV diagnosis in 45% (4-96%). Considerable variation in performance exists between clinics. The audit prompted interventions to further improve the sexual health care of people living with HIV infection.

Completion of a British Association for Sexual Health and HIV regional audit loop: HIV testing in genitourinary medicine clinics in Scotland in 2004 and 2008.

In 2004, the British Association for Sexual Health and HIV Scottish Branch audited HIV testing in new attendees diagnosed with a sexually transmitted infection at genitourinary medicine clinics in Scotland. In 2008 the audit loop was completed. Large increases were seen in rates of test offer and uptake, particularly in health boards with low baseline levels of testing. Overall rates of testing remain below those recommended and wide variability between boards persists.

Targeting of HIV pretest discussion and risk-reduction interventions in a low-prevalence setting.

Genitourinary medicine clinic attendees who were newly diagnosed as HIV antibody positive in a population with low overall HIV prevalence were compared with HIV-ve control groups in a retrospective study. Demographics and clinical data from the clinic attendance at which the HIV test was performed were analysed. Of 25,627 HIV tests, 113 were positive. Seventy-eight percent had an identified risk factor for HIV and more than half had symptoms of, or were contacts of, a sexually transmitted infection (STI) or HIV. Only eight clients testing HIV+ve had attended for routine STI testing and only two of these had no identified risk factor. Groups shown to be at higher HIV risk included attendees with past history of STI, men-who-have-sex-with-men (MSM) and those requesting HIV test without an STI screen. MSM testing HIV-ve had high rates of HIV risk behaviour.

Peripheral neuropathy in HIV-positive patients at an antiretroviral clinic in Lilongwe, Malawi.

Peripheral neuropathy (PN) is common in the setting of antiretroviral (ARV) programmes in resource-limited settings and poses significant challenges in assessment and management. A retrospective analysis was undertaken of prevalence and management of PN in a cohort of 3341 patients on highly active antiretroviral therapy. A first line ARV regimen containing stavudine (D4T) is used for clinically eligible patients. Amitriptyline is prescribed for symptom relief and in cases of persistent or escalating symptoms zidovudine (AZT) is substituted for D4T. Leg pain or numbness was reported in 1173 patients (35%). However, only 428 (13%) were given a diagnosis of PN, 228 (7%) were prescribed amitriptyline and 200 (6%) were switched to AZT. A recent pharmokinetic study in this population showed a high Cmax of D4T with the generic combination triomune (D4T 40 mg). This could account for the high prevalence of PN. The optimum time for switch to a non-D4T containing regimen is unknown.

How many cases of chlamydial infection would we miss by not testing partners for infection?

Quality Improvement Scotland standards for sexual health services require that 0.64 contacts per case should be verified as having attended within 90 days of the first partner notification interview. Partner delivered therapy results in more patients being treated than when patients are given information for partners but removes the possibility of further cases of Chlamydia trachomatis being diagnosed through the tracing of secondary contacts. An audit was performed to estimate the impact of removing secondary contacts on the number of chlamydial infections identified in our service. Patients who were not known to be contacts of chlamydial infection were included. One hundred and twenty-seven index cases generated 189 contacts, of which 100 were confirmed as tested and treated. Sixty-four were C. trachomatis positive, who in turn generated 36 new contacts. Fourteen of these were positive. Secondary contact tracing identified 22-28% more cases of chlamydial infection in our service than if all partners were treated without testing.

Genitourinary medicine clinic and general practitioner contact: what do patients want?

OBJECTIVES: While genitourinary medicine (GUM) records have historically been kept separate from other medical data, patient information is increasingly shared across the NHS. There are advantages to this in GUM: GPs are increasingly involved in delivering targets for STI screening and sexual health services. We ascertained patient attitudes to proposals to routinely send clinic letters to GPs and to share GUM data on common IT systems. METHODS: Clinic attendees in the period 24 March to 5 April 2006 completed a questionnaire concerning their opinion on letters to GPs, GUM data sharing and personal presumptions about the implications of having HIV testing. Patient demographic data, clinic test results and questionnaire answers were analysed using SPSS. RESULTS: Of 527 patients who completed the questionnaire, 187 (35%) agreed to GP contact, 337 (64%) declined and 3 (1%) failed to express a preference. Factors significantly associated with agreement to GP contact included heterosexual orientation (p<0.05), initial GP referral (p<0.001) and not considering HIV testing to have negative implications for future mortgage and life insurance applications (p<0.05). When questioned on attitudes to GP access of computerised results, 291 patients (55%) approved, 231 (44%) disagreed and 5 (1%) failed to reply; 128 patients (24%) said that they would be less likely to attend GUM if this occurred. CONCLUSIONS: Mode of referral and concerns about the implications of HIV testing affect patient preference on information sharing. A significant proportion of patients still want GUM visits to be anonymous and a policy of sharing GUM data on common IT systems may deter patient attendance.

Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana.

PROBLEM: As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them. APPROACH: Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources. LOCAL SETTING: Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART. RELEVANT CHANGES: We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects. LESSONS LEARNED: Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable.

Audit of Postal Test Kits in Edinburgh for Chlamydia trachomatis as an alternative to genitourinary medicine clinic attendance.

