HIV incidence among sexual health clinic attendees in England: First estimates for black African heterosexuals using a biomarker, 2009-2013.

INTRODUCTION: The HIV epidemic in England is largely concentrated among heterosexuals who are predominately black African and men who have sex with men (MSM). We present for the first time trends in annual HIV incidence for adults attending sexual health clinics, where 80% of all HIV diagnoses are made. METHODS: We identified newly diagnosed incident HIV using a recent infection testing algorithm (RITA) consisting of a biomarker (AxSYM assay, modified to determine antibody avidity), epidemiological and clinical information. We estimated HIV incidence using the WHO RITA formula for cross-sectional studies, with HIV testing data from sexual health clinics as the denominator. RESULTS: From 2009 to 2013, each year, between 9,700 and 26,000 black African heterosexuals (of between 161,000 and 231,000 heterosexuals overall) were included in analyses. For the same period, annually between 19,000 and 55,000 MSM were included. Estimates of HIV incidence among black Africans increased slightly (although non-significantly) from 0.15% (95% C.I.0.05%-0.26%) in 2009 to 0.19% (95% C.I.0.04%-0.34%) in 2013 and was 4-5-fold higher than among all heterosexuals among which it remained stable between 0.03% (95% C.I.0.02%-0.05%) and 0.05% (95% C.I.0.03%-0.07%) over the period. Among MSM incidence was highest and increased (non-significantly) from 1.24% (95%C.I 0.96-1.52%) to 1.46% (95% C.I 1.23%-1.70%) after a peak of 1.52% (95%C.I 1.30%-1.75%) in 2012. CONCLUSION: These are the first nationwide estimates for trends in HIV incidence among black African and heterosexual populations in England which show black Africans, alongside MSM, remain disproportionately at risk of infection. Although people attending sexual health clinics may not be representative of the general population, nearly half of black Africans and MSM had attended in the previous 5 years. Timely and accurate incidence estimates will be critical in monitoring the impact of the reconfiguration of sexual health services in England, and any prevention programmes such as pre-exposure prophylaxis

Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial

Objective To determine whether screening and treating women for chlamydial infection reduces the incidence of pelvic inflammatory disease over the subsequent 12 months

Frequency and risk factors for prevalent, incident, and persistent genital carcinogenic human papillomavirus infection in sexually active women: community based cohort study

Objective To investigate frequency and risk factors for prevalent, incident, and persistent carcinogenic human papillomavirus (HPV) in young women before the introduction of immunisation against HPV types 16 and 18 for schoolgirls

Preventing the next 'SARS' - European healthcare workers' attitudes towards monitoring their health for the surveillance of newly emerging infections: qualitative study

<p>Abstract</p> <p>Background</p> <p>Hospitals are often the epicentres of newly circulating infections. Healthcare workers (HCWs) are at high risk of acquiring infectious diseases and may be among the first to contract emerging infections. This study aims to explore European HCWs' perceptions and attitudes towards monitoring their absence and symptom reports for surveillance of newly circulating infections.</p> <p>Methods</p> <p>A qualitative study with thematic analysis was conducted using focus group methodology. Forty-nine hospital-based HCWs from 12 hospitals were recruited to six focus groups; two each in England and Hungary and one each in Germany and Greece.</p> <p>Results</p> <p>HCWs perceived risk factors for occupationally acquired infectious diseases to be 1.) exposure to patients with undiagnosed infections 2.) break-down in infection control procedures 3.) immuno-naïvety and 4.) symptomatic colleagues. They were concerned that a lack of monitoring and guidelines for infectious HCWs posed a risk to staff and patients and felt employers failed to take a positive interest in their health. Staffing demands and loss of income were noted as pressures to attend work when unwell. In the UK, Hungary and Greece participants felt monitoring staff absence and the routine disclosure of symptoms could be appropriate provided the effectiveness and efficiency of such a system were demonstrable. In Germany, legislation, privacy and confidentiality were identified as barriers.</p> <p>All HCWs highlighted the need for knowledge and structural improvements for timelier recognition of emerging infections. These included increased suspicion and awareness among staff and standardised, homogenous absence reporting systems.</p> <p>Conclusions</p> <p>Monitoring absence and infectious disease symptom reports among HCWs may be a feasible means of surveillance for emerging infections in some settings. A pre-requisite will be tackling the drivers for symptomatic HCWs to attend work.</p

