Predictors of starting and stopping chemsex in men who have sex with men in England: findings from the AURAH2 prospective study.

BACKGROUND: Chemsex (the use of psychoactive drugs in sexual contexts) has been associated with HIV acquisition and other STIs, so there is benefit in identifying those most likely to start chemsex to offer risk reduction interventions such as pre-exposure prophylaxis (PrEP). To date, there have been no data from a longitudinal study analysing factors most associated with starting and stopping chemsex. METHODS: The prospective cohort study, Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2), collected 4 monthly and annual online questionnaire data from men who have sex with men (MSM) from 2015 to 2018. We investigate the association of sociodemographic factors, sexual behaviours and drug use with starting and stopping chemsex among 622 men who completed at least one follow-up questionnaire. Poisson models with generalised estimating equations were used to produce risk ratios (RRs) accounting for multiple starting or stopping episodes from the same individual. Multivariable analysis was adjusted for age group, ethnicity, sexual identity and university education. FINDINGS: In the multivariable analysis, the under 40 age group was significantly more likely to start chemsex by the next assessment (RR 1.79, 95% CI 1.12 to 2.86). Other factors which showed significant association with starting chemsex were unemployment (RR 2.10, 95% CI 1.02 to 4.35), smoking (RR 2.49, 95% CI 1.63 to 3.79), recent condomless sex (CLS), recent STI and postexposure prophylaxis (PEP) use in the past year (RR 2.10, 95% CI 1.33 to 3.30). Age over 40 (RR 0.71, 95% CI 0.51 to 0.99), CLS, and use of PEP (RR 0.64, 95% CI 0.47 to 0.86) and PrEP (RR 0.47, 95% CI 0.29 to 0.78) were associated with lower likelihood of stopping chemsex by the next assessment. INTERPRETATION: Knowledge of these results allows us to identify men most likely to start chemsex, thus providing an opportunity for sexual health services to intervene with a package of risk mitigation measures, especially PrEP use.

Examining the potential public health benefit of offering STI testing to men in amateur football clubs: evidence from cross-sectional surveys.

BACKGROUND: In Britain, young people continue to bear the burden of sexually transmitted infections (STIs) so efforts are required, especially among men, to encourage STI testing. The SPORTSMART study trialled an intervention that sought to achieve this by offering chlamydia and gonorrhoea test-kits to men attending amateur football clubs between October and December 2012. With football the highest participation team sport among men in England, this paper examines the potential public health benefit of offering STI testing to men in this setting by assessing their sociodemographic characteristics, sexual behaviours, and healthcare behaviour and comparing them to men in the general population. METHODS: Data were collected from 192 (male) members of 6 football clubs in London, United Kingdom, aged 18-44 years via a 20-item pen-and-paper self-completion questionnaire administered 2 weeks after the intervention. These were compared to data collected from 409 men of a similar age who were resident in London when interviewed during 2010-2012 for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a national probability survey that used computer-assisted-personal-interviewing with computer-assisted-self-interview. Age standardisation and multivariable regression were used to account for sociodemographic differences between the surveys. RESULTS: Relative to men in the general population, SPORTSMART men were younger (32.8 % vs. 21.7 % aged under 25 y), and more likely to report (all past year) at least 2 sexual partners (adjusted odds ratio, AOR: 3.25, 95 % CI: 2.15-4.92), concurrent partners (AOR: 2.05, 95 % CI: 1.39-3.02), and non-use of condoms (AOR: 2.17, 95 % CI: 1.39-3.41). No difference was observed in STI/HIV risk perception (AOR for reporting "not at all at risk" of STIs: 1.25, 95 % CI: 0.76-2.04; of HIV: AOR: 1.54, 95 % CI: 0.93-2.55), nor in reporting STI testing in the past year (AOR: 0.83, 95 % CI: 0.44-1.54), which was reported by only one in six men. CONCLUSIONS: Relative to young men in the general population, football club members who completed the SPORTSMART survey reported greater sexual risk behaviour but similar STI/HIV risk perception and STI testing history. Offering STI testing in amateur football clubs may therefore widen access to STI testing and health promotion messages for men at higher STI risk, which, given the minority currently testing and the popularity of football in England, should yield both individual and public health benefit.

It matters what you measure: a systematic literature review examining whether young people in poorer socioeconomic circumstances are more at risk of chlamydia.

