Genitourinary Medicine Clinic Research Articles

P245 Monitoring the uptake and early impact of targeted hpv vaccination among men who have sex with men (msm) attending gum and hiv clinics in england

IntroductionMSM are at high risk for HPV infection and associated disease (genital warts and anal, oropharyngeal, and penile cancers). Additionally, MSM will receive little or no herd protection from the existing national vaccination programme for females. Following Joint Committee on Vaccination and Immunisation (JCVI) advice, a targeted HPV MSM vaccination pilot was introduced in GUM and HIV clinics across England from June 2016. We present plans for monitoring vaccination uptake and surveillance of infection and early disease outcomes.MethodsUptake (of three doses over a two year period) will be monitored via two existing surveillance and reporting systems: the Genitourinary medicine clinic activity dataset (GUMCADv2) and the HIV and AIDS reporting system (HARS). A seroprevalence study conducted in selected clinics for validation of these data will be considered in due course.Early impact of targeted HPV vaccination of MSM on the epidemiology of HPV infection will be detected by HPV DNA testing of rectal swabs (residual specimens following chlamydia testing) from MSM attending selected GUM clinics, starting with largely baseline collection in 2017.Expected early effects on genital warts diagnoses will be monitored (via GUMCADv2). A decline in HPV-associated cancers is not expected to be seen for some years.DiscussionA comprehensive surveillance strategy has been established to evaluate targeted HPV vaccination of MSM at GUM/HIV clinics. During the pilot, uptake will be the main outcome measure available, and surveillance systems will be established and baseline data collected to evaluate the outcomes of national implementation on infection and disease.

P217 Syphilis on the rise – implementation of enhanced surveillance

IntroductionDiagnoses of infectious syphilis have risen dramatically in the UK since the late 1990s. This resurgence has been facilitated by a number of outbreaks across the UK, occurring mainly in men who have sex with men but also in heterosexual men and women.In response, a number of enhanced surveillance initiatives have been developed and implemented across England to collect timely demographic, clinical and risk factor information. These run alongside the routine surveillance system for sexually transmitted infections, the quarterly Genitourinary Medicine Clinic Activity Dataset (GUMCADv2). The system in the East of England is described here.MethodsUp to 2016 two paper based forms were utilised. A one page ‘surveillance’ form was completed for every case of infectious syphilis, and a more detailed ‘investigation’ form used if an unusual increase required investigation. During 2016 these two forms were merged and information is now entered into an online form. All forms are completed by the diagnosing clinic.Data collected is used to generate automatic reports, identify and investigate any unusual increases and for audits against GUMCADv2.ResultsEnhanced surveillance has allowed the identification of a number of unusual increases prompting timely and appropriate investigations to be launched; identified opportunities to improve reporting standards. The change to an online system has improved the timeliness and accuracy of reporting and made the system more secure.DiscussionOngoing enhanced surveillance complementing GUMCADv2 is important. This information provides timely intelligence on the epidemiology of infectious syphilis across the region.

P123 Is there a relationship between the tendering history of a genitourinary medicine clinic and its accessibility?

IntroductionSince 2004, DH guidance has recommended that GUM clinics in England should endeavour to see patients within 48 hours of initial contact. Recent changes in service commissioning and the wider adoption of competitive tendering since 2013 has led to concerns about maintaining 48-hour access.AimTo establish whether there is a relationship between the tendering history of a GUM clinic and its accessibility.MethodsPostal questionnaires regarding tendering history were sent to lead clinicians of all 262 GUM clinics in the UK. Only questionnaires which were returned within a two-month window were analysed. Each clinic with a returned questionnaire was telephoned eight times by male and female researchers posing as patients with symptomatic and asymptomatic presentations. The researchers asked to be seen as soon as possible and recorded whether this fell within 48 hours.Results67 clinics (25.6%) returned their questionnaires on time. A chi-square test found no statistically significant difference between clinics tendered within the last five years (n=49) and the rest (n=18), regarding 48-hour access (86.5% and 86.2% respectively, p=0.916). Interestingly, 88% of contacts with clinics still undergoing a tender resulted in a 48-hour appointment compared with 100% of contacts with clinics which completed the process 3–5 years ago. However, this was not statistically significant.DiscussionThe negative effect of tendering on accessibility seems to be overstated. Moreover, if this effect does exist, it seems more pronounced during the actual tender, followed by an apparent boost in access. A larger study may be required to confirm this.

