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ObjectivesThe first UK national lockdown began on 23 March 2020, in response to the COVID-19 pandemic, and led to reduced STI/HIV service provision in the UK. We investigated sexual behaviour, use and need for sexual healthcare during the pandemic.MethodsParticipants (N=2018), including men (cis/transgender), transwomen and gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth, completed an online cross-sectional survey (23 June 2020–14 July 2020), in response to adverts on social media and dating apps.Sexual behaviour, service use and unmet need for STI testing (any new male and/or multiple condomless anal sex (CAS) partners without STI testing) in the 3 months since lockdown began were examined and compared using multivariable analyses with an equivalent 3-month period in a 2017 survey (N=1918), conducted by the same research team.ResultsSince lockdown began, 36.7% of participants reported one or more new partners, 17.3% reported CAS with multiple partners, 29.7% HIV testing (among 1815 of unknown/negative status), 24.9% STI testing and 15.4% using pre-exposure prophylaxis (PrEP).Since lockdown began, 25.3% of participants had unmet need for STI testing. This was more likely among Asian versus white participants (adjusted OR (aOR)=1.76, (1.14 to 2.72), p=0.01); for participants living in Scotland (aOR=2.02, (1.40 to 2.91), p<0.001) or Northern Ireland (aOR=1.93, (1.02–3.63), p=0.04) versus England; and for those living with HIV (aOR=1.83, (1.32 to 2.53), p<0.001).Compared to 2017, the equivalent 2020 subsample were less likely to report new male partners (46.8% vs 71.1%, p<0.001), multiple CAS partners (20.3% vs 30.8%, p<0.001) and have unmet need for STI testing (32.8% vs 42.5%, p<0.001) in the past 3 months.ConclusionsWe found potential for ongoing STI/HIV transmission among men who have sex with men during the initial UK lockdown, despite reduced sexual activity, and inequalities in service access. These findings will support public health planning to mitigate health risks during and after the COVID-19 response.

Background Oral tenofovir and emtricitabine taken as pre-exposure prophylaxis (HIV-PrEP) is highly effective at reducing Human Immunodeficiency Virus (HIV) acquisition. Nucleotide analogues have also been shown to inhibit Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) polymerase activity in vitro, raising the question as to whether tenofovir-based HIV-PrEP could be useful for the prevention and treatment of COVID-19. We sought to examine the association between HIV-PrEP use and self-reported COVID-19 testing outcomes and respiratory symptoms among men and gender diverse people who have sex with men in the UK. Methods Participants completed online surveys deployed at three time points during the COVID-19 pandemic (Survey 1 (S1) 23/06/20 − 14/07/20; S2 23/11/20 − 12/12/20; S3 23/03/21 − 14/04/21), including men (cis/transgender), transwomen or gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth. The outcome was self-reported COVID-19 testing and COVID-19 related respiratory symptoms including a new continuous cough, high temperature or loss of smell and/or taste during the most recent lookback period. All participants reporting taking HIV-PrEP in the past year were compared with those who did not. Analysis was performed using logistic regression, adjusting for sociodemographic and behavioural factors. Results Among 4,544 participants living without HIV across three surveys (89.7% of all survey respondents), 21.4% ( n  = 970) reported recently using HIV-PrEP, 564 (12.4%) participants reported respiratory symptoms and 160 (3.5%) reported a positive COVID-19 test. There was a slight, non-statistically significant positive association between HIV-PrEP use and a COVID-19 positive test in the first survey-period (P1) (adjusted Odds Ratio (aOR) = 1.11, CI = 0.51–3.98). This positive association significantly increased across survey periods (P2: aOR = 4.26, CI = 1.21–14.97, P3: aOR = 9.02, CI = 2.69–30.31). There was a positive association between HIV-PrEP use and respiratory symptoms in the first survey-period (aOR = 1.45, CI = 1.03–2.03). However, this positive association reversed in survey-period 2 and 3 (P2: aOR = 0.62, CI = 0.40–0.95, P3: aOR = 0.45, CI = 0.28–0.72). Conclusions We found no evidence that HIV-PrEP use protected against COVID-19 among participants. Conversely, we identified a positive association between HIV-PrEP use and COVID-19 which may reflect uncaptured behaviours that increase COVID-19 exposure amongst those using HIV-PrEP. The decline in respiratory symptoms in HIV-PrEP users over time might reflect some immune protection following exposures to respiratory viruses through more social mixing or a direct impact of HIV-PrEP on symptom severity.

