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

A comprehensive overview by region of condoms, natural family planning, and spermicide as a contraceptive method among men aged 13-54 years attending contraceptive services in England

OBJECTIVES

This study aimed to (1) provide a comprehensive overview of contraceptive methods self-reported by men in England, over 5 years, focusing on condoms in comparison to any male method; and (2) explore condom as a contraceptive method by region and ethnicity.

STUDY DESIGN

Data were from the Sexual and Reproductive Health Services (Contraception) England census data set from 2014/15 to 2018/19. Once missing data were removed, this left a total of 365,292 men. Two binomial logistic regression models were performed. Model 1 examined ethnicity, region, and time on condom as a method of contraception; and Model 2 examined ethnicity, region, and time by any male contraceptive. Descriptive statistics were run for natural family planning and spermicide.

RESULTS

Model 1 revealed a significant model, χ² (15) = 30,976, P < 0.001, and predicted that condoms as a method decreased in London with a greater decrease in Midlands. London saw the lowest rate of decline among the non-White ethnic group, whereas North and South regions increased probability over time. The North started at a higher probability and the South at the lowest. Model 2 also revealed a significant model, χ² (15) = 32,472, P < 0.001, with a similar pattern to Model 1. Contingency tables showed natural family planning and spermicide were the least reported methods and decreased over time.

CONCLUSIONS

As any male contraceptive method appears to be decreasing in both models, reproductive health promotion is required. This study has implications for commissioning funds and for identifying regional areas of further investigation.

Introducing video consultations at public sexual health clinics in the Netherlands: a mixed-methods study

Video consultations (in combination with remote STI testing) can benefit both public sexual health clinics (SHCs) and their clients. The Dutch public SHCs explored the extent to which video consultations are accepted and appreciated—compared to face-to-face consultations—by both young clients (under 25 years) and nurses who normally carry out consultations. A mixed-methods study, using online questionnaires and telephone interviews with both young clients (aged under 25 years) and nurses (focus groups), was conducted to evaluate acceptance and appreciation of video and face-to-face consultations of the SHCs. Young clients evaluated 333 video consultations and 100 face-to-face consultations. Clients rated the VCs and F2F consultations as being of equal high level on five evaluation criteria (e.g. how it feels to talk about sex with a nurse, contact with the nurse). These positive results were confirmed in the interviews. Most important perceived advantages of VCs were time saving, ease, and feelings of comfort and safety. The nurses evaluated 422 VCs and 120 F2F consultations, rating the VCs and F2F consultations on an equal high level on three evaluation criteria (e.g., contact with the client, possibility to continue asking questions). Increasing accessibility of SHC consultations, getting faster to the point and saving time were mentioned as advantages of VCs during the focus group sessions with nurses. Video consultations are accepted and appreciated by young clients and nurses. They can be used for standard STI consultations that do not require a physical examination.

Sexual behaviours and sexual health among middle-aged and older adults in Britain

OBJECTIVES

Population-representative studies of the sexual health of middle-aged and older adults are lacking in ageing societies. This study aimed to identify latent patterns of sexual behaviours and health of people aged 45-74 years.

METHODS

We conducted a latent class analysis of the National Attitudes and Sexual Lifestyles Survey (Natsal-3), a nationally representative survey conducted in Britain in 2011.

RESULTS

Of the 5260 respondents aged 45-74 years, 48.86% of men and 44.91% of women belonged to the Content Caseys class who reported good sexual health. The Infrequent Indigos (30.94% of men, 44.38% of women) were characterised by a lack of sexual activity, reported some dissatisfaction, and were more likely to have a disability. The Low-Functioning Lees (11.65% of men, 8.41% of women) reported some more disability and had issues with sexual functioning and higher levels of distress. The Multiple-Partnered Morgans (8.62% of men, 2.30% of women) were characterised by a greater number of sexual partners and several risk behaviours.

CONCLUSIONS

The use of these four classes can aid in improved targeting of tailored sexual health services to improve sexual function, sexual satisfaction, reduce distress and risky behaviours among middle-aged and older adults. These services should be inclusive of the disabled community.

Consultation rate and chlamydia positivity among ethnic minority clients at STI clinics in the Netherlands

Objectives

Although ethnic minority clients (EMs) from STI endemic countries have a higher risk for STI, little is known about their STI clinic consultation rate proportionality. The aim of this study was to assess consultation and chlamydia positivity rates among different EMs visiting STI clinics in the Netherlands.

Methods

We calculated consultation rates in EM groups by dividing the number of STI consultations by the total number of inhabitants in the region belonging to an EM, then compared the EM rates to native Dutch rates. Factors associated with chlamydia positivity were analysed using multivariate regression analysis.

Results

A total of 23,841 clients visiting an eastern Netherlands STI clinic between 2011 and 2013 were included in the analysis, of which 7% were EMs. The consultation rate of native Dutch clients was 22.5 per 1000, compared to 8.5 per 1000 among EMs. Consultation rates in all EMs were lower than in Dutch clients, except for Antillean or Aruban EMs and Latin American EMs.