P180 Unusual causes of genital ulceration presenting to genitourinary medicine clinic – a case series

IntroductionGenital ulceration presents frequently at GUM clinics, with herpes simplex (HSV) infection a common aetiology. A diagnosis of HSV is distressing with possible implications for relationships and future pregnancies. It is therefore important to consider other causes if atypical presentation or negative HSV PCR from area of active ulceration.MethodCase review of uncommon aetiologies of ulceration.ResultsCase 1: 25 year old. Prodromal sore throat and flu-like symptoms. Examination revealed deep ulcers on vulva and oral mucosa without eye or skin involvement. CRP 120, ESR 80, ASOT titre 400, negative autoimmune screen, monospot negative. Developed anterior uveitis and erythema nodosum 24 hours later. Diagnosed with Behcet’s disease requiring prednisolone and mycophenolate mofitil.Case 2: 28 year old. Prodromal sore throat and headache. Sexual history atypical for HSV. Known Graves’ disease, on propylthiouracil. On examination, patient looked unwell. Shallow vulval ulceration noted. Neutrophils 0.1, ESR 31. Diagnosed with apthous ulceration secondary to neutropenia and admitted for neutropenic-sepsis treatment. Required thyroidectomy with pathology revealing papillary carcinoma.Case 3: 13 year old referred by SARC. No history of sexual contact or features of child sexual exploitation. Prodromal flu-like illness. Of note, mother Influenza A positive.No response to empirical acyclovir. HSV PCR negative. Nasopharyngeal swab confirmed Influenza A. Case subsequently closed with SARC and Social Services.DiscussionThis case series highlights less common but important causes of genital ulceration. Full systemic history and clinical assessment remains essential in those where alternate diagnoses to HSV are being considered.

Clinically significant depressive symptoms and sexual behaviour among men who have sex with men.

BackgroundThe relationship between depression and sexual behaviour among men who have sex with men (MSM) is poorly understood.AimsTo investigate prevalence and correlates of depressive symptoms (Patient Health Questionnaire-9 score ≥10) and the relationship between depressive symptoms and sexual behaviour among MSM reporting recent sex.MethodThe Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) is a cross-sectional study of UK genitourinary medicine clinic attendees without diagnosed HIV (2013–2014).ResultsAmong 1340 MSM, depressive symptoms (12.4%) were strongly associated with socioeconomic disadvantage and lower supportive network. Adjusted for key sociodemographic factors, depressive symptoms were associated with measures of condomless sex partners in the past 3 months (≥2 (prevalence ratio (PR) 1.42, 95% CI 1.17–1.74; P=0.001), unknown or HIV-positive status (PR 1.43, 95% CI 1.20–1.71; P<0.001)), sexually transmitted infection (STI) diagnosis (PR 1.46, 95% CI 1.19–1.79; P<0.001) and post-exposure prophylaxis use in the past year (PR 1.83, 95% CI 1.33–2.50; P<0.001).ConclusionsManagement of mental health may play a role in HIV and STI prevention.Declaration of interestA.N.P. has received payments for presentations made at meetings sponsored by Gilead in spring 2015. N.C.N. has received support for attendance at conferences, speaker fees and payments for attendance at advisory boards from Gilead Sciences, Viiv Healthcare, Janssen Pharmaceuticals and Bristol-Myers Squibb and a research grant from Gilead Sciences. D.A. served on the advisory board for Gilead in January 2016. M.M.G. has had sponsorship to attend conferences by Bristol-Myers Squibb, been on the BioCryst advisory board and run trials for Merck, Gilead, SSAT, BioCryst and Novartis.Copyright and usage© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Inequalities in access to genitourinary medicine clinics in the UK: results from a mystery shopper survey

Study designThis study investigated whether access to genitourinary medicine (GUM) clinics meets UK-recommended standards.MethodsIn January 2014 and 2015, postal questionnaires about appointment and service characteristics were sent to lead clinicians...

Prevalence and characteristics of gastrointestinal infections in men who have sex with men diagnosed with rectal chlamydia infection in the UK: an ‘unlinked anonymous’ cross-sectional study

IntroductionGastrointestinal infections (GII) can cause serious ill health and morbidity. Although primarily transmitted through faecal contamination of food or water, transmission through sexual activity is well described, especially among men...

The eSexual Health Clinic system for management, prevention, and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis

Self-directed and internet-based care are key elements of eHealth agendas. We developed a complex online clinical and public health intervention, the eSexual Health Clinic (eSHC), in which patients with genital chlamydia are diagnosed and medically managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. Partner notification, health promotion, and capture of surveillance data are integral aspects of the eSHC. We aimed to assess the safety and feasibility of the eSHC as an alternative to routine care in non-randomised, exploratory proof-of-concept studies. Participants were untreated patients with chlamydia from genitourinary medicine clinics, untreated patients with chlamydia from six areas in England in the National Chlamydia Screening Programme's (NCSP) online postal testing service, or patients without chlamydia tested in the same six NCSP areas. All participants were aged 16 years or older. The primary outcome was the proportion of patients with chlamydia who consented to the online chlamydia pathway who then received appropriate clinical management either exclusively through online treatment or via a combination of online management and face-to-face care. We captured adverse treatment outcomes. Between July 21, 2014, and March 13, 2015, 2340 people used the eSHC. Of 197 eligible patients from genitourinary medicine clinics, 161 accessed results online. Of the 116 who consented to be included in the study, 112 (97%, 95% CI 91-99) received treatment, and 74 of those were treated exclusively online. Of the 146 eligible NCSP patients, 134 accessed their results online, and 105 consented to be included. 93 (89%, 95% CI 81-94) received treatment, and 60 were treated exclusively online. In both groups, median time to collection of treatment was within 1 day of receiving their diagnosis. 1776 (89%) of 1936 NCSP patients without chlamydia accessed results online. No adverse events were recorded. The eSHC is safe and feasible for management of patients with chlamydia, with preliminary evidence of similar treatment outcomes to those in traditional services. This innovative model could help to address growing clinical and public health needs. A definitive trial is needed to assess the efficacy, cost-effectiveness, and public health impact of this intervention. UK Clinical Research Collaboration.

Attendance of MSM at Genitourinary Medicine services in England: implications for selective HPV vaccination programme (a short communication)

BackgroundHuman papillomaviruses (HPV) immunisation programmes for female adolescents in the UK offer relatively little benefit to men who have sex with men (MSM). Targeted HPV vaccination for MSM may reduce...

Development and evaluation of an enzyme-linked immunosorbent assay for the detection of antibodies to a common urogenital derivative of Chlamydia trachomatis plasmid-encoded PGP3

BackgroundUrogenital infection with Chlamydia trachomatis is the most commonly diagnosed sexually transmitted infection in the developed world. Accurate measurement and therefore understanding the seroprevalence of urogenital C. trachomatis infections requires a rigorously optimised and validated ELISA. Previous ELISAs based on the C. trachomatis plasmid-encoded protein, PGP3, have been described but lack standardisation and critical controls or use a less common PGP3 as the capture antigen. Methodology/principal findingsA sensitive and specific indirect ELISA was developed based on recombinant PGP3 derived from a urogenital strain of C. trachomatis, serovar E (pSW2), using a rigorous validation protocol. Serum samples were collected from 166 genitourinary medicine (GUM) clinic patients diagnosed as positive or negative for urogenital C. trachomatis infection by nucleic acid amplification testing (NAATs). Overall sensitivity and specificity compared to NAATs was 68.18% and 98.0%, respectively. Sensitivities for female and male samples were 71.93% and 64.15%, respectively. Comparison of samples from these patients diagnosed positive for C. trachomatis by NAAT and patients diagnosed negative by NAAT revealed statistical significance (p≤0.0001). ConclusionsWe have developed and validated a sensitive and specific ELISA to detect anti-PGP3 antibodies as an indicator of past and current infection to C. trachomatis using PGP3 from a common urogenital strain. It is anticipated that this assay will be used for seroepidemiological analysis of urogenital C. trachomatis in populations.

Evaluation of hepatitis C testing in men who have sex with men, and associated risk behaviours, in Manchester, UK

ObjectiveTo determine the prevalence of newly diagnosed hepatitis C virus (HCV) and associated risk behaviours among men who have sex with men (MSM) in Manchester.MethodA survey among MSM attending four...

Impact and cost-effectiveness of selective human papillomavirus vaccination of men who have sex with men

Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination. We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16-25, 16-30, 16-35, and 16-40 years. Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective. Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.

Access of non-specialist sexual health services by men who have sex with men: do they differ from those attending specialist services?

ObjectivesMen who have sex with men (MSM) bear a disproportionate burden of STIs. While routine STI surveillance data suggest MSM regularly access specialist genitourinary medicine (GUM) clinics for their sexual...

What are the characteristics of, and clinical outcomes in men who have sex with men prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics in England?

ObjectivesTo explore the risk factors for, and clinical outcomes in men who have sex with men (MSM) prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics (SHCs)...

Refusal of HIV testing among black Africans attending sexual health clinics in England, 2014: a review of surveillance data

ObjectivesBlack Africans are one of the key risk groups for HIV in the UK and, among those living with HIV, an estimated 16% and 12% of black African heterosexual men...

Chlamydia diagnosis rate in England in 2012: an ecological study of local authorities

ObjectivesLocal authorities (LAs) in England commission chlamydia screening as part of the National Chlamydia Screening Programme. It is recommended that LAs achieve a chlamydia diagnosis rate of ≥2300 cases per...

Gardnerella vaginalis and Mollicute detection in rectal swabs from men who have sex with men.

