Genitourinary Medicine Clinics In England Research Articles

Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men

ObjectiveThe aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men...

Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation

The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013–2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.

Associations of depression and anxiety symptoms with sexual behaviour in women and heterosexual men attending sexual health clinics: a cross-sectional study

ObjectiveTo assess the association of symptoms of depression and anxiety with sexual risk behaviour and history, among women and heterosexual men attending genitourinary medicine (GUM) clinics.MethodsAttitudes to and Understanding of...

Ethnicity and sexual risk in heterosexual people attending sexual health clinics in England: a cross-sectional, self-administered questionnaire study

ObjectivesIn the UK, people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual behaviour and sexual health among...

O035 Is cefixime back? Trends in gonococcal resistance to current and previous front line therapies in England and Wales since the 2011 guideline change

Background/introduction Antimicrobial resistance (AMR) in Neisseria gonorrhoeae threatens effective treatment and infection control. Treatment guidelines for gonorrhoea are revised when the prevalence of resistance to first-line therapy exceeds 5%; in the UK this last occurred in 2011, prompting a treatment guideline change from cefixime to dual therapy with ceftriaxone and azithromycin. Aim(s)/objectives Describe emerging trends in gonococcal resistance to current and previous first-line therapies using data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). Methods GRASP collects N. gonorrhoeae isolates from July–September annually from 27 genitourinary medicine clinics in England and Wales. The minimum inhibitory concentration (MIC) of each isolate to seven antimicrobials is determined, then linked to demographic, clinical and behavioural data. Data from 2011–2014 were considered in this analysis. For each antimicrobial, the test for trend in resistance was determined and MIC distributions were compared using the Kolmogorov–Smirnov test. Results In 2014, there was no ceftriaxone resistance (MIC ≥ 0.125 mg/L), but the modal MIC drifted to 0.004 mg/L from 0.002 mg/L in 2011 (p Discussion/conclusion Despite the decline in resistance in cefixime, the drifting MIC distribution suggests isolates are less susceptible than previous years. Ongoing monitoring of AMR with strong compliance with national treatment guidelines is essential to retain gonorrhoea as a treatable infection.

P056 Influence of country of birth on risk of STI diagnosis among black Caribbeans in England in 2014

Background/introduction In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STIs), but it is unclear whether this is associated with their country of birth. Aim(s)/objectives To examine differences in STI diagnoses among UK- and Caribbean-born BC people. Methods Data on STI diagnoses in BC people attending genitourinary medicine (GUM) clinics and living in England were obtained from the GUM Clinic Activity Dataset (GUMCADv2). Associations between being UK- or Caribbean-born and diagnosis with an STI were derived using univariate and multivariable multilevel logistic regression models adjusted for age, gender/sexual-orientation, residence, and HIV status. Results BC people made 231,719 attendances in 2014; 81.9% were UK-born. The median age (years) was 25 for UK-born and 34 for Caribbean-born people (p ≤ 0.001). Chlamydia, non-specific genital infection and gonorrhoea were the most commonly diagnosed STIs among UK- (37.4%, 19.5% and 13.7%) and Caribbean-born attendees (32.1%, 25.2% and 13.1%). From the multilevel analysis, UK-born attendees were less likely to be diagnosed with chlamydia (aOR 0.87 [95%C.I. 0.81–0.94]) and trichomoniasis (0.83 [0.71–0.97]), and more likely to be diagnosed with genital warts (1.24 [1.07–1.45]) than Caribbean-born attendees. The adjusted odds of a gonorrhoea diagnosis did not vary by country of birth. Discussion/conclusion STI rates among black Caribbeans attending GUM clinics in England are high and might be influenced by STI epidemiology in their country of birth. Studies on the effectiveness of interventions aimed at reducing the burden of STIs in all black Caribbeans are urgently needed.

