Frequency of HIV testing among gay and bisexual men in the UK: implications for HIV prevention.

OBJECTIVES: The aim of the study was to explore HIV testing frequency among UK men who have sex with men (MSM) in order to direct intervention development. METHODS: Cross-sectional surveys were completed by 2409 MSM in Edinburgh, Glasgow and London in 2011 and a Scotland-wide online survey was carried out in 2012/13. The frequency of HIV testing in the last 2 years was measured. RESULTS: Overall, 21.2% of respondents reported at least four HIV tests and 33.7% reported two or three tests in the last 2 years, so we estimate that 54.9% test annually. Men reporting at least four HIV tests were younger and less likely to be surveyed in London. They were more likely to report higher numbers of sexual and anal intercourse partners, but not "higher risk" unprotected anal intercourse (UAI) with at least two partners, casual partners and/or unknown/discordant status partners in the previous 12 months. Only 26.7% (238 of 893) of men reporting higher risk UAI reported at least four tests. Among all testers (n = 2009), 56.7% tested as part of a regular sexual health check and 35.5% tested following a risk event. Differences were observed between surveys, and those testing in response to a risk event were more likely to report higher risk UAI. CONCLUSIONS: Guidelines recommend that all MSM test annually and those at "higher risk" test more frequently, but our findings suggest neither recommendation is being met. Additional efforts are required to increase testing frequency and harness the opportunities provided by biomedical HIV prevention. Regional, demographic and behavioural differences and variations in the risk profiles of testers suggest that it is unlikely that a "one size fits all" approach to increasing the frequency of testing will be successful.

Attitudes and first heterosexual experiences among Indians and Pakistanis in Britain: evidence from a national probability survey.

We compare attitudes, experiences of learning about sex and first intercourse among Indians (n = 393) and Pakistanis (n = 365) using a probability survey of Britain's general population aged 16-44 years conducted during 1999-2001 (n = 12,110). Higher proportions of Pakistanis (64.6%) and Indians (28.1%) reported religion as 'very important' versus 6.2% of other ethnicities. Pakistanis were more conservative in their attitudes, e.g. reporting premarital sex as wrong (adjusted odds ratios [AORs] for sociodemographic differences, 4.71 [men] and 6.59 [women]). Pakistanis were more likely to be married at first sex (AORs 6.2 [men] and 9.53 [women]), yet men were more likely than women to be in non-marital relationships at this time (69.4% versus 25.2%). Pakistani men and women and Indian women were more likely to report not using reliable contraception at first sex relative to others (AORs 2.33, 3.16 and 1.90, respectively). Pakistani and Indian women were more likely than others to report school lessons as their main source of sex education (AORs 2.23 and 1.77) and not discussing sex with their parents during adolescence (AORs 2.04 and 2.62). These unique data have implications for ensuring that sex and relationship education and health promotion messages are appropriately planned, targeted and delivered to benefit Pakistanis and Indians.

Feasibility and acceptability of offering rapid HIV tests to patients registering with primary care in London (UK): a pilot study.

OBJECTIVE: To assess the acceptability and feasibility of offering rapid HIV tests to patients registering with primary care in London, UK. METHODS: All Anglophone and Francophone patients aged between 18 and 55 years attending a large inner city general practice in London for a new patient health check were recruited. All eligible patients were offered a rapid HIV test on oral fluid and asked to participate in a qualitative interview. The uptake of rapid HIV testing among participants was measured and semistructured interviews were carried out focusing on the advantages and disadvantages of testing for HIV in primary care. RESULTS: 111 people attended the health check, of whom 85 were eligible, 47 took part in the study and 20 completed qualitative interviews. Nearly half of eligible participants (38/85, 45%) accepted a rapid HIV test. The main reason for accepting a test was because it was offered as "part of a check up". As a combined group, black African and black Caribbean patients were more likely to test in the study compared with patients from other ethnic backgrounds (p = 0.014). Participants in the qualitative interviews felt that having rapid HIV tests available in general practice was acceptable but expressed concerns about support for the newly diagnosed. CONCLUSIONS: Offering patients a rapid HIV test in primary care is feasible and could be an effective means to increase testing rates in this setting. A larger descriptive study or pragmatic trial is needed to determine whether this strategy could increase timely diagnosis and reduce the proportion of undiagnosed HIV infections in the UK.