BACKGROUND: England has invested in chlamydia screening interventions for young people. It is not known whether young people in poorer socioeconomic circumstances (SEC) are at greater risk of chlamydia and therefore in greater need of screening. OBJECTIVE: To conduct a systematic review examining socioeconomic variations in chlamydia prevalence or positivity in young people. DATA SOURCES: Eight bibliographic databases using terms related to chlamydia and SEC, supplemented by website and reference searches. ELIGIBILITY: Studies published 1999-2011 in North America, Western Europe, Australia or New Zealand, including populations aged 15-24 years, with chlamydia prevalence or positivity diagnosed by nucleic acid amplification testing. APPRAISAL AND SYNTHESIS: Two reviewers independently screened references, extracted data, appraised studies meeting inclusion criteria and rated studies as high, medium or low according to their quality and relevance. Socioeconomic variations in chlamydia were synthesised for medium/high-rated studies only. RESULTS: No high-rated studies were identified. Eight medium-rated studies reported variations in chlamydia prevalence by SEC. In 6/8 studies, prevalence was higher in people of poorer SEC. Associations were more often significant when measured by education than when using other indicators. All studies measuring positivity were rated low. Across all studies, methodological limitations in SEC measurement were identified. CONCLUSIONS: The current literature is limited in its capacity to describe associations between SEC and chlamydia risk. The choice of SEC measure may explain why some studies find higher chlamydia prevalence in young people in disadvantaged circumstances while others do not. Studies using appropriate SEC indicators (eg, education) are needed to inform decisions about targeting chlamydia screening.

Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain.

OBJECTIVES: Rates of sexually transmitted infections (STIs) in UK young people remain high in men and women. However, the National Chlamydia Screening Programme has had limited success in reaching men. The authors explored the acceptability of various medical, recreational and sports venues as settings to access self-collected testing kits for STIs and HIV among men in the general population and those who participate in sport. METHODS: A stratified random probability survey of 411 (weighted n=632) men in Great Britain aged 18-35 years using computer-assisted personal and self-interviews. RESULTS: Young men engaged well with healthcare with 93.5% registered with, and 75.3% having seen, a general practitioner in the last year. 28.7% and 19.8% had previously screened for STIs and HIV, respectively. Willingness to access self-collected tests for STIs (85.1%) and HIV (86.9%) was high. The most acceptable pick-up points for testing kits were general practice 79.9%, GUM 66.8% and pharmacy 65.4%. There was a low acceptability of sport venues as pick-up points in men as a whole (11.7%), but this was greater among those who participated in sport (53.9%). CONCLUSIONS: Healthcare settings were the most acceptable places for accessing STI and HIV self-testing kits. Although young men frequently access general practice, currently little STI screening occurs in this setting. There is considerable potential to screen large numbers of men and find high rates of infection through screening in general practice. While non-clinical settings are acceptable to a minority of men, more research is needed to understand how these venues could be used most effectively.

Serosorting and strategic positioning during unprotected anal intercourse: are risk reduction strategies being employed by gay and bisexual men in Scotland?

BACKGROUND: Unprotected anal intercourse (UAI) remains the main risk factor for HIV among men who have sex with men (MSM), but risk varies by the sexual position adopted and the risk reduction strategies used. Here, we report on sexual position, and knowledge of partners' HIV status, during UAI to assess whether MSM in Scotland are using sexual risk reduction strategies. METHODS: Anonymous, self-complete questionnaires and Orasure oral fluid specimens (OraSure Technologies, Inc., Bethlehem, Pennsylvania, USA) were provided by 1277 MSM in commercial gay venues in Glasgow and Edinburgh, Scotland, United Kingdom (59.7% response rate). Overall, 488 MSM (39.7%) reported any UAI in the past 12 months; 318 reported on partner HIV status and sexual position and are included in these analyses. RESULTS: Being equally either the insertive or receptive partner during UAI was most commonly reported; 23.1% of HIV-negative MSM reported exclusive insertive UAI, whereas no MSM with diagnosed HIV reported exclusive receptive UAI. Five diagnosed HIV-positive MSM reported always knowing their partners' HIV status and only having HIV-positive partners (50.0% of HIV-positive MSM reporting UAI; 11.9% of the diagnosed HIV-positive sample); 160 HIV-negative MSM reported having had an HIV test (and therefore being aware of their HIV-negative status), always knowing their partners' status, and only having HIV-negative partners (52.8% of HIV-negative MSM reporting UAI; 13.7% of the total HIV-negative sample). CONCLUSIONS: Behavior suggestive of serosorting and strategic positioning (among HIV-negative MSM) was evident in this sample, but inconsistent adoption of these and general versatility in sexual behavior suggest that they have a limited role.

