The ECHELON-2 Trial: 5-year results of a randomized, phase 3 study of brentuximab vedotin with chemotherapy for CD30-positive peripheral T-cell lymphoma

Background:

For patients with peripheral T-cell lymphoma (PTCL), outcomes using frontline treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like therapy are typically poor. The ECHELON-2 study demonstrated that brentuximab vedotin plus cyclophosphamide, doxorubicin, and prednisone (A+CHP) exhibited statistically superior progression-free survival (PFS) per independent central review and improvements in overall survival versus CHOP for the frontline treatment of patients with systemic anaplastic large cell lymphoma or other CD30-positive PTCL.

Patients and methods:

ECHELON-2 is a double-blind, double-dummy, randomized, placebo-controlled, active-comparator phase III study. We present an exploratory update of the ECHELON-2 study, including an analysis of 5-year PFS per investigator in the intent-to-treat analysis group.

Results:

A total of 452 patients were randomized (1 : 1) to six or eight cycles of A+CHP (N = 226) or CHOP (N = 226). At median follow-up of 47.6 months, 5-year PFS rates were 51.4% [95% confidence interval (CI): 42.8% to 59.4%] with A+CHP versus 43.0% (95% CI: 35.8% to 50.0%) with CHOP (hazard ratio = 0.70; 95% CI: 0.53–0.91), and 5-year overall survival (OS) rates were 70.1% (95% CI: 63.3% to 75.9%) with A+CHP versus 61.0% (95% CI: 54.0% to 67.3%) with CHOP (hazard ratio = 0.72; 95% CI: 0.53–0.99). Both PFS and OS were generally consistent across key subgroups. Peripheral neuropathy was resolved or improved in 72% (84/117) of patients in the A+CHP arm and 78% (97/124) in the CHOP arm. Among patients who relapsed and subsequently received brentuximab vedotin, the objective response rate was 59% with brentuximab vedotin retreatment after A+CHP and 50% with subsequent brentuximab vedotin after CHOP.

Conclusions:

In this 5-year update of ECHELON-2, frontline treatment of patients with PTCL with A+CHP continues to provide clinically meaningful improvement in PFS and OS versus CHOP, with a manageable safety profile, including continued resolution or improvement of peripheral neuropathy.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Improving Patient Flow on Adult Mental Health Units: A multimodal Study of Canberra Hospital's Acute Psychiatric Facilities

BACKGROUND

Due to increasing demands on limited resources in the health care system, many hospitals are working to improve patient flow, thereby increasing their effective capacity. Identifying barriers to patient flow provides the best available evidence to improve such flow in The Canberra Hospital's acute psychiatric units.

METHODS

This audit uses a multi-method design (combining focus groups, audits of flow in mental health units and retrospective data analysis on a cross-section of patients) to investigate current patterns of patient flow and barriers to discharge through the Canberra Hospital Mental Health Assessment & Adult Mental Health Units, and factors associated with increased length of stay.

RESULTS

Mean LoS for MHAU and AMHU was 8.45 hours and 15 days respectively. Multiple factors were associated with an increased LoS including patient factors, certain hospital processes, and limited availability of community services.

CONCLUSIONS

These findings inform recommendations on improving patient flow and future research to support increases in available funding, staffing and resources.

The effect of cell death in the initiation of lupus nephritis

Cell death and the release of chromatin have been demonstrated to activate the immune system producing autoantibodies against nuclear antigens in patients with systemic lupus erythematosus (SLE). Apoptosis, necrosis, necroptosis, secondary necrosis, autophagy and the clearance of dying cells by phagocytosis are processes believed to have a role in tolerance avoidance, activation of autoimmune lymphocytes and tissue damage by effector cells. The released chromatin not only activates the immune system; it also acts as antigen for the autoantibodies produced, including anti-dsDNA antibodies. The subsequent immune complex formed is deposited within the basement membranes and the mesangial matrix of glomeruli. This may be considered as an initiating event in lupus nephritis. The origin of the released chromatin is still debated, and the possible mechanisms and cell sources are discussed in this study.

A tool to calculate safe nurse staffing levels

A guideline from the National Institute for Health and Care Excellence and a NICE-endorsed tool on safer nursing care allow decisions on safe staffing levels to be made at a local level. Decisions must be based on sound evidence and factoring in patients' individual needs as well as numbers of patients. The Safer Nursing Care Tool helps nurses decide on safe nurse staffing for acute wards based on patients' level of sickness and dependency. It also includes quality indicators linked to nursing care to help ensure staffing levels achieve best patient care. The tool is easy to use by frontline nursing staff, but must be applied correctly and consistently for data to be valid, and to allow benchmarking against agreed standards. It should be combined with nurses' professional judgement and account for local factors.