Our objective was to investigate whether Postal Test Kits (PTKs) for Chlamydia trachomatis in Edinburgh offer an alternative to genitourinary (GU) medicine clinic attendance. All PTKs returned in the Edinburgh area over a six-month period from August 2005 were audited. Data on age and previous access to GU medicine services were collected. Return rates of kits from various sources were calculated. In all, 799 kits were returned with 72 (9%) chlamydia prevalence, and 10% had previously attended a GU medicine clinic. The largest proportion of kits were used by the 16-29 years old age group. Return rates of kits varied with distribution point, with only 15% returned from GU medicine. PTKs appear to be targeting an appropriate high-risk age group and a population not otherwise accessing GU medicine clinics. However, return rates are low and kits do not offer an adequate alternative to GU medicine clinics.

How many sexually transmitted infections (STIs) will we miss?--an algorithm to assess risk factors for STI.

A self-administered algorithm for the assessment of symptoms of, and risk factors for, sexually transmitted infection (STI) was developed. The algorithm was applied retrospectively to all cases of STI other than chlamydia diagnosed over a one-year period, to estimate the risk of missing STI diagnoses by its introduction. Three hundred and eighty-nine cases were identified, of whom 81 (21%) were asymptomatic. Seven asymptomatic cases had no identifiable risk factors for infection and might potentially have been offered a postal testing kit for chlamydia rather than a full STI screen. We estimate that 1.8% of STIs diagnosed in the unit might be missed by the introduction of the algorithm.

A rapid method for identifying high-risk patients consenting for HIV testing: introducing The Edinburgh Risk Assessment Table for HIV testing.

Lack of time for conducting standard HIV pre-test counselling has been reported as a barrier to HIV testing. Use of a risk assessment table will identify high-risk patients to whom pre-test counselling may be limited. The aim of this study is to investigate the performance of a Risk Assessment Table for HIV testing designed in the Department of Genitourinary (GU) Medicine, Edinburgh. A prospective study was carried out on patients attending the Department of GU Medicine, Edinburgh between June 30th 2002 and July 1st 2003, who consented to HIV testing. Patients with any risk factor had standard pre-and post-test counselling. Those without any risk factor were tested and provided with leaflets on HIV testing.A total of 3337 patients were tested in the study period and 727 (22%) had risk factor for HIV infection. Twenty-nine patients (0.9%) were HIV-infected. The Risk Assessment Table failed to identify two infected patients. Routine use of the Risk Assessment Table saves time of the medical staff by only providing pre-test counselling to high-risk patients.

The transcriptional landscape of the mammalian genome.

This study describes comprehensive polling of transcription start and termination sites and analysis of previously unidentified full-length complementary DNAs derived from the mouse genome. We identify the 5' and 3' boundaries of 181,047 transcripts with extensive variation in transcripts arising from alternative promoter usage, splicing, and polyadenylation. There are 16,247 new mouse protein-coding transcripts, including 5154 encoding previously unidentified proteins. Genomic mapping of the transcriptome reveals transcriptional forests, with overlapping transcription on both strands, separated by deserts in which few transcripts are observed. The data provide a comprehensive platform for the comparative analysis of mammalian transcriptional regulation in differentiation and development.

Audit of treatment and contact-tracing rates in immediate (presumptive) versus delayed (polymerase chain reaction) diagnosis of chlamydial infection.

An audit of all cases of chlamydial infection diagnosed in men at the Edinburgh genitourinary (GU) medicine clinic over a six-month period from January 2003 is reported. In all, 189 men identified as requiring treatment for possible chlamydial infection on first attendance (because of contact with a partner with chlamydia or the diagnosis of non-gonococcal urethritis [NGU] on microscopy), who later proved chlamydia-positive by polymerase chain reaction (PCR), were compared with 83 men in whom infection was identified only on receipt of a PCR result. Treatment rates were 100% in the first group and 97.6% in the second group (chi(2) 0.046, P<0.05). In men presumptively diagnosed and treated, 88.6% of contacts identified were confirmed as traced, compared with 90% confirmed as traced in the group diagnosed by PCR alone. Our audit suggests that identifying men with chlamydial NGU by routine microscopy may carry a small but significant advantage in increasing treatment rates, but makes no difference to contact-tracing success rate.

A bioinformatic screen for novel A-I RNA editing sites reveals recoding editing in BC10.

MOTIVATION: Recent studies have demonstrated widespread adenosine-inosine RNA editing in non-coding sequence. However, the extent of editing in coding sequences has remained unknown. For many of the known sites, editing can be observed in multiple species and often occurs in well-conserved sequences. In addition, they often occur within imperfect inverted repeats and in clusters. Here we present a bioinformatic approach to identify novel sites based on these shared features. Mismatches between genomic and expressed sequences were filtered to remove the main sources of false positives, and then prioritized based on these features. This protocol is tailored to identifying specific recoding editing sites, rather than sites in non-coding repeat sequences. RESULTS: Our protocol is more sensitive for identifying known coding editing sites than any previously published mammalian screen. A novel multiply edited transcript, BC10, was identified and experimentally verified. BC10 is highly conserved across a range of metazoa and has been implicated in two forms of cancer.