HIV testing trends among gay men in Scotland, UK (1996-2005): implications for HIV testing policies and prevention.

OBJECTIVE: To examine trends in the HIV testing behaviour of gay men in Scotland over a 10-year period. METHODS: Seven cross-sectional surveys in commercial gay venues in Glasgow and Edinburgh (1996-2005). 9613 men completed anonymous, self-completed questionnaires (70% average response rate). RESULTS: Among 8305 respondents included in these analyses, HIV testing increased between 1996 and 2005, from 49.7% to 57.8% (p<0.001). The proportion of men who had tested recently (in the calendar year of, or immediately before, the survey) increased from 28.4% in 1996 to 33.2% in 2005, when compared with those who have tested but not recently, and those who have never tested (adjusted odds ratio 1.31, 95% CI 1.13 to 1.52). However, among ever testers, there was no increase in rates of recent testing. Recent testing decreased with age: 31.3% of the under 25, 30.3% of the 25-34, 23.2% of the 35-44 and 21.2% of the over 44 years age groups had tested recently. Among men reporting two or more unprotected anal intercourse partners in the previous year, only 41.4% had tested recently. CONCLUSIONS: HIV testing among gay men in Scotland increased between 1996 and 2005, and corresponds with the Scottish Government policy change to routine, opt-out testing in genitourinary medicine clinics. Testing rates remain low and compare unfavourably with near-universal testing levels elsewhere. The limited change and decline across age groups in recent HIV testing rates suggest few men test repeatedly or regularly. Additional, innovative efforts are required to increase the uptake of regular HIV testing among gay men.

Behaviourally bisexual men as a bridge population for HIV and sexually transmitted infections? Evidence from a national probability survey.

We consider the potential of behaviourally bisexual men (BBM) as a bridge population in sexually transmitted infection (STI)/HIV transmission by comparing sexual risk behaviours, attitudes and sexual health outcomes of BBM (defined as men who reported sex with men and women), with men who reported (i) exclusively male partners (MEMP) and (ii) exclusively female partners (MEFP), using a probability survey of the British general population aged 16-44 years, conducted between 1999 and 2001 (n = 5168 men). About 1.3% of men who reported sex in the past five years were BBM (44.1% of all men reporting male partners); 29.0% of BBM were married/cohabiting with women. Median partner numbers in this timeframe were seven among BBM, two among MEFP and 10 among MEMP. Similar proportions of BBM and MEMP reported STI diagnosis/es in the past five years, yet BBM were less likely than MEMP to report HIV-testing (odds ratio adjusted for sociodemographics: 0.31). BBM are thus mid-way between MEFP and MEMP in their sexual risk behaviour, but are similar to MEMP in reporting STI diagnosis/es. These data have implications for health promotion and partner notification, as BBM are unlikely to be appropriately targeted by safe-sex messages aimed at men identifying as gay.

"It has to speak to people's everyday life...": qualitative study of men and women's willingness to participate in a non-medical approach to Chlamydia trachomatis screening.

OBJECTIVE: To explore the factors associated with men and women's willingness to provide a urine sample for Chlamydia trachomatis screening in various non-medical settings. METHODS: Men and women aged 16-24 years attending non-medical settings were invited to participate in urine-based screening and later to participate in a follow-up in-depth interview. Participant observation techniques were also used to collect data on young people's response to the offer of screening. RESULTS: The views of 24 men and women revealed three themes in relation to willingness to participate, particularly among men: their raised awareness of chlamydia, particularly its asymptomatic nature; the convenience of the offer; and the "non-medical" nature of the screening. In contrast, women more often felt the public nature of the settings inhibited them from agreeing to take the test and, thus, acted as a barrier to their willingness to participate in screening. CONCLUSIONS: The gender difference in willingness to participate in non-medical screening suggests that extending the reach of screening could certainly assist in bringing more young men into screening but may not necessarily destigmatise screening for women. As such, the potential benefits to men must be considered in the context of the potential psychosocial harms to women.