Learning from the design and development of the NHS Safety Thermometer

Quality issue

Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available.

Initial assessment

We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally.

Choice of solution

We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients.

Implementation

The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method.

Evaluation

Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73 651 patient entries.

Lessons learned

It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.

Psychosocial interventions for suicidal ideation, plans, and attempts: a database of randomised controlled trials

BACKGROUND

Research in suicide prevention using psychosocial interventions is rapidly advancing. However, randomised controlled trials are published across a range of medical, psychological and sociology journals, and it can be difficult to locate a full set of research studies. In this paper, we present a database of randomised controlled outcome studies on psychosocial interventions targeting suicidal behaviour. The database is updated annually and can be accessed by contacting the corresponding author.

DESCRIPTION

A comprehensive literature search of the major bibliographical databases (PsycINFO; PubMed; Cochrane Central Register of Controlled Trials) was conducted for articles published between 1800 to July 30 2013, and examined reference lists of previous relevant reviews and included papers to locate additional references. Studies were included if they featured a randomised controlled design in which the effects of a psychosocial intervention were compared to a control condition (no intervention, attention placebo, wait-list, treatment-as-usual [TAU]), another psychosocial intervention or a pharmacological intervention. In total, 12,250 abstracts were identified. Of these, 131 studies met eligibility criteria and were included. Each paper was then coded into categories of participant characteristics (age, gender, formal diagnosis, primary reason for recruitment); details of the intervention (recruitment setting, content, intervention setting, administering individual, delivery type, delivery format, delivery frequency, delivery length); and study characteristics (control and experimental conditions, primary outcome/s, secondary outcome/s, follow-up period). One paper has been published from the database using studies collected and coded prior to 2012.

CONCLUSION

The database and listing of 131 studies is available for use by suicide prevention researchers. It provides a strong starting point for systematic reviews and meta-analyses of treatments and interventions. It will be updated yearly by researchers funded through the Australian National Health and Medical Research Council Centre for Research Excellence for Suicide Prevention (CRESP), located at the Black Dog Institute, Australia. This database adds to the evidence base of best-practice psychosocial interventions for suicidal behaviour and prevention.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Oligoclonal bands in multiple sclerosis reactive against two herpesviruses and association with magnetic resonance imaging findings

BACKGROUND

Two human herpesviruses, human herpesvirus 6 (HHV-6), and Epstein-Barr virus (EBV), have been repeatedly linked to multiple sclerosis (MS).

OBJECTIVE

The aim of this study was to investigate HHV-6 and EBV reactive oligoclonal bands (OCBs), and viral DNA in the intrathecal compartment in MS.

METHODS

The reactivity of OCBs in cerebrospinal fluid (CSF) for EBV and HHV-6 antigens and stability of virus reactive OCBs over time were studied in a well-characterized MS patient cohort. Associations between virus reactive OCBs and viral DNA in CSF (and any clinical and/or radiological findings) were investigated.

RESULTS

Of patients with MS, 38% had OCBs reactive to either one of the viruses studied, compared to none in the patients with other inflammatory neurological diseases (p=0.005). The banding pattern of virus reactive OCBs remained the same over time. Furthermore, MS patients with viral DNA in CSF had more contrast enhancing lesions (CELs).

CONCLUSION

The stable presence of herpesvirus reactive OCBs in CSF further strengthens the association of MS with these viruses. The finding that herpesviruses might be linked to the appearance of active lesions warrants investigation of new therapeutic strategies to treat these viruses in MS.

Suicide prevention in schizophrenia spectrum disorders and psychosis: a systematic review

BACKGROUND

The incidence of suicide is high among patients with schizophrenia spectrum disorders and psychosis. A systematic review was performed to investigate the effectiveness of psychosocial interventions in reducing suicidal behaviour among patients with schizophrenia spectrum disorders and psychosis.

METHODS

Cochrane, PubMed and PsycINFO databases were searched to January 2012. Additional materials were obtained from reference lists. Randomised Controlled Trials describing psychosocial interventions for psychotic disorders with attention placebo, treatment as usual (TAU), no intervention or waitlist control groups were included.

RESULTS

In total, 11,521 abstracts were identified. Of those, 10 papers describing 11 trials targeting psychosocial interventions for reducing suicidal behaviour in patients with schizophrenia spectrum disorders and psychosic symptoms or disorders met the inclusion criteria. Odds Ratios describing the likelihood of a reduction in suicidal behaviour or ideation ranged from 0.09 to 1.72 at post-test and 0.13 to 1.48 at follow-up.

CONCLUSIONS

Psychosocial interventions may be effective in reducing suicidal behaviour in patients with schizophrenia spectrum disorders and psychosis, although the additional benefit of these interventions above that contributed by a control condition or treatment-as-usual is not clear.

