How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID).

OBJECTIVES: To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. METHODS: British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. RESULTS: In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. CONCLUSIONS: Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data.

OBJECTIVES: To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain. METHODS: 6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties. RESULTS: In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions. CONCLUSIONS: Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Balancing risk, intimacy and (non)compliance: a qualitative study of sex across household during COVID-19 social restrictions.

Government controls over intimate relationships, imposed to limit the spread of Sars-CoV-2, were unprecedented in modern times. This study draws on data from qualitative interviews with 18 participants in Natsal-COVID, a quasi-representative web-panel survey of the British population (n = 6,654 people), reporting that they had sex with someone from outside their household in the preceding four weeks; a period in which contact between households was restricted in the UK. Whilst only 10% of people reported sexual contact outside their household, among single people and those in non-cohabiting relationships, rates were much higher (Natsal-COVID). Our findings show that individuals did not take decisions to meet up with sexual partners lightly. Participants were motivated by needs-for connection, security, intimacy and a sense of normality. People balanced risks-of catching COVID-19, social judgement and punishment for rule-breaking-against other perceived risks, including to their mental health or relationships. We used situated rationality and social action theories of risk to demonstrate that people weighed up risk in socially situated ways and exhibited complex decision-making when deciding not to comply with restrictions. Understanding motivations for non-compliance is crucial to informing future public health messaging which accounts for the needs and circumstances of all population members.

Sexting among British adults: a qualitative analysis of sexting as emotion work governed by 'feeling rules'.

Sexting has generated considerable public and professional interest with concerns centring on young people, and potential harms to mental and sexual health. Little research thus far has explored the practice among adults and none has focused on the cultural norms relating to the emotional experience of sexting across different ages and genders. We conducted 40 semi-structured interviews with a diverse sample of adults aged 18-59 years in Britain on the role of digital technologies in participants' sexual lives. In this paper, we draw on the accounts of 34 people with experience of sexting. We identified three main themes in participants' accounts related to the emotional aspects of sexting: (1) trust, (2) desire/intimacy and (3) shame. Under each theme, we identified motivations, 'feeling rules', and examples of 'emotion work' relating to the self, the other and the dyad. We conclude that there are shared cultural norms that constitute what appropriate sexting should feel like. Interventions aiming to minimise harms arising from sexting need to build on commonly held cultural conventions regarding the 'rules of the game' concerning feelings as well as behaviours.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown. METHODS: Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction. RESULTS: Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction. CONCLUSIONS: Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

High burden of childhood tuberculosis in migrants: a retrospective cohort study from the Thailand-Myanmar border.

BACKGROUND: Tuberculosis (TB) is a leading cause of morbidity and mortality in children but epidemiological data are scarce, particularly for hard-to-reach populations. We aimed to identify the risk factors for unsuccessful outcome and TB mortality in migrant children at a supportive residential TB programme on the Thailand-Myanmar border. METHODS: We conducted retrospective analysis of routine programmatic data for children (aged ≤ 15 years old) with TB diagnosed either clinically or bacteriologically between 2013 and 2018. Treatment outcomes were described and risk factors for unsuccessful outcome and death were identified using multivariable logistic regression. RESULTS: Childhood TB accounted for a high proportion of all TB diagnoses at this TB programme (398/2304; 17.3%). Bacteriological testing was done on a quarter (24.9%) of the cohort and most children were diagnosed on clinical grounds (94.0%). Among those enrolled on treatment (n = 367), 90.5% completed treatment successfully. Unsuccessful treatment outcomes occurred in 42/398 (10.6%) children, comprising 26 (6.5%) lost to follow-up, one (0.3%) treatment failure and 15 (3.8%) deaths. In multivariable analysis, extra-pulmonary TB [adjusted OR (aOR) 3.56 (95% CI 1.12-10.98)], bacteriologically confirmed TB [aOR 6.07 (1.68-21.92)] and unknown HIV status [aOR 42.29 (10.00-178.78)] were independent risk factors for unsuccessful outcome. HIV-positive status [aOR 5.95 (1.67-21.22)] and bacteriological confirmation [aOR 9.31 (1.97-44.03)] were risk factors for death in the secondary analysis. CONCLUSIONS: Children bear a substantial burden of TB disease within this migrant population. Treatment success rate exceeded the WHO End TB target of 90%, suggesting that similar vulnerable populations could benefit from the enhanced social support offered by this TB programme, but better child-friendly diagnostics are needed to improve the quality of diagnoses.