Willingness to participate in future HIV prevention studies among gay and bisexual men in Scotland, UK: a challenge for intervention trials.

This article examines willingness to participate in future HIV prevention research among gay and bisexual men in Scotland, UK. Anonymous, self-complete questionnaires and Orasure™ oral fluid samples were collected in commercial gay venues. 1,320 men were eligible for inclusion. 78.2% reported willingness to participate in future HIV prevention research; 64.6% for an HIV vaccine, 57.4% for a behaviour change study, and 53.0% for a rectal microbicide. In multivariate analysis, for HIV vaccine research, greater age, minority ethnicity, and not providing an oral fluid sample were associated with lower willingness; heterosexual orientation and not providing an oral fluid sample were for microbicides; higher education and greater HIV treatment optimism were for behaviour change. STI testing remained associated with being more willing to participate in microbicide research and frequent gay scene use remained associated with being more willing to participate in behaviour change research. Having an STI in the past 12 months remained significantly associated with being willing to participate in all three study types. There were no associations between sexual risk behaviour and willingness. Although most men expressed willingness to participate in future research, recruitment of high-risk men, who have the potential to benefit most, is likely to be more challenging.

GSK256066, an exceptionally high-affinity and selective inhibitor of phosphodiesterase 4 suitable for administration by inhalation: in vitro, kinetic, and in vivo characterization.

Oral phosphodiesterase (PDE) 4 inhibitors such as roflumilast have established the potential of PDE4 inhibition for the treatment of respiratory diseases. However, PDE4 inhibitor efficacy is limited by mechanism-related side effects such as emesis and nausea. Delivering the inhibitor by the inhaled route may improve therapeutic index, and we describe 6-({3-[(dimethylamino)carbonyl]phenyl}sulfonyl)-8-methyl-4-{[3-methyloxy) phenyl]amino}-3-quinolinecarboxamide (GSK256066), an exceptionally high-affinity inhibitor of PDE4 designed for inhaled administration. GSK256066 is a slow and tight binding inhibitor of PDE4B (apparent IC(50) 3.2 pM; steady-state IC(50) <0.5 pM), which is more potent than any previously documented compound, for example, roflumilast (IC(50) 390 pM), tofimilast (IC(50) 1.6 nM), and cilomilast (IC(50) 74 nM). Consistent with this, GSK256066 inhibited tumor necrosis factor α production by lipopolysaccharide (LPS)-stimulated human peripheral blood monocytes with 0.01 nM IC(50) (compared with IC(50) values of 5, 22, and 389 nM for roflumilast, tofimilast, and cilomilast, respectively) and by LPS-stimulated whole blood with 126 pM IC(50). GSK256066 was highly selective for PDE4 (>380,000-fold versus PDE1, PDE2, PDE3, PDE5, and PDE6 and >2500-fold against PDE7), inhibited PDE4 isoforms A-D with equal affinity, and had a substantial high-affinity rolipram binding site ratio (>17). When administered intratracheally to rats, GSK256066 inhibited LPS-induced pulmonary neutrophilia with ED(50) values of 1.1 µg/kg (aqueous suspension) and 2.9 µg/kg (dry powder formulation) and was more potent than an aqueous suspension of the corticosteroid fluticasone propionate (ED(50) 9.3 µg/kg). Thus, GSK256066 has been demonstrated to have exceptional potency in vitro and in vivo and is being clinically investigated as a treatment for chronic obstructive pulmonary disease.

Increased HIV testing and reduced undiagnosed infection among gay men in Scotland, 2005-8: support for the opt-out testing policy?