Developing skills in clinical leadership for ward sisters

The Francis report has called for a strengthening of the ward sister's role. It recommends that sisters should operate in a supervisory capacity and should not be office bound. Effective ward leadership has been recognised as being vital to high-quality patient care and experience, resource management and interprofessional working. However, there is evidence that ward sisters are ill equipped to lead effectively and lack confidence in their ability to do so. University College London Hospitals Foundation Trust has recognised that the job has become almost impossible in increasingly large and complex organisations. Ward sisters spend less than 40% of their time on clinical leadership and the trust is undertaking a number of initiatives to support them in this role.

The high impact actions for nursing and midwifery 8: ready to go--no delays

In recent years, discharge initiatives that aim to free up hospital beds have become commonplace. However, new systems, such as bed management, have left many nurses feeling disengaged from the management of patient admission and discharge. They feel pressurised into speeding up discharge by the increasing focus on bed capacity and patient turnover, which can make them feel distanced from their primary role of caring for patients. Although new roles and initiatives can be valuable, changing the way nurses engage with discharge is key. Ensuring that the process is nurse led will lead to a faster discharge and less frustration for patients who are waiting to go home. This article, the last in our series on the high impact actions for nursing and midwifery, looks at how nursing staff can respond to the issue of discharge planning.

The high impact actions for nursing and midwifery. 7: Promoting normal birth

There is significant variation in rates of Caesarean section between maternity units. Higher rates appear to be associated with older mothers and women from certain ethnic groups. However, taking these and other demographic factors into account does not explain the differences between trusts. This eighth article in this series on the high impact actions for nursing and midwifery looks at how midwives and nurses can help to avoid unnecessary Caesarean sections.

The high impact actions for nursing and midwifery 6: where to die when the time comes

Around half of the 500,000 deaths in England each year occur in acute hospitals, while around half of all complaints made to acute trusts relate to an aspect of end of life care. Howaver, research suggest that 40% of people who die in hospital have no medical need to be there, and that 55% of people with cancer would prefer to die at home while only around 25% do so. When people die in hospital despite having a preference to die at home and no medical reason to be in hospital, it causes unnecessary distress to patients and their familes, and is costly to the NHS. This article, the seventh in our series on the high impact actions for nursing and midwifery, looks at how nurses can help to improve end of life care.

The high impact actions for nursing and midwifery 5: protection from infection

Four out of every five urinary tract infections can be traced to indwellng catheters. If the number of these infections is to be reduced significantly, nurses need to implement best practice for catheter care, and only catheterise patients when absolutely necessary.

The high impact actions for nursing and midwifery 4: your skin matters

Pressure ulcers can occur in any patient but are most commonn in high risk groups such as: older people; those who are obese, malnourished orwith continence problems; people with certain skin types; andthose with certain underlying conditions. Pressure ulcers increase morbidityand mortality, and represent a significant proportion of NHS expenditure, yet the vast majority are avoidable. This article, the fifth in our series on the high impact actions for nursing and midwifery, looks at how nurses can prevent pressure ulcers in their patients.

The high impact actions for nursing and midwifery. 3: Staying safe, preventing falls

The National Patient Safety Agency reported 152,000 falls in England and Wales in acute hospitals in 2009, 26,000 in mental health trusts and 28,000 in community hospitals. The number of falls is due to rise in line with increasing numbers of older and frail people who have more complex health needs. Many of these falls are preventable; the challenge for the NHS is to improve patient safety while protecting independence patients' rights to make informed choices.

The high impact actions for nursing and midwifery 2: fit and well to care

Each year in the health service in England, 10.3 million working days are lost to sickness absence (Chartered Institute of Personnel and Development, 2009). This is the equivalent of 4.5% of the current workforce, or 45,000 whole time equivalent nurses. This article, the third in our series on the high impact a actions for nursing and midwifery, looks at how ward managers and team leaders can provide support and information to improve nurses' health and wellbeing.

The high impact actions for nursing and midwifery 1: keeping nourished--getting better

Approximately one in four patients in NIIS hospitals are either malnourished or at risk of malnurition and as much as 70% of malnutrition in acute hospital admission is unrecognised and unmanaged. Although most of those who are malnourished live in the community, malnutrition and dehydration are key challenges for NHS organisations. Well hydrated and nourished patients get better more quickly, have a shorter length of stay and a more positive experience of care. Ensuring patients receive all of the nutrients they need is vital to the delivery of good care. This article, the second in our series on the high impact actions for nursing and midwifery, looks at how nurses can reduce malnutrition in their patients.