HPV16 and HPV18 seropositivity and DNA detection among men who have sex with men: a cross-sectional study conducted in a sexual health clinic in London.

OBJECTIVES: Men who have sex with men (MSM) have an increased risk of human papillomavirus (HPV) infection and related diseases compared with men who have sex exclusively with women. From April 2018, there has been a phased roll-out of HPV vaccination offered to MSM aged up to 45 years old who are attending sexual health clinics and HIV clinics in England. The vaccine is most effective if delivered prior to HPV infection. We estimated the proportion of MSM with no current vaccine-type infection and no serological evidence of prior infection, in a study undertaken prior to vaccine introduction. METHODS: We conducted a cross-sectional study among 484 MSM aged 18-40 years old who attended a sexual health clinic in London between 2010 and 2012. We estimated the prevalence of current and past infection by testing for HPV DNA in anogenital samples and for serum antibodies to HPV16 and HPV18. RESULTS: The median age was 30 years (IQR 25-35). The prevalence of HPV16 and HPV18 DNA was 13.2% and 6.2%, respectively. Seropositivity for HPV16 and HPV18 was 28.5% and 17.1%, respectively, with 11.4% seropositive for both types. Seropositivity for the same HPV type was strongly associated with anogenital DNA detection. 279 MSM (57.6%) tested negative for both HPV16 and HPV18 serology and were DNA negative for these two types; only 5 MSM (1.0%) were seropositive and DNA positive for both HPV types. CONCLUSIONS: This is the first study to determine both the prevalence of HPV DNA in anogenital samples and HPV seroprevalence among MSM attending a sexual health clinic in the UK. Over half of MSM in this study had no evidence of a previous or current infection with either of the high-risk HPV types included in the quadrivalent vaccine, which supports the rationale for opportunistic HPV vaccination of MSM attending sexual health clinics.

Effect of weighting for sampling and non-response on estimates of STI prevalence in the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

OBJECTIVES: In addition to researcher-designed sampling biases, population-representative surveys for biomarker measurement of STIs often have substantial missingness due to non-contact, non-consent and other study-implementation issues. STI prevalence estimates may be biased if this missingness is related to STI risk. We investigated how accounting for sampling, interview non-response and non-provision of biological samples affects prevalence estimates in the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). METHODS: Natsal-3 was a multistage, clustered and stratified probability sample of 16-74 year-olds conducted between 2010 and 2012. Individuals were sampled from all private residential addresses in Britain; respondents aged 16-44 were further sampled to provide a urine specimen based on characteristics including self-reported sexual behaviours. We generated prevalence estimates and confidence intervals for six STIs in five stages: first without accounting for sampling or non-response, then applying inverse-probability weights cumulatively accounting for interview sampling, interview non-response, urine sampling and urine non-response. RESULTS: Interview non-completion occurred for 42.3% of interview-sampled individuals; urine non-completion occurred for 43.5% of urine-sampled individuals. Interview-sampled individuals, interview respondents, those selected for urine samples and those providing urine samples were each in turn slightly more at-risk for most STIs, leading to lower prevalence estimates after incorporating each set of weights. Researcher-controlled sampling had more impact than respondent-controlled response. CONCLUSIONS: Accounting for both sampling structures and willingness to interview or provide urine specimens can affect national STI prevalence estimates. Using both types of weights, as was done in Natsal-3, is important in reporting on population-based biomarker surveys.

Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population.