Introduction HIV transmission continues among gay and bisexual men who have sex with men (GBMSM), with those who are younger, or recent migrants, or of minority ethnicity or who are gender diverse remaining at increased risk. We aimed to identify and describe recent studies evaluating the effectiveness of HIV prevention interventions for GBMSM in high income countries. Methods We searched ten electronic databases for randomized controlled trials (RCTs), conducted in high income settings, and published since 2013 to update a previous systematic review (Stromdahl et al, 2015). We predefined four outcome measures of interest: 1) HIV incidence 2) STI incidence 3) condomless anal intercourse (CLAI) (or measure of CLAI) and 4) number of sexual partners. We used the National Institute for Health and Care Excellence (UK) Quality Appraisal of Intervention Studies tool to assess the quality of papers included in the review. As the trials contained a range of effect measures (e.g. odds ratio, risk difference) comparing the arms in the RCTs, we converted them into standardized effect sizes (SES) with 95% confidence intervals (CI). Results We identified 39 original papers reporting 37 studies. Five intervention types were identified: one-to-one counselling (15 papers), group interventions (7 papers), online interventions (9 papers), Contingency Management for substance use (2 papers) and Pre-exposure Prophylaxis (PrEP) (6 papers). The quality of the studies was mixed with over a third of studies rated as high quality and 11% rated as poor quality. There was some evidence that one-to-one counselling, group interventions (4-10 participants per group) and online (individual) interventions could be effective for reducing HIV transmission risk behaviours such as condomless anal intercourse. PrEP was the only intervention that was consistently effective at reducing HIV incidence. Conclusions Our systematic review of the recent evidence that we were able to analyse indicates that PrEP is the most effective intervention for reducing HIV acquisition among GBMSM. Targeted and culturally tailored behavioural interventions for sub-populations of GBMSM vulnerable to HIV infection and other STIs should also be considered, particularly for GBMSM who cannot access or decline to use PrEP.

ObjectivesWe examined the impact of COVID-19-related restrictions on sexual behaviours, STI and HIV testing and testing need among men who have sex with men (MSM) in the UK.MethodsWe used social media and dating applications to recruit to three cross-sectional surveys (S1–S3) during the UK’s pandemic response (S1: 23 June–14 July 2020; S2: 23 November–12 December 2020; S3: 23 March–14 April 2021). Surveys included lookback periods of around 3–4 months (P1–P3, respectively). Eligible participants were UK resident men (cisgender/transgender) and gender-diverse people assigned male at birth (low numbers of trans and gender-diverse participants meant restricting these analyses to cisgender men), aged ≥16 years who reported sex with men (cisgender/transgender) in the last year (S1: N=1950; S2: N=1463; S3: N=1487). Outcomes were: recent STI/HIV testing and unmet testing need (new male and/or multiple condomless anal sex partners without a recent STI/HIV test). Crude and adjusted associations with each outcome were assessed using logistic regression.ResultsParticipants’ sociodemographic characteristics were similar across surveys. The proportion reporting a recent STI and/or HIV test increased between P1 and P2 (25.0% to 37.2% (p<0.001) and 29.7% to 39.4% (p<0.001), respectively), then stabilised in P3 (40.5% reporting HIV testing). Unmet STI testing need increased across P1 and P2 (26.0% to 32.4%; p<0.001), but trends differed between groups, for example, unmet STI testing need was higher in bisexually-identifying (vs gay-identifying) MSM across periods (adjusted OR (aOR): P1=1.64; P2=1.42), but declined in HIV-positive (vs HIV-negative/unknown) MSM (aOR: P1=2.06; P2=0.68). Unmet HIV testing need increased across P1 and P2 (22.9% to 31.0%; p<0.001) and declined in P3 (25.1%; p=0.001). During P3, MSM reporting a low life-satisfaction level (vs medium–very high) had greater unmet need (aOR: 1.44), while from P2 onwards HIV pre-exposure prophylaxis users (vs non-users) had lower unmet need (aOR: P2=0.32; P3=0.50).ConclusionConsiderable unmet STI/HIV testing need occurred among MSM during COVID-19-related restrictions, especially in bisexually-identifying men and those reporting low life satisfaction. Improving access to STI/HIV testing in MSM is essential to prevent inequalities being exacerbated.