O039 Role of primary care in the diagnosis of STIs in England

Background Sexually transmitted infection (STI) diagnoses made in genitourinary medicine (GUM) clinics have been collected in England for many years, but little is known about the contribution of GPs to STI diagnoses. Objectives To assess trends in diagnosis rates of selected STIs from GPs. Methods Longitudinal analysis of age- and sex-standardised population diagnosis rates of selected STIs from GPs in England from 2005–2014 was performed using data from the Clinical Practice Research Datalink (CPRD). Results The proportion STI diagnoses made by GPs varied by infection, ranging from 2% (gonorrhoea) to 34% (genital herpes), in 2014. From 2005–2014, diagnosis rates [95% CI] per 100,000 registered population decreased for chlamydia (51.4 [50.7–52.0] to 24.9 [24.5–25.3], p = 0.009), gonorrhoea (3.4 [3.2–3.5] to 1.8 [1.7–1.9], p = 0.02), genital warts (73.1 [72.4–73.9] to 38.4, [37.9–39.0], p = 0.004) and genital herpes (36.9 [36.4–37.4] to 26.1 [25.7–26.6], p = 0.02). Diagnosis rates for all four STIs were higher among women, particularly for chlamydia and genital herpes where respective 2014 rates were 38.3 [37.6–39.1] and 41.8 [41.0–42.5] compared to 11.1 [10.7–11.5] and 10.0 [9.7–10.4] in men. Conclusion While the rates of STI diagnoses in GUM clinics in England have steadily risen in the past 10 years, particularly in men, diagnosis rates of these four STIs in GPs have decreased between 2005 and 2014. The high diagnosis rates seen in women in GPs, suggest that primary care has an important role in the diagnosis of STIs in women although their relative contribution may have declined in recent years.

Cost and cost-effectiveness of an HIV pre-exposure prophylaxis (PrEP) programme for high-risk men who have sex with men in England: results of a static decision analytical model

BackgroundThe efficacy and effectiveness of pre-exposure prophylaxis (PrEP) for preventing HIV infection acquisition by high-risk men who have sex with men (MSM) is established. We estimated the cost and cost-effectiveness of a proposed daily oral PrEP programme covering 10 000 high-risk MSM attending genitourinary medicine clinics in England. MethodsFrom the perspective of public providers, a static decision analytical model was used to investigate lifetime HIV infections, treatment costs, and quality-adjusted-life-year (QALY) losses associated with daily PrEP given for 1 year, beginning in 2016, compared with no intervention. A cohort of MSM who were not known to be HIV positive at their first attendance in 2012 and had tested HIV negative between 42 and 365 days previously was identified. These men were followed up from the date of their earliest negative HIV test in 2012 for up to 1 year either until they seroconverted or until their last attendance. HIV incidence was calculated as the number of seroconversions (new HIV diagnoses) per 100 person-years. Data sources including genitourinary medicine clinic activity data were used to estimate HIV incidence in year 1 and thereafter. Costs were updated to 2013–14 values and both future costs and QALYs were discounted at 3·5%. Budgetary impact was undiscounted. FindingsAt 86% effectiveness, delivery of PrEP to 10 000 high-risk MSM in the first year (target population with an HIV incidence of 2·4 per 100 person-years in year 1) resulted in 178 fewer lifetime HIV infections, 28 delayed infections, and an incremental cost-effectiveness ratio (ICER) of £26 300, compared with no PrEP. More conservative assumptions of 64% PrEP effectiveness gave an ICER of £54 500, compared with no PrEP. ICER was highly sensitive to year 1 HIV incidence (eg, with HIV incidence of 3·3 per 100 person-years and at 86% PrEP effectiveness, ICER was £4170), PrEP effectiveness, PrEP drug costs, and potential changes in antiretroviral treatment cost upon patent expiry. An investment of £54 million in year 1 breaks even anywhere from year 42 (86% PrEP effectiveness) to beyond year 61 (64% PrEP effectiveness). InterpretationThe model shows that the estimated cost-effectiveness of PrEP is very sensitive to key variables (eg, year 1 HIV incidence and patient adherence), about which there is much uncertainty, especially if programme scale-up occurs. A substantial reduction in the price of antiretroviral drugs, when used for PrEP, is needed to give the necessary assurance of cost-effectiveness, and for an affordable public health programme of sufficient size. FundingNone.