OBJECTIVE: To examine changes in HIV testing and undiagnosed infection among men who have sex with men in Scotland between 2005 and 2008. METHODS: Self-completed questionnaires and Orasure oral fluid collection kits were distributed to men visiting the commercial gay scene in Glasgow and Edinburgh. RESULTS: Questionnaires and oral fluid specimens were provided by 1350 men (51.6% response rate) in 2005 and 1277 (59.7% response rate) in 2008. 2572 men were eligible for inclusion in the analyses. Recent HIV testing increased from 33.2% in 2005 to 48.3% in 2008 (p<0.001). HIV prevalence was comparable in 2005 and 2008 (4.4% and 4.6%, respectively). Among HIV-positive men, there was a reduction in undiagnosed infection between 2005 and 2008 from 41.7% to 26.3% (p=0.08). Undiagnosed HIV did not differ between men who were and were not tested in the past year. In 2008, only four (26.7%) HIV-positive men tested in the past 6 months were undiagnosed, compared with 11 (42.3%) HIV-positive men who had not tested (p=0.03). CONCLUSION: There was a substantial increase in recent HIV testing between 2005 and 2008. Although there was a concurrent (non-significant) reduction in undiagnosed HIV, there was no difference in undiagnosed infection between men who had and had not tested recently. However, lower proportions of undiagnosed infection among the most recent HIV-positive testers suggest frequent testing could play a role in reducing undiagnosed HIV and should remain central to HIV prevention efforts.

HIV-related sexual risk behaviour between 1996 and 2008, according to age, among men who have sex with men (Scotland).

OBJECTIVE: To examine changes in the proportions of those reporting 2+ unprotected anal intercourse (UAI) partners in the previous 12 months among men who have sex with men (MSM) in Scotland between 1996 and 2008. Differences according to age group were also examined. METHODS: Logistic regression was used with data from eight cross-sectional anonymous, self-report surveys in commercial gay venues in Glasgow and Edinburgh (N=10,223). Data were stratified according to survey and age group (<25 years vs ≥25 years). RESULTS: The percentage of 2+ UAI partners reported in the previous 12 months increased significantly between 2000 and 2002, adjusted for age group. When the surveys were divided into two time periods (1996-2000 and 2002-2008), no significant differences were found within each time period in the percentage of 2+ UAI partners reported (adjusted for age group). However, a significant increase was found when the aggregated figures for 2002-2008 were compared with those for 1996-2000. At the aggregate level, those aged <25 years were significantly more likely than those aged ≥25 years to report 2+ UAI partners in the previous 12 months (adjusted for survey). CONCLUSIONS: HIV-related sexual risk behaviour did not change significantly between 2002 and 2008 among MSM in Scotland, after the increases noted between 2000 and 2002. A significant minority of MSM continue to engage in relatively high levels of sexual risk, and younger generations appear to be at particular risk. This represents a public health concern and highlights the need for targeted age-specific interventions.

Factors associated with genitourinary medicine clinic attendance and sexually transmitted infection diagnosis among central and east European migrants in London.

OBJECTIVES: There has been a large influx of central and east European (CEE) migrants to the U.K. following the expansion of the European Union. This paper examines factors associated with genitourinary medicine (GUM) clinic attendance and sexually transmitted infection (STI) diagnosis among CEE migrants in London. METHODS: A survey of sexual behaviour was conducted among CEE migrants attending two central London GUM clinics (n=299) and community venues in London (n=2276). Routinely collected clinic data were also analysed. RESULTS: CEE migrants made up 2.9% of male and 7.0% of female attendees at the clinics. Half the women attending sessions for female sex workers were from CEE countries, and paying for sex was widely reported by men. Women were more likely than men to have attended a GUM clinic in the U.K. (7.6% vs. 4.5%, p=0.002). GUM survey respondents were more likely than community survey respondents to report one or more new sexual partners in the past year (women 67.9% vs. 28.3%, p < 0.001; men 75.6% vs. 45.1%, p < 0.001) and homosexual partnership(s) in the past 5 years (men 54.3% vs. 1.8%, p < 0.001), but were less likely to report assortative heterosexual mixing (women 25.9% vs. 74.2%, p < 0.001; men 56.5% vs. 76.3%, p < 0.001). CONCLUSIONS: CEE patients make up a notable minority of patients attending two central London GUM clinics. Higher numbers of sexual partners, homosexual partnerships and sexual mixing with people from outside the country of origin are associated with GUM clinic attendance. Heterosexual CEE men report behaviours associated with HIV/STI acquisition but appear to be underutilising GUM services.

Central and east European migrant men who have sex with men: an exploration of sexual risk in the U.K.