Background Men and gender-diverse people who have sex with men are disproportionately affected by health conditions associated with increased risk of severe illness due to COVID-19 infection. Methods An online cross-sectional survey of men and gender-diverse people who have sex with men in the UK recruited via social networking and dating applications from 22 November-12 December 2021. Eligible participants included self-identifying men, transgender women, or gender-diverse individuals assigned male at birth (AMAB), aged ≥ 16, who were UK residents, and self-reported having had sex with an individual AMAB in the last year. We calculated self-reported COVID-19 test-positivity, proportion reporting long COVID, and COVID-19 vaccination uptake anytime from pandemic start to survey completion (November/December 2021). Logistic regression was used to assess sociodemographic, clinical, and behavioural characteristics associated with SARS-CoV-2 (COVID-19) test positivity and complete vaccination (≥ 2 vaccine doses). Results Among 1,039 participants (88.1% white, median age 41 years [interquartile range: 31-51]), 18.6% (95% CI: 16.3%-21.1%) reported COVID-19 test positivity, 8.3% (95% CI: 6.7%-10.1%) long COVID, and 94.5% (95% CI: 93.3%-96.1%) complete COVID-19 vaccination through late 2021. In multivariable models, COVID-19 test positivity was associated with UK country of residence (aOR: 2.22 [95% CI: 1.26-3.92], England vs outside England) and employment (aOR: 1.55 [95% CI: 1.01-2.38], current employment vs not employed). Complete COVID-19 vaccination was associated with age (aOR: 1.04 [95% CI: 1.01-1.06], per increasing year), gender (aOR: 0.26 [95% CI: 0.09-0.72], gender minority vs cisgender), education (aOR: 2.11 [95% CI: 1.12-3.98], degree-level or higher vs below degree-level), employment (aOR: 2.07 [95% CI: 1.08-3.94], current employment vs not employed), relationship status (aOR: 0.50 [95% CI: 0.25-1.00], single vs in a relationship), COVID-19 infection history (aOR: 0.47 [95% CI: 0.25-0.88], test positivity or self-perceived infection vs no history), known HPV vaccination (aOR: 3.32 [95% CI: 1.43-7.75]), and low self-worth (aOR: 0.29 [95% CI: 0.15-0.54]). Conclusions In this community sample, COVID-19 vaccine uptake was high overall, though lower among younger age-groups, gender minorities, and those with poorer well-being. Efforts are needed to limit COVID-19 related exacerbation of health inequalities in groups who already experience a greater burden of poor health relative to other men who have sex with men.

Introduction HIV transmission continues among gay and bisexual men who have sex with men (GBMSM), with those who are younger, or recent migrants, or of minority ethnicity or who are gender diverse remaining at increased risk. We aimed to identify and describe recent studies evaluating the effectiveness of HIV prevention interventions for GBMSM in high income countries. Methods We searched ten electronic databases for randomized controlled trials (RCTs), conducted in high income settings, and published since 2013 to update a previous systematic review (Stromdahl et al, 2015). We predefined four outcome measures of interest: 1) HIV incidence 2) STI incidence 3) condomless anal intercourse (CLAI) (or measure of CLAI) and 4) number of sexual partners. We used the National Institute for Health and Care Excellence (UK) Quality Appraisal of Intervention Studies tool to assess the quality of papers included in the review. As the trials contained a range of effect measures (e.g. odds ratio, risk difference) comparing the arms in the RCTs, we converted them into standardized effect sizes (SES) with 95% confidence intervals (CI). Results We identified 39 original papers reporting 37 studies. Five intervention types were identified: one-to-one counselling (15 papers), group interventions (7 papers), online interventions (9 papers), Contingency Management for substance use (2 papers) and Pre-exposure Prophylaxis (PrEP) (6 papers). The quality of the studies was mixed with over a third of studies rated as high quality and 11% rated as poor quality. There was some evidence that one-to-one counselling, group interventions (4–10 participants per group) and online (individual) interventions could be effective for reducing HIV transmission risk behaviours such as condomless anal intercourse. PrEP was the only intervention that was consistently effective at reducing HIV incidence. Conclusions Our systematic review of the recent evidence that we were able to analyse indicates that PrEP is the most effective intervention for reducing HIV acquisition among GBMSM. Targeted and culturally tailored behavioural interventions for sub-populations of GBMSM vulnerable to HIV infection and other STIs should also be considered, particularly for GBMSM who cannot access or decline to use PrEP.