Frequency and correlates of culture-positive infection with Neisseria gonorrhoeae in England: a review of sentinel surveillance data.

Reference laboratories are increasingly using more sensitive rapid molecular techniques, such as nucleic acid amplification tests (NAATs), to diagnose infections with Neisseria gonorrhoeae. We determined the proportion of patients at sentinel genitourinary medicine clinics in England whose NAAT-positive diagnoses were also culture-positive for N. gonorrhoeae, and investigated whether they differed from those that were not. Behavioural and clinical data from all NAAT-positive patients reported from 23 clinics included in the Gonoccocal Resistance to Antimicrobials Surveillance Programme from July to September 2012 were included in this analysis. Unadjusted and adjusted associations between patient characteristics and culture-positive infection with N. gonorrhoeae were determined. Of 3076 NAAT-positive patients, 46.4% had culture-positive infections. Most NAAT-positive patients were <35 years old (73.0%), white (67.9%), and men who had sex with men (60.1%). Women and men who had sex with men were less likely than heterosexual men to have culture-positive infections (adjusted OR (95% CI) 0.53 (0.41 to 0.68), p<0.001; and 0.74 (0.59 to 0.93), p=0.010, respectively), while those who were symptomatic (4.61 (3.92 to 5.42), p<0.001), and those presenting with infection at multiple sites (2.15 (1.76 to 2.62), p<0.001) were more likely to have culture-positive infections. Although gonococcal isolates were available from almost half of the NAAT-positive patients, culture was not attempted or may have failed in the remainder. Patients with culture-positive isolates were not representative of all NAAT-positive patients. Routine culture is necessary for monitoring emerging antimicrobial resistance and to inform gonorrhoea treatment guidelines.

An early evaluation of clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoea in genitourinary medicine clinics in England

ObjectivesTo estimate the costs and benefits of clinical pathways incorporating a point of care (POC) nucleic acid amplification test (NAAT) for chlamydia and gonorrhoea in genitourinary medicine (GUM) clinics compared...

P3.284 Factors Associated with Variations in Culture Confirmation For Neisseria Gonorrhoea: A Study of Patients Attending Five Genitourinary Medicine Clinics in England

BackgroundScreening for gonorrhoea at genitourinary medicine (GUM) clinics in England is routinely performed using Nucleic Acid Amplification Tests (NAATs), but confirmation of NAAT-positive specimens by culture is required to monitor...

P3.174 The Sexual Health of Male and Female Sex Workers Attending Genitourinary Medicine Clinics in England

BackgroundSex workers (SWs) are assumed to be at increased risk of sexually transmitted infections (STIs), but there are limited comparative data with other population groups. Previously, SW sexual health data...

Decreased susceptibility to cephalosporins among gonococci: data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) in England and Wales, 2007–2011

Effective treatment of gonorrhoea is fundamental to public health control; however, the ability of Neisseria gonorrhoeae to successively develop resistance to different treatments has hampered control efforts. The extended-spectrum cephalosporins--cefixime and ceftriaxone--have been recommended in the UK for treatment of gonorrhoea since 2005. We looked at surveillance data from England and Wales to ascertain the current usefulness of these drugs and to inform changes to national treatment guidelines. We obtained data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) for patients attending 26 genitourinary medicine clinics in England and Wales between 2007 and 2011. We did analyses with univariate and multivariable logistic regression methods to identify trends in susceptibility to cephalosporins and risk factors associated with infection with isolates with decreased susceptibility to cefixime, and we assessed changes in prescribing practices. We did molecular typing to investigate genetic relatedness of non-susceptible isolates. The prevalence of decreased susceptibility to both cefixime and ceftriaxone rose between 2007 and 2010 but was more noticeable for cefixime (an increase from 1·5% in 2007 to 17·1% in 2010), with a bimodal distribution of minimum inhibitory concentration recorded between 2009 and 2010. By multivariable analysis, isolates with decreased susceptibility to cefixime were associated with infection in men who have sex with men (odds ratio 5·47, 95% CI 3·99-7·48; p<0·0001) and year of isolation (in 2010, 13·08, 7·49-22·8; p<0·0001). Such isolates had a largely clonal population, with most belonging to genogroup G1407 and harbouring the penA mosaic gene. Data from 2011 showed a significant decline in prevalence of isolates with decreased cefixime susceptibility, falling from 17·1% in 2010 to 10·8% in 2011 (p<0·0001), concomitant with the change in prescribing practice in 2010 from cefixime to ceftriaxone plus azithromycin. Guidance for treatment of gonorrhoea in England and Wales was changed in 2010 to prolong the use of cephalosporins. The decline in prevalence of isolates with decreased cefixime susceptibility cannot be attributed unequivocally to this change in prescribing practice; however, the association is striking. Department of Health (England), Public Health England.