The public health utility of assays to test for recent HIV infection: an evaluation on UK case-based surveillance data

Determining accurate, real-time epidemic trends for HIV is an ongoing challenge due to the lengthy asymptomatic period of infection. Current available methods to determine the number of new infections are based on back calculation models of diagnosis data and/or simulation models of behavioural data. Both approaches do not provide timely estimates for recent years or estimates for risk groups other than gay, bisexual and men who have sex with men (MSM), for whom there are less published data on risk behaviours. The aim of this thesis is to explore the public health utility of serological HIV incidence assays applied to case-based surveillance data in the UK. For the first five years of Public Health England’s surveillance programme, I determined demographic predictors for a recent infection diagnosis and estimated HIV incidence in both sexual health clinic attendees and the general population. I also undertook a feasibility study for enhanced behavioural surveillance among MSM with incident infection to explore if this could highlight new trends in risk behaviours or if more traditional infectious disease control methods, such as active case finding, could become more applicable to HIV. Between 2009 and 2013, I found predictors for a recent infection diagnosis to have been younger age (15-24 years compared to + 50 years) (adjusted odd ratio (AOR) 2.8 95% C.I 2.2-3.7), the UK as probable country of infection (AOR 1.4 95% C.I 1.2-1.6) and higher CD4 counts (>1000 cells/mm3 compared to >50≤200 cells/mm3, AOR: 14.3, 95% C.I. 8.9-22.8) in MSM, and UK country of birth (AOR: 1.7, 95% C.I. 1.2-2.3) and UK country of infection (AOR: 1.4 95% C.I. 1.1-1.8) in heterosexuals. HIV incidence was up to 30-fold higher in sexual health clinic attendees (130 per 100,000 person years (pys) in 2009 increasing to 200 per 100,000 pys in 2013) compared to the general population (between 6 and 6.5 per 100,000 over the years), with little change over the period. The two key populations most affected were MSM, with approximately 300 infections per 100,000 pys, and black African heterosexuals, with between 45 and 70 infections per 100,000 pys. The number of new HIV infections was five-fold higher in London compared to outside London. The behavioural surveillance data showed that nearly all men had exhibited high risk behaviours in the six months before diagnosis; half had had a sexually transmitted infection (STI) in the previous year. Men had met partners mainly via mobile phone dating apps. Despite two thirds of sexual partners having been contactable, only one in five had been contacted with men indicating preference to notify partners themselves. Findings from this thesis show serological HIV incidence assays applied to case-based surveillance data in the UK can produce timely estimates of HIV incidence for the whole population. It is currently the only method allowing comparisons by geography which may enable prevention resources to be targeted more effectively. In light of the ongoing decline in new HIV diagnoses and likely transmission, and the roll out of a new biomedical intervention (pre-exposure prophylaxis (PrEP)), all sources of HIV epidemic intelligence will be crucial to work towards the elimination of HIV. Whilst the enhanced behavioural surveillance was feasible in this group, it is unlikely to discover new risk behaviours or facilitate active case finding. However, there is a role for this approach of data collection among recent seroconverters; the surveillance scheme, now referred to as SHARE (Surveillance of HIV Acquired Recently: Enhanced), has been modified and rolled out on a national scale to obtain insights into how new infections may or may not relate to exposure of PrEP in light of the ongoing PrEP trial (https://www.prepimpacttrial.org.uk/). Findings of this new initiative will feed into future evaluations of PrEP use in the UK.Open Acces

What is the cost of pelvic inflammatory disease and how much could be prevented by screening for Chlamydia trachomatis? Cost analysis of the Prevention Of Pelvic Infection (POPI) trial