BACKGROUND: Mycoplasma genitalium is a common sexually transmitted infection. Treatment guidelines focus on those with symptoms and sexual contacts, generally with regimens including doxycycline and/or azithromycin as first-line and moxifloxacin as second-line treatment. We investigated the prevalence of antimicrobial resistance (AMR)-conferring mutations in M. genitalium among the sexually-active British general population. METHODS: The third national survey of sexual attitudes and lifestyles (Natsal-3) is a probability sample survey of 15 162 men and women aged 16-74 years in Britain conducted during 2010-12. Urine test results for M. genitalium were available for 4507 participants aged 16-44 years reporting >1 lifetime sexual partner. In this study, we sequenced regions of the 23S rRNA and parC genes to detect known genotypic determinants for resistance to macrolides and fluoroquinolones respectively. RESULTS: 94% (66/70) of specimens were re-confirmed as M. genitalium positive, with successful sequencing in 85% (56/66) for 23S rRNA and 92% (61/66) for parC genes. Mutations in 23S rRNA gene (position A2058/A2059) were detected in 16.1% (95%CI: 8.6% to 27.8%) and in parC (encoding ParC D87N/D87Y) in 3.3% (0.9%-11.2%). Macrolide resistance was more likely in participants reporting STI diagnoses (past 5 years) (44.4% (18.9%-73.3%) vs 10.6% (4.6%-22.6%); p=0.029) or sexual health clinic attendance (past year) (43.8% (23.1%-66.8%) vs 5.0% (1.4%-16.5%); p=0.001). All 11 participants with AMR-conferring mutations had attended sexual health clinics (past 5 years), but none reported recent symptoms. CONCLUSIONS: This study highlights challenges in M. genitalium management and control. Macrolide resistance was present in one in six specimens from the general population in 2010-2012, but no participants with AMR M. genitalium reported symptoms. Given anticipated increases in diagnostic testing, new strategies including novel antimicrobials, AMR-guided therapy, and surveillance of AMR and treatment failure are recommended.

Epidemiology of genital warts in the British population: implications for HPV vaccination programmes.

OBJECTIVES: To estimate the prevalence of, and describe risk factors for, genital warts (GWs) in the British population, following the introduction of the bivalent (human papillomavirus (HPV)-16/18) vaccination programme in girls, and prior to the switch to quadrivalent (HPV-6/11/16/18) vaccine (offering direct protection against GWs) and compare this with GW diagnoses in the prevaccination era. METHODS: Natsal-3, a probability sample survey in Britain, conducted in 2010-2012, interviewed 9902 men and women aged 16-44. Natsal-2, conducted in 1999-2001, surveyed 11 161 men and women aged 16-44. Both surveys collected data on sexual behaviour and sexually transmitted infection diagnoses using computer-assisted interview methods. RESULTS: In Natsal-3, 3.8% and 4.6% of sexually experienced men and women reported ever having a diagnosis of GWs, with 1.3% of men and 1.7% of woman reporting a GWs diagnosis in the past 5 years. GWs were strongly associated with increasing partner numbers and condomless sex. Diagnoses were more frequent in men who have sex with men (MSM) (11.6% ever, 3.3% past 5 years) and in women reporting sex with women (10.8% ever, 3.6% past 5 years). In the age group who were eligible for vaccination at the time of Natsal-3 (16-20 years), a similar proportion of same-aged women reported a history of GWs in Natsal-2 (1.9%, 1.1-3.4) and Natsal-3 (2.6%, 1.5-4.4). CONCLUSIONS: These data provide essential parameters for mathematical models that inform cost-effectiveness analyses of HPV vaccination programmes. There was no evidence of population protection against GWs conferred by the bivalent vaccine. Even with vaccination of adolescent boys, vaccination should be offered to MSM attending sexual health clinics.

Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK.

BACKGROUND: Human papillomavirus (HPV) is the most widespread sexually transmitted infection worldwide. It causes several health consequences, in particular accounting for the majority of cervical cancer cases in women. In the United Kingdom, a vaccination campaign targeting 12-year-old girls started in 2008; this campaign has been successful, with high uptake and reduced HPV prevalence observed in vaccinated cohorts. Recently, attention has focused on vaccinating both sexes, due to HPV-related diseases in males (particularly for high-risk men who have sex with men) and an equity argument over equalising levels of protection. METHODS: We constructed an epidemiological model for HPV transmission in the UK, accounting for nine of the most common HPV strains. We complemented this with an economic model to determine the likely health outcomes (healthcare costs and quality-adjusted life years) for individuals from the epidemiological model. We then tested vaccination with the three HPV vaccines currently available, vaccinating either girls alone or both sexes. For each strategy we calculated the threshold price per vaccine dose, i.e. the maximum amount paid for the added health benefits of vaccination to be worth the cost of each vaccine dose. We calculated results at 3.5% discounting, and also 1.5%, to consider the long-term health effects of HPV infection. RESULTS: At 3.5% discounting, continuing to vaccinate girls remains highly cost-effective compared to halting vaccination, with threshold dose prices of £56-£108. Vaccination of girls and boys is less cost-effective (£25-£53). Compared to vaccinating girls only, adding boys to the programme is not cost-effective, with negative threshold prices (-£6 to -£3) due to the costs of administration. All threshold prices increase when using 1.5% discounting, and adding boys becomes cost-effective (£36-£47). These results are contingent on the UK's high vaccine uptake; for lower uptake rates, adding boys (at the same uptake rate) becomes more cost effective. CONCLUSIONS: Vaccinating girls is extremely cost-effective compared with no vaccination, vaccinating both sexes is less so. Adding boys to an already successful girls-only programme has a low cost-effectiveness, as males have high protection through herd immunity. If future health effects are weighted more heavily, threshold prices increase and vaccination becomes cost-effective.