The chlamydia positivity rate among all clients was 15.5%, and Antillean or Aruban ethnicity (27.1%) EMs had the highest rates. Multivariate analysis identified the following factors associated with chlamydia positivity: Eastern or Northern European EM, African EM, Antillean or Aruban EM, STI related symptoms, heterosexual preference, partner in a risk group, receiving a partner notification, and having had three or more partners in the past six months.

Conclusion

On a population level, most EMs visit STI clinics less often than native Dutch clients, but they have a higher rate of positive chlamydia diagnoses. STI clinics should increase outreach activities for EM clients because they are insufficiently reached by current practices, but contribute substantially to chlamydia incidence rates.

Recreational drug use and use of drugs associated with chemsex among HIV-negative and HIV-positive heterosexual men and women attending sexual health and HIV clinics in England

Background

There is little information on the prevalence of recreational drug use among UK heterosexual men and women, in particular on use of drugs associated with ‘chemsex’ within gay communities. The aim of this study was to examine among HIV-negative and HIV-positive heterosexual men and women in England: (i) the prevalence of recreational drug use (including use of drugs associated with chemsex), (ii) socio-economic/lifestyle correlates of drug use, and (iii) the association of drug use with sexual behavior measures and mental health symptoms.

Methods

Data are from the AURAH study of HIV-negative individuals attending sexual health clinics across England (2013–2014) and the ASTRA study of HIV-positive individuals attending HIV outpatient clinics in England (2011–2012). Prevalence of recreational drug use (past three months) and associations are presented separately among the four sample groups: HIV-negative (N = 470) and HIV-positive (N = 373) heterosexual men and HIV-negative (N = 676) and HIV-positive (N = 637) women.

Results

The age standardized prevalence of any drug use was 22.9%, 17.1%, 15.3%, and 7.1% in the four sample groups respectively. In all groups, cannabis was the drug most commonly used (range from 4.7% to 17.9%) followed by cocaine (1.6% to 8.5%). The prevalence of use of drugs associated with chemsex was very low among HIV-negative participants (1.0% heterosexual men, 0.2% women) and zero among HIV-positive men and women. In age-adjusted analysis, factors linked to drug use overall and/or to cannabis and cocaine use specifically in the four sample groups included Black/mixed Caribbean and white (vs. Black/mixed African) ethnicity, lower level of education , cigarette smoking, and higher risk alcohol consumption. Associations of recreational drug use with measures of condomless sex, depression, and anxiety were observed in the four groups, but were particularly strong/apparent among women.

Conclusion

Providers need to be aware of cannabis and cocaine use and its potential link with sexual risk behavior and symptoms of depression and anxiety among heterosexual men and women attending sexual health and HIV clinics.

Surveying testing preferences in Black, Latin American, and other minorities for the co-design of digital vending machines for HIV self-testing

The use of digital vending machines (VMs) to delivery HIV self-testing (HIVST) could expand HIV testing in priority populations. We surveyed primarily Black African (BA) participants and other minority ethnicities, to identify acceptability, preferences, and concerns of using VMs for HIVST dispensing. A structured survey was developed with Black African and Caribbean, Latin American and other Minorities (BLAM) communities, and distributed between September 2018 and January 2019. Participants were recruited using mobile tablet surveys distributed by outreach volunteers, and online through BLAM communities’ websites, workshops, and language-specific messages on social media. Descriptive analyses were undertaken stratified by ethnic groups. One hundred and twenty-eight (67.0%) participants identified as BAs, 31 (16.2%) Black Caribbeans (BCs), 22 (11.5%) Latin Americans (LAs), and 10 (5.2%) other non-white ethnicities (ONWEs). Rates of willingness to use the HIVST were high in all groups except BCs (BAs 77.9%, BCs 53.6%, LAs 81.8%, ONWEs 80.0%). Most participants favoured healthcare-associated venues for VM placement, but there were differences in community venues favoured by different ethnic groups and concerns reported. HIVST is acceptable in many BLAM communities and increases understanding of the concerns and how to address them in the design of VMs for HIVST, to expand HIV testing in these priority communities.

A Multidimensional Approach to Assessing Infectious Disease Risk: Identifying Risk Classes Based on Psychological Characteristics

Prevention of infectious diseases depends on health-related behavior, which is often influenced by psychological characteristics. However, few studies assessing health-related behavior have examined psychological characteristics to identify risk groups, and this multidimensional approach might improve disease risk assessment. We aimed to characterize subgroups based on psychological characteristics and examine their influence on behavior and disease risk, using chlamydia as a case study. Selected participants (heterosexuals aged 18–24 years and females aged 18–24 years who had sex with both men and women) in a Dutch longitudinal cohort study (the Mathematical Models Incorporating Psychological Determinants: Control of Chlamydia Transmission (iMPaCT) Study) filled out a questionnaire and were tested for chlamydia (2016–2017). Latent class analysis was performed to identify risk classes using psychological predictors of chlamydia diagnosis. Two classes were identified: class 1 (n = 488; 9% chlamydia diagnosis) and class 2 (n = 325; 13% chlamydia diagnosis). The proportion of participants with high shame, high impulsiveness, and lower perceived importance of health was higher in class 2 than in class 1. Furthermore, persons in class 2 were more likely to be male and to report condomless sex compared with class 1, but the number of recent partners was comparable. Thus, risk classes might be distinguished from each other by psychological characteristics beyond sexual behavior. Therefore, the impact of the same intervention could differ, and tailoring interventions based on psychological characteristics might be necessary to reduce chlamydia prevalence most effectively.