Increased attendances of people of eastern European origin at sexual health services in London.

OBJECTIVE: To describe the service use of migrants from eight central and eastern European (CEE) countries at two central London genitourinary medicine (GUM) clinics before and after accession to the European Union on 1 May 2004. METHODS: KC60 data collected between 1 June 2001 and 30 April 2007. Data refer to new attendances and exclude those attending for follow-up appointments. RESULTS: 102,604 people attended the clinics at least once over the study period. Between May 2006 and 30 April 2007 individuals born in the eight CEE countries accounted for 7.9% of attendances among women and 2.5% of attendances made by men; the proportion increasing significantly over the 6-year study period (p<0.001). Syphilis was more likely in CEE men (age-adjusted odds ratio (OR) 2.98, 95% CI 1.07 to 8.29) and family planning services were more likely to be required for CEE women (23.9% vs 12.4%, age-adjusted OR 2.33, 95% CI 2.02 to 2.68, p<0.001), than for those born elsewhere. A larger proportion of men from CEE countries were recorded as homosexual or bisexual than men from other countries (38.3% vs 31.9%, p = 0.003). CONCLUSIONS: CEE migrants already have a substantial impact on GUM services in London. If attendance rates continue at the current level CEE women will soon account for over 10% of new attendances. Although the majority of CEE migrants are men, proportionately fewer CEE men accessed GUM services than women. Sexual and reproductive health services need to adapt quickly to meet the needs of this growing population.

10-year update on chemotherapy for non-small cell lung cancer.

BACKGROUND: A 1995 meta analysis of chemotherapy in patients with advanced non-small cell carcinoma indicated clinical benefit from cisplatin based chemotherapy. Subsequent studies have aimed to increase the efficacy or decrease the toxicity of chemotherapy. PATIENT AND METHODS: Illustrative studies and meta analyses of different aspects of chemotherapy which have taken place over the last decade, are reviewed. RESULTS: The use of novel (third generation) chemotherapy agents has resulted in a further increase in patient survival. Gemcitabine was shown to be associated with an increase in progression free survival when compared to other third generation agents as well as a strong tendency to increased overall survival. An increase in survival was also shown with doublet chemotherapy regimes as compared to the use of single agents only. The use of triplet agent chemotherapy results in no further increased survival, but increased toxicity. Cisplatin is associated with increased survival over carboplatin based chemotherapy regimens when third generation agents are used, but increased nausea and vomiting. Non-platin third generation combinations give equivalent survival to platin-based regimens. CONCLUSIONS: First line chemotherapy given to patients with advanced NSCLC should be two-drug combination regimen. Non-platin containing regimens may be used as an alternative to platinum based regimens in the first line.

Increase in HIV sexual risk behaviour in homosexual men in Scotland, 1996-2002: prevention failure?

OBJECTIVE: To investigate trends in homosexual men's sexual risk behaviour for HIV infection in Scotland. METHODS: Cross sectional surveys in 1996, 1999, and 2002 were carried out in "gay" bars in Glasgow and Edinburgh, Scotland. 6508 men-2276 (79% response rate) in 1996, 2498 (78%) in 1999, and 1734 (62%) in 2002. RESULTS: In 1996, 10.7% of men surveyed and in 1999, 11.2% reported unprotected anal intercourse (UAI) with casual partners, compared with 18.6% in 2002 (p < 0.001). There was also a significant increase in men reporting that they "knew" their casual partners' HIV status, despite no increase in HIV testing among men who reported UAI with casual partners. In 2002, increases in UAI with more than one partner, in UAI with casual partners and in reporting seroconcordance remained significant after adjusting for confounding factors including HIV testing status and demographic characteristics. CONCLUSIONS: High risk sexual behaviour among homosexual men in Scotland increased between 1999 and 2002. Men showed increased confidence of shared antibody status, despite no increase in HIV testing, or evidence of discussion of HIV status. Explanations for this must include consideration of a cultural shift in the perception of HIV and "prevention failure" on the part of governments and health agencies.