Trichomonas vaginalis infection is uncommon in the British general population: implications for clinical testing and public health screening.

INTRODUCTION: Variable use of new molecular assays, asymptomatic infections and a lack of population data mean that the population burden of Trichomonas vaginalis is uncertain. We investigated the age-specific prevalence of T. vaginalis within the sexually active British general population to inform testing strategies. METHODS: Britain's third National Survey of Sexual Attitudes and Lifestyle (Natsal-3) is a probability sample survey of 15 162 individuals aged 16-74 years, undertaken during 2010-2012. Urine from 4386 participants aged 16-44 years reporting ≥1 lifetime sexual partner was tested for T. vaginalis using in-house real-time PCR. RESULTS: Urinary T. vaginalis was detected in seven women and no men providing urine samples, giving a weighted prevalence estimate of 0.3% (95% CI 0.1% to 0.5%) in sexually experienced women aged 16-44 years. Of the seven women with T. vaginalis detected, four were of black or mixed ethnicity (prevalence 2.7% (0.9% to 7.7%) in this group) and five reported recent partners of black or mixed ethnicity. Six of the women reported symptoms, and five reported sexual health clinic attendance in the past 5 years (prevalence in those reporting clinic attendance: 1.0% (0.4% to 2.3%)). The prevalence of a self-reported history of T. vaginalis (past 5 years) was 0.1% (0.0% to 0.2%) in women and 0.0% (0.0% to 0.2%) in men aged 16-44 years. CONCLUSIONS: Our British population prevalence estimates indicate that T. vaginalis is a rare infection. These data support policies that restrict asymptomatic screening for T. vaginalis and suggest deployment of molecular tests should be focused within clinical settings and guided by symptoms and local demography.

Mixed-methods evaluation of a novel online STI results service.

OBJECTIVES: Evidence on optimal methods for providing STI test results is lacking. We evaluated an online results service, developed as part of an eSexual Health Clinic (eSHC). METHODS: We evaluated the online results service using a mixed-methods approach within large exploratory studies of the eSHC. Participants were chlamydia- positive and negative users of online postal self-sampling services in six National Chlamydia Screening Programme (NCSP) areas and chlamydia-positive patients from two genitourinary medicine (GUM) clinics between 21 July 2014 and 13 March 2015. Participants received a discreetly worded National Health Service 'NHS no-reply' text message (SMS) informing them that their test results were ready and providing a weblink to a secure website. Participants logged in with their date of birth and mobile telephone or clinic number. Chlamydia-positive patients were offered online management. All interactions with the eSHC system were automatically logged and their timing recorded. Post-treatment, a service evaluation survey (n=152) and qualitative interviews (n=36) were conducted by telephone. Chlamydia-negative patients were offered a short online survey (n=274). Data were integrated. RESULTS: 92% (134/146) of NCSP chlamydia-positive patients, 82% (161/197) of GUM chlamydia-positive patients and 89% (1776/1997) of NCSP chlamydia-negative participants accessed test results within 7 days. 91% of chlamydia-positive patients were happy with the results service; 64% of those who had tested previously found the results service better or much better than previous experiences. 90% of chlamydia-negative survey participants agreed they would be happy to receive results this way in the future. Interviewees described accessing results with ease and appreciated the privacy and control the two-step process gave them. CONCLUSION: A discreet SMS to alert users/patients that results are available, followed by provision of results via a secure website, was highly acceptable, irrespective of test result and testing history. The eSHC results service afforded users privacy and control over when they viewed results without compromising access.

