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ObjectivesThe COVID-19 pandemic and its related restrictions have affected attendance to and delivery of UK sexual healthcare services (SHS). We surveyed the impact on sexual behaviour of men having sex with men (MSM) to inform future SHS provision.MethodsWe conducted a cross-sectional, anonymous, web-based survey among HIV-negative MSM at high risk of HIV infection who attended 56 Dean Street, a sexual health and HIV clinic. The survey was conducted over a 7-day period in August 2020. Data on sociodemographic characteristics, sexual behaviour and related mental well-being experienced during lockdown (defined as 23 March–30 June 2020) were extracted. Categorical and non-categorical variables were compared according to HIV pre-exposure prophylaxis (PrEP) use.Results814 MSM completed the questionnaire: 75% were PrEP users; 76% reported they have been sexually active, of which 76% reported sex outside their household. 75% reported fewer partners than prior to lockdown. Isolation/loneliness (48%) and anxiety/stress (27%) triggered sexual activity, and 73% had discussed COVID-19 transmission risks with their sexual partners. While 46% reported no change to emotions ordinarily experienced following sex, 20% reported guilt for breaching COVID-19 restrictions. 76% implemented one or more changes to their sexual behaviour, while 58% applied one or more steps to reduce COVID-19 transmission during sex. 36% accessed SHS and 30% reported difficulties in accessing testing/treatment. Of those who accessed SHS, 28% reported an STI diagnosis. PrEP users reported higher partner number, engagement in ‘chemsex’ and use of SHS than non-PrEP users.ConclusionsCOVID-19 restrictions had a considerable impact on sexual behaviour and mental well-being in our survey respondents. High rates of sexual activity and STI diagnoses were reported during lockdown. Changes to SHS provision for MSM must respond to high rates of psychological and STI-related morbidity and the challenges faced by this population in accessing services.

Historically, human monkeypox virus cases in the UK have been limited to imported infections from west Africa. Currently, the UK and several other countries are reporting a rapid increase in monkeypox cases among individuals attending sexual health clinics, with no apparent epidemiological links to endemic areas. We describe demographic and clinical characteristics of patients diagnosed with human monkeypox virus attending a sexual health centre. In this observational analysis, we considered patients with confirmed monkeypox virus infection via PCR detection attending open-access sexual health clinics in London, UK, between May 14 and May 25, 2022. We report hospital admissions and concurrent sexually transmitted infection (STI) proportions, and describe our local response within the first 2 weeks of the outbreak. Monkeypox virus infection was confirmed in 54 individuals, all identifying as men who have sex with men (MSM), with a median age of 41 years (IQR 34–45). 38 (70%) of 54 individuals were White, 26 (48%) were born in the UK, and 13 (24%) were living with HIV. 36 (67%) of 54 individuals reported fatigue or lethargy, 31 (57%) reported fever, and ten (18%) had no prodromal symptoms. All patients presented with skin lesions, of which 51 (94%) were anogenital. 37 (89%) of 54 individuals had skin lesions affecting more than one anatomical site and four (7%) had oropharyngeal lesions. 30 (55%) of 54 individuals had lymphadenopathy. One in four patients had a concurrent STI. Five (9%) of 54 individuals required admission to hospital, mainly due to pain or localised bacterial cellulitis requiring antibiotic intervention or analgesia. We recorded no fatal outcomes. Autochthonous community monkeypox virus transmission is currently observed among MSM in the UK. We found a high proportion of concomitant STIs and frequent anogenital symptoms, suggesting transmissibility through local inoculation during close skin-to-skin or mucosal contact, during sexual activity. Additional resources are required to support sexual health and other specialist services in managing this condition. A review of the case definition and better understanding of viral transmission routes are needed to shape infection control policies, education and prevention strategies, and contact tracing. None.

BackgroundPrimary syphilis is characterised by the appearance of an ulcerated lesion (chancre) on the anogenital or oral mucosa from which Treponema pallidum DNA may be detectable by PCR. Serological tests for syphilis may be non-reactive in early infection, even after the appearance of a chancre. We reviewed the use of a multiplex-PCR (M-PCR) test to determine the added value of T. pallidum DNA detection in the management of individuals presenting with mucocutaneous ulceration at a sexual health service in central London.MethodsWe performed a cross-sectional analysis of all individuals with detectable T. pallidum DNA from September 2019 to April 2020. Electronic patient records were reviewed and concomitant results for treponemal serology and/or rapid plasma reagin (RPR) extracted, along with demographic data, history of syphilis and indices of sexual behaviour including number of sexual partners contacted. Any subsequent treponemal serology and RPR results were also reviewed.ResultsM-PCR swab specimens were performed in 450 individuals, of whom 63 (14%) had detectable T. pallidum DNA; 60 of 63 (95%) were gay or bisexual men and 11 of 63 (17%) were living with HIV. A history of treated syphilis was present in 17 of 63 (27%). Same-day treponemal serology/RPR testing was performed in 58 of 63 (92%) patients. Of the 58 who had same-day syphilis serology/RPR, 9 (16%) had their syphilis infection confirmed by treponemal DNA PCR alone. A total of 165 partners were traced as contacts of infection, of whom 25 (15%) were contacts of individuals diagnosed by M-PCR testing alone.ConclusionIn individuals with T. pallidum PCR-positive lesions, around one in six in our cohort were negative on standard diagnostic serological tests for syphilis. Treponemal DNA testing is an important addition to serological assays in individuals with mucocutaneous ulceration who are at risk of recent syphilis infection and facilitates early diagnosis and contact tracing.