BackgroundOnline postal self-sampling (OPSS) allows people to test for sexually transmitted infections by ordering a kit online, taking samples at home and posting them to a lab for analysis. Its use in England has increased rapidly over the past decade, however there is limited research on the implementation and impact of OPSS. The ASSIST study sought to understand this in three case study cities, with disruption coming through as a dominant theme.MethodsWe interviewed 60 sexual health staff and stakeholders, conducted an analysis of 57 implementation documents and undertook contextual observation at three clinics. Data collection and analysis were informed by Normalisation Process Theory.ResultsWe identified three disruptive events which shaped OPSS implementation:Austerity: Sexual health became a local government responsibility in 2013, exposing it to significant funding cuts. Spending reduced by 18% between 2013-14 and 2021-22, while incidence of chlamydia, gonorrhoea and syphilis grew over the same period. This contributed to the decision to adopt OPSS in some cities, as it was seen as a cost-saving initiative.COVID-19: Lockdowns accelerated the implementation of OPSS in some cities, with access to clinics restricted. In other cities, it caused implementation to reverse, due to resources being redirected towards pandemic response or delivery models becoming unaffordable because of rapid, unexpected increases in OPSS use.Mpox: The epidemic in 2022 required at-risk individuals to be examined and/or vaccinated in sexual health clinics. Occurring immediately after COVID-19, it exacerbated many of the challenges services were facing but also enabled OPSS and clinic access to be rebalanced in some areas.DiscussionSexual health services have been particularly vulnerable to disruption over the past decade, although the impact of this has varied depending on context. Although it can be damaging, it has enabled innovation and service improvement in some circumstances.

Background Increasing rates of sexually transmitted infections (STIs) in men-who-have-sex-with-men (MSM) in England is a pressing public health concern. Interventions targeting MSM, including information provision that effectively promotes sexual health, are needed. To support such intervention development, it is necessary to understand acceptable ways of delivering sexual health information. We explored the acceptability and potential uses and impacts of delivering sexual health information to MSM through social media and geosocial networking apps or dating apps. Methods Semi-structured interviews were conducted in person or by telephone with 25 MSM resident in England recruited via dating apps and social media advertisements. Interviews explored sexual health information sources, perceptions and uses. Attitudes towards sexual health promotion through social media and dating apps were then discussed. The data were analysed using thematic analysis. Results Sexual health information delivery through social media and dating apps was considered acceptable. Receiving information when browsing social media was viewed positively by most, as people have time to absorb information. In contrast, concerns were expressed that sharing or commenting on social media sexual health information may lead to judgements and discrimination. While social media reaches a high proportion of the population, dating apps can easily target MSM. However, tensions exist between the ability to provide information at an opportune time through dating apps, when users are connecting with new sexual partners, with the potential to adversely affect the app user’s experience. Hypothetical and actual uses and impacts of sexual health information ranged from no impact to reading information, sharing with peers, and increased awareness, to influencing healthcare-seeking, decision-making and risk-taking behaviours. Ensuring that information is engaging, positive in tone, not too clinical, focused on building social norms and delivered by trusted organisations were viewed as important for supporting its use. Conclusions Overall, these findings support the development of new interventions that use dating apps and social media for sexual health promotion.

ObjectivesWe examined sexual behaviour, sexually transmitted infection (STI) and HIV testing and testing need, and identified associated factors, among gay, bisexual and other men who have sex with men (GBMSM) in the UK after COVID-19 restrictions ended, and compared these with ‘pre-pandemic’ estimates.MethodsWe analysed survey data from GBMSM (N=1039) recruited via social media and Grindr in November–December 2021. We then compared Grindr-recruited 2021 participants (N=437) with those from an equivalent survey fielded in March–May 2017 (N=1902). Questions on sexual behaviour and service use had lookback periods of 3–4 months in both surveys. Unmet testing need was defined as reporting any new male and/or multiple condomless anal sex (CAS) partners without recent STI/HIV testing. Participants were UK residents, GBMSM, aged ≥16 years who reported sex with men in the last year. Multivariable logistic regression identified associated sociodemographic and health-related factors with unmet STI/HIV testing need in 2021, and then for 2017/2021 comparative analyses, adjusting for demographic differences.ResultsIn 2021, unmet STI and HIV testing need were greater among older GBMSM (aged ≥45 years vs 16–29 years; adjusted OR (aOR): 1.45 and aOR: 1.77, respectively), and lower for pre-exposure prophylaxis (PrEP) users (vs non-PrEP users; aOR: 0.32 and aOR: 0.23, respectively). Less unmet STI testing need was observed among HIV-positive participants (vs HIV-negative/unknown; aOR: 0.63), and trans and non-binary participants (vs cisgender male; aOR: 0.34). Between 2017 (reference) and 2021, reported sexual risk behaviours increased: ≥1 recent new male sex partner (72.1%–81.1%, aOR: 1.71) and ≥2 recent CAS partners (30.2%–48.5%, aOR: 2.22). Reporting recent STI testing was greater in 2021 (37.5%–42.6%, aOR: 1.34) but not recent HIV testing, and there was no significant change over time in unmet STI (39.2% vs 43.7%) and HIV (32.9% vs 39.0%) testing need.DiscussionComparable community surveys suggest that UK resident GBMSM may have engaged in more sexual risk behaviours in late 2021 than pre-pandemic. While there was no evidence of reduced STI/HIV service access during this time, there remained considerable unmet STI/HIV testing need.