BACKGROUND: Since May 2004, 10 central and east European (CEE) countries have joined the European Union. While HIV rates remain low among men who have sex with men (MSM) in CEE countries, there is no research on the sexual behaviour of CEE MSM in the U.K. METHODS: CEE MSM living in the U.K. (n=691) were recruited for an online questionnaire by two popular MSM websites. RESULTS: The majority of men had arrived in the U.K. since May 2004. A previous sexually transmitted infection (STI) diagnosis was reported by 30.7%, and 4.8% reported being HIV positive, the majority diagnosed in the U.K. Unprotected anal intercourse with a casual partner of unknown or discordant HIV status was reported by 22.8%. Men who had been in the U.K. for longer (>5 years vs. <1 year) reported more partners in the past 5 years (67.2% vs. 50.4% had >10 partners, p < 0.001) and were less likely to report their most recent partner was from their home country (14.9% vs. 33.6%, p < 0.001). Among migrant CEE MSM living in London, 15.4% had been paid for sex in the U.K. and 41.5% had taken recreational drugs in the past year. CONCLUSION: CEE MSM in the U.K. are at risk for the acquisition and transmission of STI and HIV through unprotected anal intercourse with non-concordant casual partners. Sexual mixing with men from other countries, commercial sex and increased partner numbers may introduce additional risk. This has important implications for the cross-border transmission of infections between the U.K. and CEE countries.

Sexual and HIV risk behaviour in central and eastern European migrants in London.

BACKGROUND: Accession of 10 Central and Eastern European (CEE) countries to the E.U. resulted in the largest migratory influx in peacetime British history. No information exists on the sexual behaviour of CEE migrants within the U.K. The aim of this study was to assess the sexual lifestyles and health service needs of these communities. METHODS: A survey, delivered electronically and available in 12 languages, of migrants from the 10 CEE accession countries recruited from community venues in London following extensive social mapping and via the Internet. Reported behaviours were compared with those from national probability survey data. RESULTS: 2648 CEE migrants completed the survey. Male CEE migrants reported higher rates of partner acquisition (adjusted OR (aOR) 2.1, 95% CI: 1.3 to 2.1) and paying for sex (aOR 3.2, 95% CI: 2.5 to 4.0), and both male and female CEE migrants reported more injecting drug use (men: aOR 2.2, 95% CI: 1.3 to 3.9; women: aOR 3.0, 95% CI 1.1 to 8.1), than the general population; however, CEE migrants were more likely to report more consistent condom use and lower reported diagnoses of sexually transmitted infections (STI). Just over 1% of respondents reported being HIV positive. Most men and a third of women were not registered for primary care in the U.K. DISCUSSION: CEE migrants to London report high rates of behaviours associated with increased risk of HIV/STI acquisition and transmission. These results should inform service planning, identify where STI and HIV interventions should be targeted, and provide baseline data to help evaluate the effectiveness of such interventions.

Central and East European migrant men who have sex with men in London: a comparison of recruitment methods.

BACKGROUND: Following the expansion of the European Union, there has been a large influx of Central and East European (CEE) migrants to the UK. CEE men who have sex with men (MSM) represent a small minority within this population that are none-the-less important to capture in sexual health research among the CEE migrant community. This paper examines the feasibility of recruiting CEE MSM for a survey of sexual behaviour in London using respondent driven sampling (RDS), via gay websites and in GUM clinics. METHODS: We sought CEE MSM to start RDS chain referral among GUM clinic attendees, our personal contacts and at gay events and venues in central London. We recruited CEE MSM (n = 485) via two popular websites for gay men in Britain (March-May 2009) and at two central London GUM clinics (n = 51) (July 2008-March 2009). RESULTS: We found seventeen men who knew other CEE MSM in London and agreed to recruit contacts into the study. These men recruited only three men into the study, none of whom recruited any further respondents, and RDS was abandoned after 7 months (July 2008-January 2009). Half of the men that we approached to participate in RDS did not know any other CEE MSM in London. Men who agreed to recruit contacts for RDS were rather more likely to have been in the UK for more than one year (94.1% vs 70.0%, p = 0.052). Men recruited through gay websites and from GUM clinics were similar. CONCLUSIONS: The Internet was the most successful method for collecting data on sexual risk behaviour among CEE MSM in London. CEE MSM in London were not well networked. RDS may also have failed because they did not fully understand the procedure and/or the financial incentive was not sufficient motivation to take part.

Sexual risk behaviour of men who have sex with men: emerging patterns and new challenges.