O13 HIV incidence in an open national cohort of MSM attending GUM clinics in England

BackgroundEndemic HIV transmission in men who have sex with men (MSM) is a major concern in England. Since 2008, a new national anonymised genitourinary medicine (GUM) clinic reporting system provides...

Association of Alzheimer Disease Pathology with Abnormal Lipid Metabolism: The Hisayama Study

<h3>Objective</h3> The aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men (GBMSM). <h3>Methods</h3> Data are from the Antiretrovirals, Sexual Transmission Risk and Attitude (ASTRA) study of people living with HIV and attending one of eight HIV outpatient clinics in England (2011–2012) and the Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) study of HIV-negative/unknown status individuals attending one of 20 genitourinary medicine clinics in England (2013–2014). This analysis included GBMSM only. For each study, the prevalence of depressive symptoms (Patient Health Questionnaire-9 score ≥10) was presented according to three categories of sex in the past 3 months (considering anal/vaginal sex with men/women and anal sex with men in separate definitions): (1) no sex, (2) condom-protected sex only and (3) CLS. Multinomial logistic regression with ‘condom-protected sex only’ as the reference group was used to adjust for age and (for ASTRA participants) time since HIV diagnosis. <h3>Results</h3> There were opposing associations of depression with recent sexual behaviour: the prevalence of depression was higher among those who reported no sex and those who reported CLS, compared with those who reported condom-protected sex only. Among the 2170 HIV-positive GBMSM in ASTRA, considering anal/vaginal sex with men/women, the prevalence of depressive symptoms was 32%, 20% and 28%, respectively, among men reporting no sex (n=783), condom-protected sex only (n=551) and CLS (n=836) (global p&lt;0.001). Among the 1477 HIV-negative GBMSM in AURAH, the prevalence of depressive symptoms was 12%, 8% and 13%, respectively, for no sex (n=137), condom-protected sex only (n=487) and CLS (n=853) (global p=0.017). Patterns were similar after adjustment and when only considering anal sex between men. <h3>Conclusions</h3> Depression may be linked both to lack of sexual activity and to sexual risk taking. When investigating associations between depression and CLS, it is important to separate out individuals reporting condom-protected sex only from those reporting no sex.

The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England

In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics. Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n = 345), black African (n = 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England. Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively). Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses.

Building the bypass—implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009

ObjectiveThe objective of this study was to examine changes in patient routes into genitourinary medicine (GUM) clinics since policy changes in England sought to improve access to sexual healthcare.MethodsCross-sectional patient...

O2-S1.02 Is concurrency the new serial monogamy? Evidence from a large survey of people attending contrasting genitourinary medicine (GUM) clinics in England