Sexual health clinic attendance and non-attendance in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

OBJECTIVES: In Britain, sexual health clinics (SHCs) are the most common location for STI diagnosis but many people with STI risk behaviours do not attend. We estimate prevalence of SHC attendance and how this varies by sociodemographic and behavioural factors (including unsafe sex) and describe hypothetical service preferences for those reporting unsafe sex. METHODS: Complex survey analyses of data from Britain's third National Survey of Sexual Attitudes and Lifestyles, a probability survey of 15 162 people aged 16-74 years, undertaken 2010-2012. RESULTS: Overall, recent attendance (past year) was highest among those aged 16-24 years (16.6% men, 22.4% women), decreasing with age (<1.5% among those 45-74 years). Approximately 15% of sexually-active 16-74 year olds (n=1002 men; n=1253 women) reported 'unsafe sex' (condomless first sex with a new partner and/or ≥2 partners and no condom use, past year); >75% of these had not attended a SHC (past year). However, of non-attenders aged 16-44 years, 18.7% of men and 39.0% of women reported chlamydia testing (past year) with testing highest in women aged <25 years. Of those aged 16-44 years reporting unsafe sex, the majority who reported previous SHC attendance would seek STI care there, whereas the majority who had not would use general practice. CONCLUSION: While most reporting unsafe sex had not attended a SHC, many, particularly younger women, had tested for chlamydia suggesting engagement with sexual health services more broadly. Effective, diverse service provision is needed to engage those at-risk and ensure that they can attend services appropriate to their needs.

Using the eSexual Health Clinic to access chlamydia treatment and care via the internet: a qualitative interview study.

OBJECTIVE: We developed the eSexual Health Clinic (eSHC), an innovative, complex clinical and public health intervention, embedded within a specialist sexual health service. Patients with genital chlamydia access their results online and are offered medical management via an automated online clinical consultation, leading to antibiotic collection from community pharmacy. A telephone helpline, staffed by Sexual Health Advisers, is available to support patients and direct them to conventional services if appropriate. We sought to understand how patients used this ehealth intervention. METHODS: Within exploratory studies of the eSHC (2014-2015), we conducted in-depth interviews with a purposive sample of 36 patients diagnosed with chlamydia, who had chosen to use the eSHC (age 18-35, 20 female, 16 male). Thematic analysis was conducted. RESULTS: Participants described choosing to use this ehealth intervention to obtain treatment rapidly, conveniently and privately, within busy lifestyles that hindered clinic access. They described completing the online consultation promptly, discreetly and with ease. The information provided online was considered comprehensive, reassuring and helpful, but some overlooked it in their haste to obtain treatment. Participants generally described being able to collect treatment from pharmacies discreetly and promptly, but for some, poor awareness of the eSHC by pharmacy staff undermined their ability to do this. Those unsuitable for remote management, who were directed to clinic, described frustration and concern about health implications and clinic attendance. However, the helpline was a highly valued source of information, assistance and support. CONCLUSION: The eSHC is a promising adjunct to traditional care. Its users have high expectations for convenience, speed and privacy, which may be compromised when transitioning from online to face-to-face elements of the eSHC. Managing expectations and improving implementation of the pharmacy process, could improve their experiences. Positive views on the helpline provide further support for embedding this ehealth intervention within a specialist clinical service.

Impact and Cost-effectiveness of Selective Human Papillomavirus Vaccination of Men Who Have Sex With Men.

Background: Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination. Methods: We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16-25, 16-30, 16-35, and 16-40 years. Results: Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective. Conclusions: Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.

Patterns of chlamydia testing in different settings and implications for wider STI diagnosis and care: a probability sample survey of the British population.