The sexual and reproductive health of young people in Adjumani district, Uganda: qualitative study of the role of formal, informal and traditional health providers.

This qualitative study of young people and health care workers in Adjumani, northern Uganda, found that young people are generally very knowledgeable about STD spread and prevention as well as methods for prevention of pregnancy. Health workers are the most important category of people providing information on sexual and reproductive health (SRH) for young people. However, many health workers are conservative with regard to adolescent sexuality. There is a lack of training in and guidelines for working with adolescents. This, along with inadequate access to SRH services for young people, accounts for the failure to adequately deal with young people's problems. Physical, social, psychological and economic factors create barriers to service accessibility. Socio-economic, religious and cultural factors affect sexual behaviour and outcomes in Adjumani district, making some young people vulnerable, particularly young women. In an effort to find alternative services that meet their needs better, young people visit informal and traditional health care providers despite having to pay for these services. The confidentiality and privacy that they offer could be a lesson for formal health care providers. Further training and integration of traditional health care providers is essential as they already play a major part in SRH service delivery to young people.

Good in parts: the Gay Men's Task Force in Glasgow--a response to Kelly.

We know that peer education, or the use of popular opinion leaders (POLs), works in terms of reducing reported risk behaviour for HIV infection amongst gay men. The work of Jeffrey Kelly and his colleagues provides some of the best scientific evidence in support of this approach. Influenced by this work, we undertook a peer education intervention amongst gay men in bars in Glasgow--the Gay Men's Task Force (GMTF)--but failed to demonstrate any reduction in sexual risk behaviour for HIV infection. In this paper we describe why we were unable to repeat in Scotland the success in small cities in the USA of the POL model. Our explanations include: failure to replicate the 'core elements' of POL; spatial and temporal differences between the original POL settings and the bars of Glasgow; and the currency of ideas such as 'peer education' beyond the protocols designed for their implementation. However, we also describe some of the successful features of the GMTF in Glasgow, and the continued value of peer education in contributing to reductions in sexual risk behaviour for HIV infection.

Is use of antiretroviral therapy among homosexual men associated with increased risk of transmission of HIV infection?

BACKGROUND/OBJECTIVE: There is concern that use of highly active antiretroviral therapy (HAART) may be linked to increased sexual risk behaviour among homosexual men. We investigated sexual risk behaviour in HIV positive homosexual men and the relation between use of HAART and risk of HIV transmission. METHODS: A cross sectional study of 420 HIV positive homosexual men attending a London outpatient clinic. Individual data were collected from computer assisted self interview, STI screening, and clinical and laboratory databases. RESULTS: Among all men, sexual behaviour associated with a high risk of HIV transmission was commonly reported. The most frequently reported type of partnership was casual partners only, and 22% reported unprotected anal intercourse with one or more new partners in the past month. Analysis of crude data showed that men on HAART had fewer sexual partners (median 9 versus 20, p=0.28), less unprotected anal intercourse (for example, 36% versus 27% had insertive unprotected anal intercourse with a new partner in the past year, p=0.03) and fewer acute sexually transmitted infections (33% versus 19%, p=0.004 in the past 12 months) than men not on HAART. Self assessed health status was similar between the two groups: 72% on HAART and 75% not on HAART rated their health as very or fairly good, (p=0.55). In multivariate analysis, differences in sexual risk behaviour between men on HAART and men not on HAART were attenuated by adjustment for age, time since HIV infection. CD4 count and self assessed health status. CONCLUSION: HIV positive homosexual men attending a London outpatient clinic commonly reported sexual behaviour with a high risk of HIV transmission. However, behavioural and clinical risk factors for HIV transmission were consistently lower in men on HAART than men not on HAART. Although use of HAART by homosexual men with generally good health is not associated with higher risk behaviours, effective risk reduction interventions targeting known HIV positive homosexual men are still urgently needed.