IntroductionHIV-1 pre-exposure prophylaxis (PrEP) has been available in England since March 2020 on the National Health Service using generic emtricitabine and tenofovir disoproxil. 56 Dean Street (56DS) provided PrEP through (1) additional private care from September 2015, estimated to be providing 11% of England’s PrEP in 2019; and (2) the IMPACT trial, as well as monitoring those self-sourcing PrEP. Providing PrEP at scale through a nurse-led service required a safety net for complex individuals. 56DS introduced a consultant-led PrEP outpatient service, the PrEP review clinic, in January 2018 and we report the outcomes of this service.MethodsWe present a retrospective case note review of the PrEP review clinic with descriptive outcomes from 26 January 2018 to 20 December 2019. Reason for referral, demographics, PrEP management and PrEP discontinuations were recorded.Results13 980 unique users accessed PrEP from 56DS during the two year evaluation period. 220 individuals were seen in the PrEP review clinic. Majority of patients were referred for renal issues (114 of 220, 51.8%), followed by side effects (59 of 220, 26.8%) and comorbidities (38 of 220, 17.2%). Of those with renal issues, 89 (out of 114, 78.1%) users were referred for an abnormal estimated glomerular filtration rate (eGFR). 35 (out of 114, 30.7%) PrEP users had an eGFR between 45 and 59 mL/min/1.73 m2, of whom 2 (5.7%) discontinued PrEP. Majority of users were advised to stop supplements±switch to event-based dosing (24 of 35, 68.6%). Ten PrEP users were referred with an eGFR between 30 and 44 mL/min/1.73 m2; 4 (40%) stopped or did not start PrEP and 6 (60%) were asked to stop supplements±switch to event-based dosing.DiscussionA small proportion of PrEP users have complex PrEP issues. Methods to manage renal dysfunction with PrEP included stopping supplements and switching to event-based dosing. Those with side effects were managed with an array of options, with only modest effectiveness. Other PrEP options are needed to support those with toxicities or intolerances.

ObjectivesRectal swab specimens, either alone or pooled with first-void urine (FVU) and pharyngeal swab specimens, are used to test for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection in men who have sex with men (MSM). Following introduction of human papillomavirus (HPV) vaccination for MSM attending UK sexual health services (SHSs), HPV testing of residual CT/NG test specimens has been proposed to monitor HPV prevalence in this population. Performance of HPV detection in such specimens has not been evaluated previously.MethodsMSM attending a UK SHS provided three specimens: (1) rectal swab for CT/NG, (2) pooled rectal/pharyngeal/FVU specimen for CT/NG and (3) dedicated anal swab for HPV. Specimen 3 and residual material from specimens 1 and 2 were tested for type-specific HPV DNA. HPV detection was by an in-house multiplex PCR and luminex-based genotyping assay.ResultsA total of 129 MSM were recruited with a mean age of 38.1 years; 24% were HIV-positive. Of the 129 MSM, 92 (71%) had any type-specific HPV DNA in ≥1 specimen; 80 (62%) had high risk (HR) HPV. Of 123 participants with sufficient residual pooled and dedicated specimens, 70 (56.9%) had detectable HPV on both, and 40 (32.5%) were negative on both; overall concordance was 89% (95% CI 83% to 94%), and kappa statistic was 0.78 (95% CI 0.66 to 0.89). Pooled samples had a 4.1% (95% CI −1.9% to 10.0%) higher test positivity rate than dedicated samples.Of 125 participants with sufficient residual rectal and specimens, 74 (59.2%) had detectable HPV on both, and 36 (28.8%) were negative on both; overall concordance was 88% (95% CI 81% to 93%), and kappa statistic was 0.74 (95% CI 0.61 to 0.86). Residual rectal samples had 5.6% (95%CI −0.6% to 11.8%) higher test positivity than dedicated samples.ConclusionsWe observed high concordance between the dedicated and residual STI test specimens. Our data support the strategy of testing residual specimens for HPV prevalence monitoring in MSM to evaluate the impact of the targeted vaccination programme.