PURPOSE OF REVIEW: Antiretroviral treatment means that an increasing number of men who have sex with men (MSM) are living with HIV. The present review focuses on continuing transmission of HIV, risk factors for HIV infection in HIV-negative MSM, risk behaviour and risk reduction interventions among HIV-positive MSM, sexually transmitted infections, HIV and ageing and new and emerging populations of MSM communities. RECENT FINDINGS: Transmission of HIV infection continues in populations of MSM; transmission may be particularly high from main partners. Serosorting offers limited protection against HIV infection for HIV-negative MSM; negotiated safety and strategic positioning may be partially protective. For HIV-positive men, serosorting is a strategy to prevent HIV transmission, but has contributed to high rates of new non-HIV sexually transmitted infections. Sexual networks are important to the understanding of emerging sexually transmitted infections; ageing brings a new dimension to research on HIV. SUMMARY: Strategies other than exclusive condom use have emerged in communities of MSM to reduce the risk of HIV transmission, including serosorting and strategic positioning. 'Combination prevention' - using social structural, behavioural and biomedical approaches in tandem - could reduce the risk of HIV transmission, and may be particularly suited to HIV-positive MSM.

Circumcision among men who have sex with men in Scotland: limited potential for HIV prevention.

OBJECTIVE: Male circumcision has been shown to reduce the risk of HIV acquisition among heterosexual men but the impact among men who have sex with men (MSM) is not known. In this paper, we explore the feasibility of research into circumcision for HIV prevention among MSM in Scotland. METHODS: Anonymous, self-complete questionnaires and Orasure oral fluid collection kits were distributed to men visiting the commercial gay scenes in Glasgow and Edinburgh. RESULTS: 1508 men completed questionnaires (70.5% response rate) and 1277 provided oral fluid samples (59.7% response rate). Overall, 1405 men were eligible for inclusion in the analyses. 16.6% reported having been circumcised. HIV prevalence was similar among circumcised and uncircumcised men (4.2% and 4.6%, respectively). Although biologically, circumcision is most likely to protect against HIV for men practising unprotected insertive anal intercourse (UIAI), only 7.8% (91/1172) of uncircumcised men reported exclusive UIAI in the past 12 months. Relatively few men reported being willing to participate in a research study on circumcision and HIV prevention (13.9%), and only 11.3% of uncircumcised men did so. CONCLUSION: The lack of association between circumcision and HIV status, low levels of exclusive UIAI, and low levels of willingness to take part in circumcision research studies suggest circumcision is unlikely to be a feasible HIV prevention strategy for MSM in the UK. Behaviour change should continue to be the focus of HIV prevention in this population.

Knowledge of Chlamydia trachomatis among men and women approached to participate in community-based screening, Scotland, UK.

BACKGROUND: Poor awareness and knowledge of Chlamydia trachomatis could be a barrier to uptake of screening. This study aimed to determine the level of awareness and knowledge of chlamydia among young people who were being approached in a variety of community settings and offered opportunistic screening. METHODS: Men and women aged 16-24 years were approached in education, health and fitness, and workplace settings and invited to complete a self-administered questionnaire then provide a urine sample for chlamydia testing. Follow-up semi-structured interviews with 24 respondents were carried out after test results were received. RESULTS: 363 questionnaires were completed (43.5% from men). Whilst awareness of chlamydia was high, knowledge decreased as questions became increasingly focussed so that around half of respondents were unaware of the asymptomatic nature of chlamydia infections. Men's knowledge of symptoms was consistently lower than women's, with most men failing to identify unusual discharge as a symptom in men (men 58.3%, female 45.8%, p = 0.019); fewer men knew unusual discharge was a symptom among women (men 65.3% female 21.4%, p < 0.001). The asymptomatic nature of the infection resonated with respondents and was the commonest piece of information they picked up from their participation in the study. CONCLUSIONS: Despite scientific gains in understanding chlamydia infection, public understanding remains limited. Greater efforts are required to translate scientific evidence to the public. An improvement in knowledge may maximise gains from interventions to improve detection.

Contact with HIV prevention services highest in gay and bisexual men at greatest risk: cross-sectional survey in Scotland.