Gay men's HIV testing behaviour in Scotland.

This paper reports on the social and demographic factors associated with HIV testing in gay men in Scotland. Trained sessional research staff administered a short self-complete questionnaire to men in gay bars during January and February 1999 in Glasgow and Edinburgh, Scotland. Questionnaires were completed by 2,498 men (response rate of 77.5%). Half (1,190; 50%) reported ever having been HIV antibody tested, with men in Edinburgh more likely to report testing. Testing was associated with being older (26 years plus), higher education, reporting one unprotected anal intercourse (UAI) partner, or six or more UAI partners, in the last year, genitourinary medicine clinic service use, and lifetime experience of sexually transmitted infections. There was no relationship between HIV testing and treatment optimism, or evidence of a "post-Vancouver" effect. Over a fifth of men who said that they knew their own HIV status at last UAI had never been tested. Current testing policy needs to be challenged if there is to be an increase in the number of gay men who know their HIV status and, if tested HIV-positive, to then access antiretroviral treatments.

Does bar-based, peer-led sexual health promotion have a community-level effect amongst gay men in Scotland?

This paper evaluates the effectiveness of a bar-based, peer-led community-level intervention to promote sexual health amongst gay men. The intervention consisted of peer education within bars, gay specific genitourinary medicine (GUM) services and a free-phone hotline. Data were collected at baseline (1996) and at follow-up (1999) in gay bars in Glasgow (intervention city) and Edinburgh (control city). During the intervention peer educators interacted with 1484 men and new clients increased at the gay specific GUM service. However, the hotline was under-utilized and abused. The outcome measures were: reported hepatitis B vaccination; HIV testing; unprotected anal intercourse (UAI) with casual partners; negotiated safety; and amongst men reporting UAI with a regular partner, the proportion who knew their own and their partner's HIV status. Significant differences in sexual health behaviours were observed across locations and across time, but the only significant intervention effects were amongst men who had direct contact with the intervention, with higher uptake of hepatitis B vaccination and HIV testing. The intervention did not produce community-wide changes in sexual health behaviours. These results question the replication and transferability of peer-led, community-level sexual health promotion for gay men outwith the USA and across time.

The Gay Men's Task Force: the impact of peer education on the sexual health behaviour of homosexual men in Glasgow.

OBJECTIVE: To assess the impact of a peer education intervention, based in the "gay" bars of Glasgow, which sought to reduce sexual risk behaviours for HIV infection and increase use of a dedicated homosexual men's sexual health service, and in particular increase the uptake of hepatitis B vaccination. DESIGN: Self completed questionnaires administered to men who have sex with men (MSM) in Glasgow's gay bars. SUBJECTS: 1442 men completed questionnaires in January 1999, 7 months after the end of the 9 month sexual health intervention. MAIN OUTCOME MEASURES: Self reported contact with the peer education intervention, reported behaviour change, and reported sexual health service use. RESULTS: The Gay Men's Task Force (GMTF) symbol was recognised by 42% of the men surveyed. Among men who reported speaking with peer educators 49% reported thinking about their sexual behaviour and 26% reported changing their sexual behaviour. Logistic regressions demonstrated higher levels of HIV testing, hepatitis B vaccination, and use of sexual health services among men who reported contact with the intervention. These men were more likely to have used the homosexual specific sexual health service. Peer education dose effects were suggested, with the likelihood of HIV testing, hepatitis B vaccination, and use of sexual health services being greater among men who reported talking to peer educators more than once. CONCLUSION: The intervention had a direct impact on Glasgow's homosexual men and reached men of all ages and social classes. Higher levels of sexual health service use and uptake of specific services among men who had contact with the intervention are suggestive of an intervention effect. Peer education, as a form of health outreach, appears to be an effective intervention tool in terms of the uptake of sexual health services, but is less effective in achieving actual sexual behaviour change among homosexual men.