Ethnic variations in sexual partnerships and mixing, and their association with STI diagnosis: findings from a cross-sectional biobehavioural survey of attendees of sexual health clinics across England

OBJECTIVES

Ethnic differences in partnership types and sexual mixing patterns may contribute to elevated STI diagnosis rates among England's Black Caribbean (BC) population. We examined the differences between BC and White British/Irish (WBI) sexual health clinic (SHC) attendees' reported partnerships and sexual mixing, and whether these differences could explain ethnic inequalities in STI, focusing on attendees reporting only opposite-sex partners (past year).

METHODS

We surveyed attendees at 16 SHCs across England (May to September 2016), and linked their survey responses to routinely collected data on diagnoses of bacterial STI or trichomoniasis ±6 weeks of clinic attendance ('acute STI'). Behaviourally-heterosexual BC and WBI attendees (n=1790) reported details about their ≤3 most recent opposite-sex partners (past 3 months, n=2503). We compared BC and WBI attendees' reported partnerships and mixing, in gender-stratified analyses, and used multivariable logistic regression to examine whether they independently explained differences in acute STI.

RESULTS

We observed differences by ethnic group. BC women's partnerships were more likely than WBI women's partnerships to involve age-mixing (≥5 years age difference; 31.6% vs 25.5% partnerships, p=0.013); BC men's partnerships were more often 'uncommitted regular' (35.4% vs 20.7%) and less often casual (38.5% vs 53.1%) than WBI men's partnerships (p<0.001). Acute STI was higher among BC women than WBI women (OR: 2.29, 95% CI 1.24 to 4.21), with no difference among men. This difference was unaffected by partnerships and mixing: BC women compared with WBI women adjusted OR: 2.31 (95% CI 1.30 to 4.09) after adjusting for age and partner numbers; 2.15 (95% CI 1.07 to 4.31) after additionally adjusting for age-mixing, ethnic-mixing and recent partnership type(s).

CONCLUSION

We found that differences in sexual partnerships and mixing do not appear to explain elevated risk of acute STI diagnosis among behaviourally-heterosexual BC women SHC attendees, but this may reflect the measures used. Better characterisation of 'high transmission networks' is needed, to improve our understanding of influences beyond the individual level, as part of endeavours to reduce population-level STI transmission.

HIV Testing and Sexual Health Among Black African Men and Women in London, United Kingdom

Importance

Black African adults are disproportionately affected by HIV in the United Kingdom. Many within this population acquire HIV after migration or are diagnosed late. Data are needed to inform targeted interventions to increase HIV testing and prevention in this population.

Objective

To inform future HIV prevention strategies by estimating diagnosed and undiagnosed HIV infection and measuring changes in HIV testing rates in black African adults in London, United Kingdom.

Design, Setting, and Participants

This cross-sectional study used a self-completed survey conducted from September 20 to December 3, 2016. Questionnaires were linked to an optional, anonymous oral fluid HIV test and compared with data from a previous survey (2004). Respondents were recruited from social and commercial venues frequented by black African adults in London. Of 2531 individuals approached in 63 venues, 752 agreed to participate. Data were analyzed initially in March 2017 (as part of internal reporting) and again in August 2018.

Main Outcomes and Measures

Self-reported HIV testing within the past 5 years; diagnosed and undiagnosed HIV prevalence. Logistic regression examined factors associated with HIV testing by sex.

Results

In total, 292 women (median [interquartile range] age, 31 [25.0-41.5] years) and 312 men (median [interquartile range] age, 35 [25.0-41.5] years) were included in the analysis. More than half of men (159 [51.0%]) and women (154 [52.7%]) had been tested for HIV in the past 5 years. In multivariable analysis, HIV testing was associated with a range of factors in both sexes, including health service attendance, time in the United Kingdom, and sexually transmitted infection diagnosis. Increases in HIV testing in the past 5 years were observed between 2004 and 2016 for both sexes. In the 2016 sample, 219 of 235 women (93.2%) and 206 of 228 men (90.4%) tested HIV negative. Among those testing positive, 56.3% of women (9 of 16) and 40.9% of men (9 of 22) self-reported as HIV negative or untested, indicating they were living with undiagnosed HIV. A fifth of women (20.7%) and 25.0% of men reported condomless last sex with a partner of different or unknown HIV status in the past year.

Conclusions and Relevance

Despite efforts to increase HIV testing, uptake in black African communities in London remains modest. This study identified a large fraction of undiagnosed infection-greater than other at-risk populations-suggesting that the prevention and care needs of this group are not adequately met.