Preparing for PrEP; the cost of delaying universal access in England.

OBJECTIVES: Pre-exposure prophylaxis (PrEP) is not commissioned within National Health Service (NHS) England. Individuals can access it privately online or by enrolment into a clinical trial. We established a list of individuals not enrolled in trials, awaiting PrEP. In response to the observation that patients awaiting PrEP trials were being referred with newly diagnosed HIV, we aimed to measure attendance, incident HIV, STI acquisition and missed opportunities for prevention. METHODS: The search was conducted for patients on the list from November 2017 to November 2019. We examined the electronic clinical records of those on the list and extracted demographic information, STI and HIV diagnoses. In addition, for those diagnosed with HIV, we reviewed risk factors including chemsex and prior postexposure prophylaxis. RESULTS: There were 1073 patients on list, and 520 (48.6%) were still awaiting recruitment in a PrEP trial. Eight (0.75%) had an enrolment appointment booked while 200 (18.64%) had been contacted and deemed ineligible according to PrEP trial criteria. 45 (32.15%) had not responded to contact. We identified 15 new HIV infections in patients awaiting PrEP. Of these, 9/15 (60.00%) did not meet eligibility criteria at point of contact, though had been eligible at first referral. CONCLUSION: It is unacceptable that 15 patients acquired HIV while waiting. The individual lifetime cost of treating HIV is estimated at £360 800(1). This equals £5 412 000 for these 15 infections notwithstanding the psychological and physical burden. We advocate the immediate role out of universal PrEP for those who need it on the NHS. While this decision is delayed, harm is coming to those waiting. Wider provision of PrEP may encourage increased attendance, but must consider additional resources to accommodate added visits. We are relieved that at the point of final submission (21 March 2020) NHS England have recently announced funding of PrEP for eligible patients from, further details are pending.

Prevalence and characteristics of gastrointestinal infections in men who have sex with men diagnosed with rectal chlamydia infection in the UK: an 'unlinked anonymous' cross-sectional study.

INTRODUCTION: Gastrointestinal infections (GII) can cause serious ill health and morbidity. Although primarily transmitted through faecal contamination of food or water, transmission through sexual activity is well described, especially among men who have sex with men (MSM). METHODS: We investigated the prevalence of GIIs among a convenience sample of MSM who were consecutively diagnosed with rectal Chlamydia trachomatis (CT) at 12 UK genitourinary medicine clinics during 10 weeks in 2012. Residual rectal swabs were coded, anonymised and tested for Shigella, Campylobacter, Salmonella, shiga toxin-producing Escherichia coli and enteroaggregative E. coli (EAEC) using a real-time PCR. Results were linked to respective coded and anonymised clinical and demographic data. Associations were investigated using Fisher's exact tests. RESULTS: Of 444 specimens tested, overall GII prevalence was 8.6% (95% CI 6.3% to 11.6%): 1.8% (0.9% to 3.6%) tested positive for Shigella, 1.8% (0.9% to 3.6%) for Campylobacter and 5.2% (3.5% to 7.7%) for EAEC. No specimens tested positive for Salmonella or other diarrhoeagenic E. coli pathotypes. Among those with any GII, 14/30 were asymptomatic (2/7 with Shigella, 3/6 with Campylobacter and 9/17 with EAEC). Shigella prevalence was higher in MSM who were HIV-positive (4.7% (2.1% to 10.2%) vs 0.5%(0.1% to 3.2%) in HIV-negative MSM; p=0.01). CONCLUSIONS: In this small feasibility study, MSM with rectal CT appeared to be at appreciable risk of GII. Asymptomatic carriage may play a role in sexual transmission of GII.

Cancer prevalence in a metropolitan HIV clinic.

INTRODUCTION: Morbidity and mortality rates from AIDs defining cancers have fallen significantly since the introduction of highly active antiretroviral therapy (HAART). Patients are now living longer with HIV and are at a greater risk of other HIV- and non-HIV related malignancies. We report what we believe to be the first UK cancer prevalence study in the modern HAART era. METHODS: A retrospective review of electronic clinic letters was performed for all patients currently receiving, and those who had died whilst receiving, their HIV care at our centre. Demographics of patients with pre-cancerous changes, an active or previous cancer were recorded. RESULTS: There were 438 active patients (369 male, 69 female) and 18 deceased patients (12 male, 6 female) in April 2014. Thirty-six out of four hundred fifty-six (8%) cancer diagnoses were found overall. Thirty-one out of four hundred thirty-eight (7%) diagnoses in active patients and 5/18 (28%) in deceased patients. More than half of those diagnosed with cancer were aged 50 or over (17/31 [55%]). In active patients 17/31 (55%) were AIDs defining cancers, with the most common type of cancer diagnosis overall being Kaposi's sarcoma (12/31 [39%]). There were 5/31 (16%) cases of non-Hodgkin's lymphoma. The most common non-AIDs defining cancer was basal cell carcinoma of which there were 5/31 (16%) cases, followed by squamous cell carcinoma (3/31 [10%]) and testicular cancer (3/31 [10%]). Other cancers included colorectal (2/31 [6%]) and prostate cancer (1/31 [3%]). In all five deceased patients, cancer was the cause of death. There were four acute presentations with an aggressive glioma, Burkitt's lymphoma, an undiagnosed primary lung malignancy and a late diagnosed cervical cancer. The fifth patient died following the recurrence of a transitional cell cancer of the bladder after an initial diagnosis of seven years earlier. Eighteen out of sixty-nine (26%) of females were found to have at least mild dyskariosis on cervical screening. Anal intraepithelial neoplasia was diagnosed in 4/438 (1%) of patients. CONCLUSIONS: Non-AIDS defining malignancies account for almost half of the cancers in our cohort. This number may rise further as patients live longer with HIV. Good communication between oncologists and HIV physicians is paramount to manage the complex interactions of HIV and cancer, increase HIV testing in cancer services and address cancer risk factors in existing HIV patients.