BackgroundAnorectal swab specimens, either alone, or pooled with first catch urine (FCU) and pharyngeal swab specimens, are used to test for STIs in MSM. The residual sample, after routine testing, may be used to monitor human papillomavirus (HPV) prevalence in this population, but the sensitivity of HPV detection in such specimens is unknown.MethodsMSM attending a UK sexual health clinic were consented to collect additional specimens to compare the detection of HPV in a dedicated swab, with detection in a residual anorectal and/or pooled specimen. All subjects provided 3 specimens: (i) anorectal swab (for chlamydia(CT)/gonorrhoea(GC) testing); (ii) pooled anorectal/pharyngeal/FCU specimen (for GC/CT); (iii) dedicated anorectal swab for HPV. Specimen (iii) and residual material from specimens (i) and (ii) were tested for type-specific HPV DNA (19 confirmed/possible high-risk (HR) genotypes and genotypes 6/11). HPV detection was by in-house multiplex PCR and Luminex-based genotyping assay.Results129 MSM were recruited; mean age 38.1 years; 24% were HIV-positive. 92/129 (71%) had type-specific HPV DNA detected in ≥1 specimen; 80/129 (62%) had HR-HPV. 70/123 participants (56.9%) with sufficient residual pooled specimen, and a dedicated HPV specimen had detectable HPV on both and 40 (32.5%) were HPV-negative on both; overall concordance 89% (95%CI 83,94). Prevalence in pooled samples was 4.1% (-1.9,10.0) higher than dedicated samples. 74/125 participants (59.2%) with sufficient residual anorectal specimen, and dedicated anorectal HPV specimen had detectable HPV on both and 36 (28.8%) were HPV-negative on both; overall concordance 88% (81,93). Prevalence in residual samples was 5.6% (-0.6,11.8) higher than dedicated samples.ConclusionResidual anorectal and pooled STI test specimens offer comparable sensitivity to anal HPV swab samples, which are typically used in prevalence studies. This supports use of residual samples to monitor HPV prevalence, as currently proposed in the UK to evaluate the impact of targeted MSM HPV vaccination.DisclosureNo significant relationships.

BackgroundThe comparative efficacy, and cost-effectiveness, of imiquimod (IMIQ) or podophyllotoxin (PDX) cream, either alone or in combination with the quadrivalent HPV vaccine (Gardasil®, Merck) in the treatment and prevention of recurrence of anogenital warts is unknown.MethodsA randomised, controlled, multi-centre, partially-blinded factorial trial with an economic evaluation. Participants had new or recurrent warts; not treated within 3 months; no qHPV-vaccination. Randomisation, stratified by gender, previous warts, HIV status to IMIQ 5% (16W), or PDX 0.15% cream (4W, extended to 16W if warts persist). Simultaneous blinded randomisation to Gardasil® or saline control (0–2–6 months). Composite primary outcome of wart clearance at 16W and remaining clear to 48W; analysis by logistic regression with multiple imputation for missing follow-up values. Economic evaluation considered the costs per quality-adjusted life year (QALY) for the National Health Service in England.Results503 participants enrolled; mean age 31 years; 66% male (20% of males MSM); 50% previous warts; 2% known HIV+. Adjusted OR (95%CI) for IMIQ relative to PDX 0.81 (0.54, 1.23); vaccine relative to placebo 1.46 (0.97, 2.20). aOR for primary outcome components (same comparators) of wart-free at W16 0.77 (0.52,1.14) and 1.30 (0.89,1.91) and remaining wart-free at 48W (in those wart-free at W16) 0.98 (0.54,1.78) and 1.39 (0.73,2.63) respectively. PDX without qHPV vaccine had the highest probability of being cost-effective across willingness-to-pay thresholds of GBP0–50,000/QALY. Adding qHPV vaccine to PDX exceeded GBP80,000/QALY.ConclusionThough the effect of vaccine was not statistically significant, the odds of clearance at 16W+48W (primary outcome) were 46% higher with vaccine, consistent with the effects seen in component outcomes, wart-free at 16W, and 48W. IMIQ and PDX had similar efficacy; there was no evidence of a lower recurrence with IMIQ. PDX without qHPV vaccine is likely most cost-effective at the current qHPV price, but addition of qHPV may become cost-effective with reduced pricing.DisclosureNo significant relationships.

Background The use of simulation to train novice surgeons in laparoscopic skills is becoming increasingly popular. To maximize benefit from simulation, training needs to be delivered and assessed in a structured manner. This study aimed to define performance goals, demonstrate construct validity of the training program, and evaluate whether novice surgeons could reach the preset performance goals. Methods Nine expert laparoscopic surgeons established performance goals for three basic modules of an augmented-reality laparoscopic simulator. The three laparoscopic modules were used by 40 novice surgeons and 40 surgical trainees (postgraduate years [PGYs] 1–4). The performance outcomes were analyzed across the different groups (novice, PGYs 1 and 2, PGYs 3 and 4, expert) to determine construct validity. Then 26 recruited novices trained on the three modules with the aim of reaching the performance goals. Results The results demonstrated a significant difference in performance between all levels of experience for time ( p  < 0.001), motion analysis ( p  < 0.001), and error score ( p  < 0.001), thus demonstrating construct validity. All 26 novice surgeons significantly improved in performance with repetition for the metrics of time ( p  < 0.001) and motion analysis ( p  < 0.001). For two of the modules, the proficiency goals were reached in fewer than 10 trials by 80 % of the study participants. Conclusion Basic skills in laparoscopic surgery can be learned and improved using proficiency-based simulation training. It is possible for novice surgeons to achieve predefined performance goals in a reasonable time frame.