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United Kingdom

Is the UK meeting its national guidelines for HIV testing of MSM?

9 May, 16 | by Leslie Goode, Blogmaster

The potential role of frequent HIV testing in curbing the HIV epidemic among the MSM population has long been recognized. The introduction of the strategy of ‘opt-out’ testing in the UK (2007), as in other countries at around the same time, brought a steep rise in testing, followed by stabilization (McDaid & Hart (STIs); Saxton & Hughes (STIs) (for New Zealand); Heijman & Prins (STIs)  (Netherlands)), and may now ‘have reached its limit in maximizing routine uptake’ (McDaid & Flowers).  Nonetheless, amongst UK MSM at least, HIV incidence is not declining.  UK guidelines currently recommend annual HIV testing for MSM, and three-monthly testing for those ‘at higher risk’.  But how far are these goals being met?  An audit conducted in UK GUM clinics (Desai & Suillivan/STIs) was reassuring;  but a recent (2013) cross-sectional survey of gay bars in Glasgow reports levels of HIV testing over the previous six months of only 37%, and a relatively high proportion of ‘high-risk’ takers figuring among those who had never tested (OR: 0.51)( McDaid & Flowers (STIs)).

Last month saw the publication of study (McDaid & Flowers (M&F)) based on data from three cross-sectional surveys – Glasgow/Edinburgh gay commercial venues; an internet-based Scotland-wide survey; London gay social venues – and including 2409 MSM in total.  Frequency of testing was reckoned over a two-year period, and classified as ‘one or less’, ‘two or three times’, or ‘four or more times’.  On this basis, the study estimates the proportion testing annually at only 54.9%  – and the proportion of those reporting higher risk unprotected anal intercourse (UAI) (=37.8% of the total) who tested four or more times at only 26.7%.  So neither in respect to MSM in general, nor in respect to those ‘at high risk’ are the UK national guidelines being met.  Moreover, involvement in higher risk UAI – unlike number of sexual partners and AI partners – turns out not to be significantly correlated with the highest rates of testing; while more of those reporting higher risk activities claimed to have tested as a result of a perceived risk event, rather than as part of a regular check-up.  The authors conjecture the episodes of higher risk UAI may have been less frequent events (albeit reported by a third of participants) after which the participants, being risk-aware, took appropriate preventative action.  This seems a plausible interpretation.

Studies of HIV testing in other countries published in STI Journal seem to show a broadly comparable situation, with testing levels for MSM and high-risk MSM consistently falling short of respective national guidelines.  Thus Saxton & Hughes (STIs) in location based surveys in Auckland report levels of MSM annual testing rising slowly to 50% in 2011; while Guy & Hellard (STIs) surveying testing in Australian GP clinics give figures for annual testing by MSM, and high-risk MSM, of 35% and 15% respectively as of 2010.  As for the US, Katz & Stekler (STIs) report levels of annual testing of 77%, but, as the location of this survey was GP clinics, an appropriate UK comparator would be the study reported by Desai & Suillivan/STIs, which reports levels of 92%.

In their recommendations M&F stress the importance of reducing the known barriers to HIV testing, and also draw our attention to the key role that testing will have in facilitating the effectiveness of future PrEP interventions, given the need for participants in PrEP to have an accurate knowledge of their HIV status.

 

 

Reported 86% effectiveness for MSM PrEP by PROUD study makes this intervention a viable option for UK health services

25 Mar, 15 | by Leslie Goode, Blogmaster

The Conference on Retroviruses and Opportunistic Infections has recently taken place.  At that event the UK PROUD (PRe-exposure Option for reducing HIV in the UK: immediate or Deferred) study of pre-exposure prophylaxis (PrEP) for MSM reported its results, prior to publication in the coming months.  The headline figure is an astonishing 86% for the reduction of risk of infection in the intervention group.  Hitherto, results of PrEP trials, largely conducted in Africa, have often been disappointing.  This is probably on account of poor adherence (VOICE D( STI/blog); Haberer & Bangsberg (STI/blog); Hendrix & Bumpus (STI/blog)).  The good result achieved here is no doubt attributable to good adherence.  It demonstrates, as these earlier trials have not, the true effectiveness of PrEP.