BACKGROUND: Men who have sex with men (MSM) remain the group most at risk of acquiring HIV in the UK and new HIV prevention strategies are needed. In this paper, we examine what contact MSM currently have with HIV prevention activities and assess the extent to which these could be utilised further. METHODS: Anonymous, self-complete questionnaires and Orasure™ oral fluid collection kits were distributed to men visiting the commercial gay scenes in Glasgow and Edinburgh in April/May 2008. 1508 men completed questionnaires (70.5% response rate) and 1277 provided oral fluid samples (59.7% response rate); 1318 men were eligible for inclusion in the analyses. RESULTS: 82.5% reported some contact with HIV prevention activities in the past 12 months, 73.1% obtained free condoms from a gay venue or the Internet, 51.1% reported accessing sexual health information (from either leaflets in gay venues or via the Internet), 13.5% reported talking to an outreach worker and 8.0% reported participating in counselling on sexual health or HIV prevention. Contact with HIV prevention activities was associated with frequency of gay scene use and either HIV or other STI testing in the past 12 months, but not with sexual risk behaviours. Utilising counselling was also more likely among men who reported having had an STI in the past 12 months and HIV-positive men. CONCLUSIONS: Men at highest risk, and those likely to be in contact with sexual health services, are those who report most contact with a range of current HIV prevention activities. Offering combination prevention, including outreach by peer health workers, increased uptake of sexual health services delivering behavioural and biomedical interventions, and supported by social marketing to ensure continued community engagement and support, could be the way forward. Focused investment in the needs of those at highest risk, including those diagnosed HIV-positive, may generate a prevention dividend in the long term.

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research.

BACKGROUND: Improving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses. METHODS: Literature searches of 23 databases, including Medline, Embase and POPLINE(R), were conducted. Literature from 1970-2006 concerning the 11-24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data. RESULTS: Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13-19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health. CONCLUSION: Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

Willingness of young men and women to be tested for Chlamydia trachomatis in three non-medical settings in Glasgow, UK.

OBJECTIVE: To assess the willingness of young men and women to be tested for Chlamydia trachomatis in three non-medical settings. METHODS: Men and women aged between 16 and 24 years were invited to complete a self-administered questionnaire and provide a urine sample in non-medical settings: 'education' (one further education college), 'health and fitness' (three local authority leisure centres) and 'workplace' (two call centres). RESULTS: Eighty-four percent of age-eligible users approached in the settings agreed to complete a questionnaire (n = 363). Among the sexually active people (n = 346), the uptake of screening varied by setting [education 19.1% (22/115), health and fitness 48.8% (62/127), workplace 27.8% (29/104); p<0.001]. Health and fitness settings (OR 4.08; 95% CI 2.04-8.14) and perception of being at risk of having chlamydia (OR 2.47; 95% CI 1.33-4.58) were strong predictors of providing a urine sample. Adjusting for setting and age group (<20 years vs 20+ years), women were less likely than men to provide a urine sample (OR 0.42; 95% CI 0.26-0.70). All five positive cases (4.4%; 4.9% in men, 3.8% in women) were contacted with their results by a health adviser and invited to be treated at a local genitourinary medicine clinic. CONCLUSIONS: Men were more willing than women to be tested for C. trachomatis in these non-medical settings, but uptake varied by setting. Thus, increasing opportunities for the take-up of testing in particular non-medical settings might be a more effective approach to including young men who are not reached by clinic control efforts.

Development of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours.

BACKGROUND: Systematic reviews based on the critical appraisal of observational and analytic studies on HIV prevalence and risk factors for HIV transmission among men having sex with men are very useful for health care decisions and planning. Such appraisal is particularly difficult, however, as the quality assessment tools available for use with observational and analytic studies are poorly established. METHODS: We reviewed the existing quality assessment tools for systematic reviews of observational studies and developed a concise quality assessment checklist to help standardise decisions regarding the quality of studies, with careful consideration of issues such as external and internal validity. RESULTS: A pilot version of the checklist was developed based on epidemiological principles, reviews of study designs, and existing checklists for the assessment of observational studies. The Quality Assessment Tool for Systematic Reviews of Observational Studies (QATSO) Score consists of five items: External validity (1 item), reporting (2 items), bias (1 item) and confounding factors (1 item). Expert opinions were sought and it was tested on manuscripts that fulfil the inclusion criteria of a systematic review. Like all assessment scales, QATSO may oversimplify and generalise information yet it is inclusive, simple and practical to use, and allows comparability between papers. CONCLUSION: A specific tool that allows researchers to appraise and guide study quality of observational studies is developed and can be modified for similar studies in the future.