The numbers of rectal sexually transmitted infections are on the rise especially among men who have sex with men. Males from men who have sex with men population are encouraged to send a rectal swab to the laboratory for sexually transmitted infection screening at their visit to the Genitourinary Medicine Clinic. In healthy asymptomatic males, the range of pathogens tested is limited therefore other pathogens may be left untreated allowing infections to persist among sexual partners. Molecular techniques have revolutionarised sexually transmitted infection testing enabling the detection of previously difficult-to-culture pathogens in extra-genital sites and have increased the evidence base for their clinical significance. The present study tests 107 rectal swabs from men who have sex with men negative for Chlamydia trachomatis and Neisseria gonorrhoeae against quantitative polymerase chain reaction (qPCR) assays targeting five common sexually transmitted bacteria which include Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum and Gardnerella vaginalis. The pathogenic role of these five bacteria in men who have sex with men is currently unknown. Amongst the 107 patients, a positive qPCR was obtained respectively for G. vaginalis 89 (83.2%); U. urealyticum 26 (24.3%); M. hominis 26 (24.3%); M. genitalium 10 (9.3%) and U. parvum 5 (4.7%). Bacterial loads in single and co-infections were compared for each organism. G. vaginalis and M. hominis loads were significantly ( p = 0.007 and p = 0.005, respectively) higher when co-infecting with at least one other organism. Amongst co-infections, the loads of each organism were assessed to determine possible synergies. G. vaginalis and M. hominis displayed a synergistic pattern ( r = 0.51; p = 0.02) which is in keeping with a similar synergy detected previously in the vagina of women with bacterial vaginosis. This study outlines that potential significant infections are being missed in men who have sex with men population; however, further research is warranted to confirm a pathogenesis in the rectal mucosa before routine screening can be introduced to clinical settings.

Ureaplasma parvum and Mycoplasma genitalium are found to be significantly associated with microscopy-confirmed urethritis in a routine genitourinary medicine setting.

Inflammation of the urethra defined by an excess of polymorphonuclear leukocytes in the absence of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae is called non-chlamydial non-gonococcal urethritis (NCNGU). Although Mycoplasma genitalium is now recognised as causing a sexually transmitted infection, the clinical significance of the other Mollicute species is less clear. This study used specific real-time quantitative polymerase chain reaction assays to detect and quantify four Mollicute species, M. genitalium, M. hominis, Ureaplasma urealyticum and U. parvum, in urine specimens from men with and without NCNGU. A total of 165 urine specimens from male patients attending a genitourinary medicine clinic were eligible for the study, with microscopy-confirmed (≥5 polymorphonuclear leukocytes in urethral swab) NCNGU in 75 (45.5%) and non-confirmed NCNGU in 90 (54.5%). Chi-squared statistical analysis indicated a significantly higher prevalence of U. parvum (17.3% vs. 5.6%; p = 0.03) and M. genitalium (12% vs. 0%; p < 0.001) in NCNGU. In a subset analysis, M. genitalium was also significantly (p = 0.03) higher in men who have sex with men (MSM; 13.5%) compared to non-MSM (3.1%). No significant associations were reported for U. urealyticum and M. hominis In conclusion, this study supports a clinically significant role in NGNCU for both U. parvum and M. genitalium.

Prevalence of hepatitis B and hepatitis C in a UK genitourinary medicine clinic.

National guidelines state that hepatitis B and C testing should be targeted to those with risk factors. However, there is little data to support this recommendation. There is also limited data of viral hepatitis prevalence in attendees at genitourinary medicine clinics. We report the prevalence of hepatitis B infection in an unselected genitourinary medicine population, and hepatitis C directed by risk assessment including all men who have sex with men. Routinely collected clinic data from statutory returns was combined with laboratory test result data. Clinical notes of those testing positive were reviewed to determine risk factors and HIV status. HBsAg was positive in 13 (0.2%) of 6020 patients and hepatitis C Ab/Ag in 12 (1.0%) of 1153. All patients who tested positive for viral hepatitis infection had risk factors that would have prompted testing under national guidelines. Five of the 12 with positive hepatitis C Ab/Ag (0.4% of those tested) tested positive for hepatitis C RNA, indicating current infection. The prevalence of hepatitis B and C were in line with previously published data. Our results do provide support for the basis of targeted testing for viral hepatitis, as stipulated in national guidelines, in that all patients testing positive had risk factors.

Decline in genital warts diagnoses among young women and young men since the introduction of the bivalent HPV (16/18) vaccination programme in England: an ecological analysis

BackgroundFor several decades, diagnoses of genital warts at genitourinary medicine (GUM) clinics in England had been increasing. In 2008, a national human papillomavirus (HPV) vaccination programme was introduced using the...