A comparison of high-risk sexual behaviour and HIV testing amongst a bar-going sample of homosexual men in London and Edinburgh.

BACKGROUND: This study compared high-risk sexual and HIV testing behaviour amongst homosexual men recruited from gay bars in London and Edinburgh. METHODS: A cross-sectional survey monitoring high-risk sexual and HIV testing behaviour using a self-completed questionnaire was conducted in November and December 1996. RESULTS: Two thousand, three hundred and ninety-seven questionnaires were returned (1,366 recruited in London and 1,031 in Edinburgh), with a response rate of 77%. A larger proportion of men surveyed in London had had unprotected anal intercourse (UAI) with one or more male partners in the previous year (35%) than in Edinburgh (30%). Men recruited in Edinburgh were less likely to have had an HIV test (54%) than men in London (63%). In both surveys, 25% of men who reported UAI with partners of the same HIV status as themselves also reported never having had an HIV test. CONCLUSIONS: The observed dissimilarities in the HIV epidemic in the two cities may be accounted for by the differences in self-reported high-risk sexual and HIV testing behaviours between the two populations. A large proportion of men in both cities continue to engage in high-risk sexual behaviour suggesting continued transmission of HIV in these populations. Thus, there is a continued need for innovative and relevant health promotion amongst homosexual men in the UK.

Female control of sexuality: illusion or reality? Use of vaginal products in south west Uganda.

This paper reports on a trial of vaginal products that were distributed and used by 131 women and 21 men in south west Uganda. It focuses specifically upon the issue of female control in heterosexual relationships and examines whether methods which are ostensibly under women's control, will in practice give women greater control of their sexual health. Participants were invited to select two from a range of vaginal products that included the female condom, contraceptive sponge, film, tablets, foam and gel, and use each for five weeks and their favourite product for a further three months. They were interviewed up to seven times over a five-month period. Although the women perceived that a major advantage of the products (with the exception of the female condom) was that they could be used secretly, less than 40% were using the products without their partner's knowledge after one week and this proportion declined over time with only 22% using the products secretly after ten weeks. In the main male partners were told as women felt it their duty to inform them. In general the women were very much more positive about the products than they were about the male condom, as were the men. A contributory factor to their popularity among women was the greater control they gave them. Even though, use of these products in practice often involved negotiation with male partners, the fact that use was contingent on women's action was empowering and increased somewhat their ability to control their sexual health.

Sexual health seeking behaviours of young people in the Gambia.

In the Gambia, sexually transmitted infections (STIs) and their complications are a major health problem and although the prevalence of HIV-1 in the Gambia is currently low, it is increasing. Relatively little is known about the sexual health treatment-seeking behaviours of young people in West Africa. This information is vital to target resources appropriately. To investigate this concept, twelve single-sex focus group discussions (FGDs), within three rural villages, elicited the views, opinions, attitudes and experiences of 49 young men (mean age 17.4 years; range 15-21) and 48 young women (mean age 18.2 years; range 15-25). The participants talked openly about sexual activity within their peer communities. Six major themes were identified from the FGDs: (1) groups perceived to be at risk of acquiring STIs; (2) STI transmission and classification; (3) treatment-seeking behaviours; (4) barriers to treatment; (5) consequences of non-treatment; and (6) problem resolution strategies. The study concludes that whilst there may be barriers to improving sexual and reproductive health, young people in rural West Africa have enthusiasm for and commitment to finding solutions to the problems that local communities face.