The UK trial included 545 participants at 13 practices. 276 were randomized to receive PrEP immediately, while the remaining 269 received it after a year.  Earlier PrEP trials have been blind and placebo-controlled.  But this design had the advantage of demonstrating the effectiveness of PrEP in real life. The participants were aware if they were taking the active drug and could have changed their sexual behaviour accordingly.  Given one of the major concerns around PrEP is that of risk compensation – i.e. taking advantage of the protection of PrEP to engage in more risky behaviour than they would otherwise (Marcus & Grant (STI/blog); Baeten & Celum (STI/blog)) – this was a valuable aspect of the trial.

In the period to October 2014, there were 22 HIV infections – 3 in the immediate, and 19 in the deferred group.  This gives us the headline figure of 86%.  At this point, ethical considerations dictated that the study design be changed so all participants received PrEP from then on.  Initially, this study was intended to be a pilot, and to be followed by a larger scale trial.  The decisiveness of the interim findings, however, led to cancellation of that further study.  (For an interesting commentary on the need for researchers to keep pace with changing ethical parameters, see Cohen & Sugarman (STI/blog)).  Cost-effectiveness analyses are apparently underway.  No details are given in the report.  But evidently the high effectiveness observed in the study will allow investigators to present a far more positive case for PrEP than has been warranted by earlier trials (see Borquez & Hallett (STI); Gomez & Hallett (STI/blog); Cremin & Garnett (STI)).  They are also working with stakeholders on how PrEP services could be commissioned across NHS and local authorities.

Training for sexual health and HIV gets the online treatment

17 May, 10 | by John Evans-Jones, STI Blogmaster

By Harriet Smith at Munro and Forster, on behalf of the British Association for Sexual Health and HIV ( BASHH):

A free and comprehensive online resource supporting specialist training in sexual health and HIV was launched today (22nd April) at the Second Joint Conference of BASHH with the British HIV Association.

eHIV-STI, e-Learning for Sexual Health and HIV, has been developed by the British Association for Sexual Health and HIV (BASHH) in partnership with the Royal College of Physicians and Department of Health e-Learning for Healthcare.  It has been designed to reflect the UK sexual health and HIV specialist medical training curriculum and is suitable for all those involved in treating and supporting people with sexually transmitted infections.

Dr Jackie Sherrard, Clinical Project Lead said, ‘With increasing numbers of healthcare professionals involved in the management of STIs, it is important that we continue to provide high quality and innovative education and training resources. eHIV-STI is one such resource that we are proud to offer. It is an essential knowledge framework written by senior clinicians and provides flexible learning to fit in with busy working schedules.’

For more information on the e-learning visit www.eHIV-STI.com or email HIV-STI.support@e-lfh.org.uk.

PRESS CONTACT DETAILS:

For further information, please contact Harriet Smith, on behalf of BASHH at Munro and Forster, harriet.smith@munroforster.com or 020 7815 3905

Are the new Standards for Managing STIs a good thing?

31 Mar, 10 | by John Evans-Jones, STI Blogmaster

Front Cover

Source: medFASH

This month`s journal sees a stirring editorial by Dr. Celia Skinner (1) in support of the new UK standards for the management of Sexually Transmitted Infections ( 2), published by the medical sexual health charity “MedFASH” in collaboration with all the major players in the field. Many would see such a document as being rather dry but like Dr. Skinner I see it as a real opportunity. The internal market in healthcare within the UK National Health Service (NHS) can often seem to divide clinicians who could be working together for patients. The standards attempt to prise us apart from our economic sparring to look at the bigger picture.

The NHS “commissioning” process has had the potential to squeeze out those with more specialist expertise in sexually transmitted infection care in favour of greater population coverage from ( cheaper ) non-specialist services. The standards acknowledge this trend  to be appropriate in part but with the proviso that there remains a specialist – possessing a UK “Certificate of Completion of Training (CCT) in Genitourinary Medicine (GUM)- at the hub to deliver complex STI care ( termed “Level 3 “). It also reinforces and advances the patient safety and care quality movement which has existed in UK healthcare since the scandals of the 1990s.