BackgroundConcurrency is an important risk behaviour for STI transmission at the population level, yet few surveys ask detailed questions about concurrency. Even if partnerships do not overlap, there is potential for STI transmission if the gap between the end of one partnership and the start of the next is short. We examined the prevalence of concurrency, quantified the gap between partners and examined gender differences in a high-risk population.MethodsCross-sectional survey of 2203 people attending four contrasting GUM clinics in England in 2009. Attendees completed a questionnaire including questions about their three most recent partnerships in the 3 months prior to attending GUM. Gaps between partners were calculated as the time between most recent sex with a previous partner and first sex with a more recent partner. Partnerships were considered concurrent if the gap was negative.Results92% of attendees reported sex partner(s) in the last 3 months, yet, while the median number of partners was 1387 men (48%) and 294 women (28%) reported 2+ partners in this time (p&lt;0.001). For 49% of these attendees, ≥2 of their 3 most recent partners were concurrent (p=0.07 for gender difference). Among the 347 concurrent partnerships reported, the median overlap was long: 113 days (IQR: 28–460 days) with just 40 partnerships (12%) involving an overlap of &lt;2 weeks (no significant gender difference). 40% of attendees with concurrent partners had not used condoms consistently with either partner, and a further 24% of attendees with concurrent partners reported not using condoms at all with either partner. In addition (see Abstract O2-S1.02 figure 1), while 78% of men's partners and 70% of women's were overlapping or had a brief gap (&lt;2 weeks), just 12% and 20% respectively involved a gap between partners of &gt;4 weeks.Abstract O2-S1.02 Figure 1Cumulative percentage distribution of the time between partners in the 3 months prior to attending GUM clinic reported by attendees with 2+ partners, by gender.ConclusionsThe majority of GUM attendees reported few partners in the last 3 months, yet half of those with 2+ partners had concurrent partnerships, such that concurrency is as common as serial monogamy in this population. These partnerships typically overlapped by a number of weeks and condoms were seldom used, if at all. Among the serially monogamous, sex with a new partner within days of last sex with a former partner was common so the potential for STI transmission is high. Understanding concurrency and the gaps experienced by high-risk individuals is important for ensuring that health promotion and partner notification are delivered appropriately and effectively.

Cephalosporin MIC creep among gonococci: time for a pharmacodynamic rethink?

Gonorrhoea has been among the easiest infections to cure with antibiotics. Nevertheless, emerging resistance has driven repeated treatment shifts. Decreased cephalosporin susceptibility is now being reported. We examined cephalosporin MIC trends for Neisseria gonorrhoeae in the UK and undertook pharmacodynamic analyses to predict efficacy against strains with raised MICs. Neisseria gonorrhoeae isolates were collected annually in a structured surveillance from 26 genitourinary medicine clinics in England and Wales. MICs were determined by agar dilution and confirmed by Etests. Pharmacodynamic modelling was performed for cefixime and ceftriaxone with Monte Carlo simulations. There was a progressive emergence of small numbers of gonococci with cephalosporin MICs of 0.125-0.25 mg/L; these were not seen before 2005 but, for ceftriaxone and cefixime, respectively, accounted for 0.4% (95% confidence interval 0.2%-1.1%) and 2.8% (1.6%-4.8%) of the 1253 isolates collected in 2008; such MICs are 16-64 times the modal values for the species. Pharmacodynamic analysis was complicated by evidence that cephalosporins need a longer period with the free drug level above MIC than the 7-10 h required for penicillin G; nevertheless, pharmacodynamic analyses predict that failures with the standard 400 mg cefixime po and 250 mg ceftriaxone im regimens become likely around the present MIC maxima. Gonococci with ceftriaxone and cefixime MICs of 0.125-0.25 mg/L are accumulating in the UK. These MICs lie on the edge of likely responsiveness to current regimens, which need review. Possible responses include: (i) higher cephalosporin doses; (ii) multidose cephalosporin regimens; (iii) multidrug regimens; (iv) microbiologically directed treatment; or, in the future, (v) drug cycling. The practicalities of these approaches are discussed.

A review of cervical cytology in genitourinary medicine clinics in England between 1997 and 2008

The current cervical screening guidelines lay the duty of care of women under 25 years of age on genitourinary (GU) medicine clinics. To date there has not been an extensive review of cervical cytology results sourced from GU medicine departments. We reviewed the annual reports of the cervical screening programme, with their extensive and comparative data, including records of cervical cytology from GU medicine. There is a clear and progressive trend of rising percentages of 'severe dyskaryosis' in laboratory reported GU medicine cervical smears. The trend and observations indicate that GU medicine physicians should take young women's concern on cervical cancer seriously. The programme of opportunistic cervical screening in GU medicine should not be discouraged.