BACKGROUND: Following widespread rollout of chlamydia testing to non-specialist and community settings in the UK, many individuals receive a chlamydia test without being offered comprehensive STI and HIV testing. We assess sexual behaviour among testers in different settings with a view to understanding their need for other STI diagnostic services. METHODS: A probability sample survey of the British population undertaken 2010-2012 (the third National Survey of Sexual Attitudes and Lifestyles). We analysed weighted data on chlamydia testing (past year), including location of most recent test, and diagnoses (past 5 years) from individuals aged 16-44 years reporting at least one sexual partner in the past year (4992 women, 3406 men). RESULTS: Of the 26.8% (95% CI 25.4% to 28.2%) of women and 16.7% (15.5% to 18.1%) of men reporting a chlamydia test in the past year, 28.4% of women and 41.2% of men had tested in genitourinary medicine (GUM), 41.1% and 20.7% of women and men respectively tested in general practice (GP) and the remainder tested in other non-GUM settings. Women tested outside GUM were more likely to be older, in a relationship and to live in rural areas. Individuals tested outside GUM reported fewer risk behaviours; nevertheless, 11.0% (8.6% to 14.1%) of women and 6.8% (3.9% to 11.6%) of men tested in GP and 13.2% (10.2% to 16.8%) and 9.6% (6.5% to 13.8%) of women and men tested in other non-GUM settings reported 'unsafe sex', defined as two or more partners and no condom use with any partner in the past year. Individuals treated for chlamydia outside GUM in the past 5 years were less likely to report an HIV test in that time frame (women: 54.5% (42.7% to 65.7%) vs 74.1% (65.9% to 80.9%) in GUM; men: 23.9% (12.7% to 40.5%) vs 65.8% (56.2% to 74.3%)). CONCLUSIONS: Most chlamydia testing occurred in non-GUM settings, among populations reporting fewer risk behaviours. However, there is a need to provide pathways to comprehensive STI care to the sizeable minority at higher risk.

'Can you recommend any good STI apps?' A review of content, accuracy and comprehensiveness of current mobile medical applications for STIs and related genital infections.

OBJECTIVE: Seeking sexual health information online is common, and provision of mobile medical applications (apps) for STIs is increasing. Young people, inherently at higher risk of STIs, are avid users of technology, and apps could be appealing sources of information. We undertook a comprehensive review of content and accuracy of apps for people seeking information about STIs. METHODS: Search of Google Play and iTunes stores using general and specific search terms for apps regarding STIs and genital infections (except HIV), testing, diagnosis and management, 10 September 2014 to 16 September 2014. We assessed eligible apps against (1) 19 modified Health on The Net (HON) Foundation principles; and (2) comprehensiveness and accuracy of information on STIs/genital infections, and their diagnosis and management, compared with corresponding National Health Service STI information webpage content. RESULTS: 144/6642 apps were eligible. 57 were excluded after downloading. 87 were analysed. Only 29% of apps met ≥6 HON criteria. Content was highly variable: 34/87 (39%) covered one or two infections; 40 (46%) covered multiple STIs; 5 (6%) focused on accessing STI testing. 13 (15%) were fully, 46 (53%) mostly and 28 (32%) partially accurate. 25 (29%) contained ≥1 piece of potentially harmful information. Apps available on both iOS and Android were more accurate than single-platform apps. Only one app provided fully accurate and comprehensive information on chlamydia. CONCLUSIONS: Marked variation in content, quality and accuracy of available apps combined with the nearly one-third containing potentially harmful information risks undermining potential benefits of an e-Health approach to sexual health and well-being.

Finding sexual partners online: prevalence and associations with sexual behaviour, STI diagnoses and other sexual health outcomes in the British population.

OBJECTIVES: Online venues might facilitate sexual encounters, but the extent to which finding partners online is associated with sexual risk behaviour and sexual health outcomes is unclear. We describe use of the internet to find sexual partners in a representative sample in Britain. METHODS: The third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) was a cross-sectional probability survey of 15 162 adults (aged 16-74 years) undertaken 2010-2012. We estimated prevalence of, and identified factors associated with, finding sexual partners online among those reporting ≥1 new sexual partners in the past year. RESULTS: Finding sexual partners online in the past year was reported by 17.6% (95% CI 15.6 to 19.9) of men and 10.1% (8.5-11.9) of women, and most common among those aged 35-44 years. After age-adjustment, those reporting a non-heterosexual identity were more likely to report this. Finding partners online was also associated with reporting sexual risk behaviours: condomless sex with ≥2 partners (adjusted OR (aOR) men: 1.52 (1.03 to 2.23); women: 1.62 (1.06 to 2.49)), concurrent partnerships (aOR men: 2.33 (1.62 to 3.35); women: 2.41 (1.49 to 3.87)) and higher partner numbers (reporting ≥5 partners aOR men: 5.95 (3.78 to 9.36); women: 7.00 (3.77 to 13.00)) (all past year). STI diagnoses and HIV testing were more common among men reporting finding partners online (adjusted for age, partner numbers, same-sex partnerships), but not women. CONCLUSIONS: Finding partners online was associated with markers of sexual risk, which might be important for clinical risk assessment, but this was not matched by uptake of sexual health services. Online opportunities to find partners have increased, so these data might underestimate the importance of this social phenomenon for public health and STI control.