These standards are potentially a  massive boost to our ability in the NHS  to provide high quality sexual health care in a unified manner. Of course, they are not legally binding so will require passion and vision for us to go beyond local squabbles to look after our patients better. Indeed the Australian Sexual Health Clinician Chris Fairley, who also writes an editorial in this issue (3), believes that their impact might even be international. I therefore call upon my UK colleagues in the field to keep an open mind and let the this document into their hearts !

  1. Standards for the management of sexually transmitted infections (STIs). British Association for Sexual Health and HIV (BASHH) / Medical Foundation for AIDS and Sexual Health (MedFASH). January 2010. http://www.medfash.org.uk/activities/activities.html#BASHH
  2. Standards for the Management of Sexually Transmitted Infections: will they have an impact ? Skinner C. Sex Transm Infect 2010;86:81-82. http://sti.bmj.com/content/86/2/81.extract
  3. An international perspective of the newly published Standards for the Management of STIs. Fairley C. Sex Transm Infect 2010:86:80-81 http://sti.bmj.com/content/86/2/80.extract

Time to improve HIV testing and recording of HIV diagnosis in UK primary care – a response

8 Feb, 10 | by Craig Raybould, Journal Manager

Please see letter below from Surinder Singh in response to the article

Richard Ma
Time to improve HIV testing and recording of HIV diagnosis in UK primary care

Sex Transm Infect 2009; 85: 486
http://sti.bmj.com/cgi/content/extract/85/7/486

Richard Ma makes some excellent points in his editorial (1). I would like to ‘correct’ a misperception but add to the current debate about HIV-testing and subsequent care within UK general practice. Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to remember, the serious debate began when patients with HIV and AIDS were denied local services and traditional primary care, particularly when entering the terminal stages of their illness (2). It was also apparent that patients living in one part of the country but receiving care in London were having problems accessing general practitioner (GP)-type services (3). It is true that HAART seemed to focus the mind – it became fairly obvious that prescribing could be one of the facets of care which could be examined in the “shared-care” process. However, in the present context let’s examine some of the dynamics in shared care. Primary care is undoubtedly becoming more involved in the care of patients with HIV/AIDS though it has been argued that general practice could still do more (4), for example in trying to uncover the unidentified 21000 people with HIV infection in the UK (5). Yet up to now the problem has been that patients have liked the highly successful hospital model, a model that has either implicity or in some cases explicity “taken over” GP care. In truth this gold standard model is not sustainable and this is the reason why general practice has to be more involved. The barriers to full primary care involvement have been outlined before (1,3,4) but patient fears about disclosure, confidentiality and stigma are still present. Things change in general practice as they do in Medicine; early in the UK it would necessarily take an hour to ‘counsel’a patient about an HIV test, now we can do the test in the privacy of our consulting room and give the result to the patient 2 minutes later (we are about to embark on point-of-care testing in our practice). The real questions are these: (a) How can we expect a more pressured primary (6) to take up the challenge of increasing testing when the priorities within general practice seem to increase all the time (6). Furthermore it is appropriate to be mindful of the often complex needs of the various heterogenous groups which are affected by HIV infection (gay men, African men, women and children, drug-users)? As the recent research paper states “further work is needed on the mechanisms required to deliver increased HIV testing in primary care”(7). (b) Next and increasingly important especially if more cases of HIV infection are uncovered in GP, what is the optimal location for a systematic approach to HIV/AIDS – the chronic condition? In other words what system or systems will be responsible for regular patient monitoring of CD counts & viral loads, surveillance of cervical smears and perhaps immunisations as well as offering basic prevention activities, for example smoking cessation advice in those already at higher risk of ischaemic heart disease? References:

1. Ma, R. (Editorial) Time to improve HIV testing and recording of HIV diagnosis in UK primary care: Sex Transm Infect 2009;85:486 doi:10.1136/sti.2009.038091

2. Smits,A., Mansfield,S., Singh,S. (1990). Facilitating care of patients with HIV infection by hospital and primary care teams. British Medical Journal 300, 241-243. ISSN: 0959-8146 3. Mansfield,S., Singh,S. (1993). Who should fill the care gap in HIV disease? Lancet 342(8873), 726-728. ISSN: 0140-6736