International audienceObjectives: To describe healthcare settings attended by women with clinical pelvic inflammatory disease (PID), to calculate the cost of a PID episode and to estimate how many cases could be prevented in London annually at current chlamydia screening levels. Methods: An ethnically diverse sample of 2259 16-24 year old, sexually active, female London students were recruited to a chlamydia screening trial in 2004-6 of whom 94% (2115) were followed up after 12 months for incidence of PID. A cost analysis examined healthcare settings attended by women with PID; the cost of an episode of PID; and the number of cases of PID in London due to untreated chlamydia at baseline which could be prevented per year at 2009 annual screening levels. Results: Of 35 PID cases 17 (47%) first presented in general practice, 15 (42%) at a genitourinary medicine clinic, two elsewhere and one was admitted to hospital. The average number of consultations for a PID episode was 2.0 (range 1-4) and the average cost was £163 (range £29-£960). Assuming 414,345 sexually active women aged 16-24 in London, 6% chlamydia prevalence at baseline, and a 7.3% difference in PID rates between screened and unscreened chlamydia positives, 391 (95% C.I. -44 to 882) cases of chlamydia associated PID costing £63,733 could be prevented each year in London at 21.5% 2009 annual screening levels. Conclusions: Most women with PID were managed in the community. The number and cost of PID cases prevented by a single annual chlamydia screen is low, suggesting that cost-effectiveness may depend mainly on the prevention of long-term sequelae

Re‐assessing the late <scp>HIV</scp> diagnosis surveillance definition in the era of increased and frequent testing

Abstract: Objectives: Late HIV diagnosis (CD4 <350 cells/mm3) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re‐assessed 1‐year mortality following late diagnosis. Methods: We used national epidemiological and laboratory surveillance data from all people diagnosed with HIV in England, Wales, and Northern Ireland (EW&NI). Those with a baseline CD4 <350 were reclassified as ‘not late’ if they had evidence of recent infection (recency test and/or negative test within 24 months). A correction factor (CF) was the number reclassified divided by the number with a CD4 <350. Results: Of the 32 227 people diagnosed with HIV in EW&NI between 2011 and 2019 with a baseline CD4 (81% of total), 46% had a CD4 <350 (uncorrected late diagnosis rate): 34% of gay and bisexual men (GBM), 65% of heterosexual men, and 56% of heterosexual women. Accounting for recency test and/or prior negative tests gave a ‘corrected’ late diagnosis rate of 39% and corresponding CF of 14%. The CF increased from 10% to 18% during 2011–2015, then plateaued, and was larger among GBM (25%) than heterosexual men and women (6% and 7%, respectively). One‐year mortality among people diagnosed late was 329 per 10 000 after reclassification (an increase from 288/10 000). Conclusions: The case‐surveillance definition of late diagnosis increasingly overestimates late presentation, the extent of which differs by key populations. Adjustment of late diagnosis is recommended, particularly for frequent testers such as GBM

Re-assessing the late HIV diagnosis surveillance definition in the era of increased and frequent testing.

OBJECTIVES: Late HIV diagnosis (CD4 <350 cells/mm3 ) is a key public health metric. In an era of more frequent testing, the likelihood of HIV diagnosis occurring during seroconversion, when CD4 counts may dip below 350, is greater. We applied a correction, considering markers of recent infection, and re-assessed 1-year mortality following late diagnosis. METHODS: We used national epidemiological and laboratory surveillance data from all people diagnosed with HIV in England, Wales, and Northern Ireland (EW&NI). Those with a baseline CD4 <350 were reclassified as 'not late' if they had evidence of recent infection (recency test and/or negative test within 24 months). A correction factor (CF) was the number reclassified divided by the number with a CD4 <350. RESULTS: Of the 32 227 people diagnosed with HIV in EW&NI between 2011 and 2019 with a baseline CD4 (81% of total), 46% had a CD4 <350 (uncorrected late diagnosis rate): 34% of gay and bisexual men (GBM), 65% of heterosexual men, and 56% of heterosexual women. Accounting for recency test and/or prior negative tests gave a 'corrected' late diagnosis rate of 39% and corresponding CF of 14%. The CF increased from 10% to 18% during 2011-2015, then plateaued, and was larger among GBM (25%) than heterosexual men and women (6% and 7%, respectively). One-year mortality among people diagnosed late was 329 per 10 000 after reclassification (an increase from 288/10 000). CONCLUSIONS: The case-surveillance definition of late diagnosis increasingly overestimates late presentation, the extent of which differs by key populations. Adjustment of late diagnosis is recommended, particularly for frequent testers such as GBM.UK Medical Research Council programme MRC_MC_UU_00002/1