4. Singh,S., Dunford,A., Carter,Y.H. (2001). Routine care of people with HIV infection and AIDS: should interested general practitioners take the lead? British Journal of General Practice 51(466), 399-403. ISSN: 0960 -1643

5. Health Protection Agency. HIV in the United Kingdom: 2009 Report. 2009, London, Health Protection Agency also available athttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1227515298354 (accessed 7.1.2010)

6. Oakeshott, P; Aghaizu A; Prime, K; Hay P. Promoting long acting reversible contraception & HIV-testing: more work for harassed GPs. BJGP (2009) Vo 59 (569) 895-6 7. Evans HER, Mercer CH,Rait G et al. Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005. Sex Transm Infect 2009;85:520-6.

Conflict of Interest:

None declared

Chlamydia screening at the crossroads

11 Jan, 10 | by Jackie Cassell, Editor of STI

As financial screws tighten, and a general election approaches, British clinical readers are expecting lean times ahead.   Services for sexually transmitted infections (STI) are unlikely to get major billing in party manifestoes, and political support tends to be driven by committed individuals rather than public demand.

These are particularly interesting times for England’s National Chlamydia Screening Programme (NCSP).  The programme has been the subject of a report by the National Audit Office, followed by a hearing of Parliament’s Public Accounts Committee before the Christmas break.

The NCSP was announced in 2003, and differed from pilot studies in several respects.  Both English pilots(1,2,3) had achieved high rates of coverage within their single year of operation, with general practice a predominant setting, and using some form of payment for general practitioners who participated, while only one(3) had included males in the target group.

During the financial year April 2008-2009 an estimated 15.9% of England’s 6.7M 15-24 year old population had been tested for Chlamydia outside specialist genitourinary medicine clinics – still far short of the estimated one third which was achieved in the pilots and thought to be needed to achieve a real impact on incidence.    However, whatever happens now the programme will continue to have a major impact on the organisation of sexual health services.  The dissemination of testing into family planning (contraception) clinics, other young people’s services and increasingly into general practice has already mainstreamed awareness of STIs among the public and professionals. The next few months will be crucial in defining public policy on the balance and relationship between the NCSP (simple service, high throughput) and specialist STI services (complex and expensive, and focussing on the needs of individuals of higher than average risk behaviour or worse than average luck).

The NCSP was criticised by the National Audit Office(4 ) for multiple and weak branding, disorganised and cost-inefficient commissioning, and highly variable partner notification (and even treatment) rates. The report is definitely worth a read, along with its sister publication – a report on the NCSP to the Department of Health by Dr Ruth Hussey. The NCSP was implemented in a period of increasing devolution of a wide range of healthcare resource decisions to local areas, with pressure applied where needed by blunt instruments such as the “Vital Signs Indicator” which last year set a standard of 17% coverage for the NCSP .  In this respect, its difficulties  are likely to be a wider sign of the times as suggested by the Chair of the Public Accounts Committee, who remarked in closing: “What went wrong? You ploughed ahead with local, fragmented implementation, the programme has been inefficient, it has wasted public funds and each programme has been buying its own kit, devising its own marketing and websites.

Although the Public Accounts Committee’s recommendations are not yet published, a flavour of what we can expect can be inferred from a webcast of the hearing at http://www.parliamentlive.tv/Main/Player.aspx?meetingId=5227 or, if you prefer the written word, at http://www.publications.parliament.uk/pa/cm/cmpubacc.htm#uncorr

A more coherent branding and commissioning of the NCSP will have implications for the branding, and prioritisation, of more specialist STI services. Clinicians and providers will need to think and advocate long and hard for a locally effective the future balance between the NCSP (whatever form it may take), and the broader picture of services for STIs, including specialist services. Who and what will they be for, if everyone offers a yearly chlamydia test?

4. National Audit Office:  Young People’s Sexual Health. http://www.nao.org.uk/publications/0809/young_peoples_sexual_health.aspx
5. Dr Ruth Hussey.  Review of the National Chlamydia Screening Programme.  Crown publication, London, 2009. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_108285

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