How nurses can implement the high impact actions to improve quality and cost effectiveness

In November 2009 the NHS Institute for Innovation and Improvement published a list of eight high impact actions for nursing and midwifery and stated that, if implemented across the NHS, the actions could save over pounds 9 bn a year while improving the quality of care. The NHS Institute has now published a selection of case studies from different settings demonstrating successful initiatives relating to each action and a range of other supporting material. This article, the first in a Nursing Times series summarising the main information on how the high impact actions can be achieved, sets the context for the initiative. Subsequent articles will discuss the individual actions and offer practical information on implementation.

Implementing the eight high impact actions to transform healthcare and boost efficiency

Nurses and midwives could improve care and save billions of pounds a year by implementing the eight high impact actions unveiled by the chief nursing officer for England Dame Christine Beasley in 2009. We explore how staff can implement the actions through leadership and knowledge of change management processes.

Developing, testing and applying instruments for measuring rising dependency-acuity's impact on ward staffing and quality

PURPOSE

This paper aims to explains how relatively simple nurse staffing formulas from "best practice" ward dependency-acuity data can be used for nursing workforce planning and development.

DESIGN/METHODOLOGY/APPROACH

The paper combines literature, detailed ward surveys, workshop and expert group/stakeholder information to generate and test care levels/nurse multipliers for setting ward establishments.

FINDINGS

The paper finds that professional-judgement based ward staffing can be abandoned, while complex acuity-quality, timed-task and regression-based nurse staffing algorithms for setting ward establishments may be unnecessary since the new multipliers, underpinned by robust validity and reliability testing, seem to be remarkably accurate nurse-staffing determiners at a fraction of the cost.

RESEARCH LIMITATIONS/IMPLICATIONS

As care levels and multipliers stand they are suitable only for UK National Health Service acute wards. Primary care, mental health, learning disability and other specialist group care levels and multipliers need developing.

PRACTICAL IMPLICATIONS

Users, at a minimum, can adopt care level data and multiplier staffing recommendations for benchmarking purposes. Ultimately, the algorithms can be used to: adjust ward establishments according to workload; or set staffing for new, inpatient services.

ORIGINALITY/VALUE

The paper offers a simple system for assessing patients' nursing needs and setting ward staffing accordingly.

Sexual health services for South Asians in London, UK: a case-control study

National guidance on sexual health in England recommends service development to meet the specific needs of ethnic minority populations. Our aim was to evaluate mode of referral, number of sexually transmitted infections (STIs) diagnosed, and the offering and uptake of HIV testing in patients of South Asian ethnicity. A retrospective case-control study was undertaken in two London genito-urinary (GU) medicine clinics. There were 250 case-control pairs with approximately equal numbers of men and women. South Asians were less likely to have an STI (Odds ratio [OR] 0.66, 95% confidence interval [CI] 0.45, 0.97) or to report risk factors for HIV (OR 0.45, 95% CI 0.28, 0.71). Offering and uptake of HIV antibody testing were high in both South Asian and non-South Asian groups (OR 0.62, 95% CI 0.27, 1.51). South Asians were significantly more likely than controls to have been referred by other medical services rather than self-referred (OR 2.00, 95% CI 1.32, 3.01), which is in keeping with poorer access to GU medicine services in London.

Application of a noninvasive oral fluid test for detection of treponemal IgG in a predominantly HIV-infected population

The performance of a time-resolved fluorescence immunoassay (TRFIA) for detection of treponemal IgG from oral fluid specimens has been assessed in a predominantly HIV-infected population. Serological investigation is the method of choice for confirming clinical suspicion of syphilis; however, in the primary stage of disease, direct detection of treponemes in lesion fluid or Treponema pallidum DNA is recommended because of the reduced sensitivity of serological tests. There may be occasions when blood for serological investigation is difficult to obtain due to individual patient preference or logistical necessity to improve participation in screening initiatives, particularly in outreach situations. Collection of oral fluid for detection of treponemal antibody may prove an attractive alternative and, with this in mind, an oral fluid assay for detection of treponemal IgG was developed. Time-resolved fluorescence was used to detect treponemal IgG extracted from commercially available oral fluid collection devices. Paired serum and saliva samples were obtained from 210 individuals, 101 of whom were diagnosed with syphilis on the grounds of medical examination confirmed by serological testing. Oral fluid specimens from 14 subjects were rejected because they contained insufficient control antibody or were inhibitory. The population tested was predominantly men who have sex with men, many of whom were HIV infected. The overall sensitivity and specificity of the oral fluid assay was 95.8 and 86.1%, respectively, based on the 5th percentile of the positive results, and 93.7 and 91.1%, respectively, based on a cutoff derived by mixture model analysis. For individuals with primary syphilis, the optimum sensitivity of the oral fluid assay was 87.5%, whereas in those with disease classified as secondary syphilis and early latent syphilis, the sensitivity of the oral fluid assay was 100 and 94.7%, respectively. The oral fluid assay is a useful alternative to serological testing in certain situations, and further development of this technology to enable detection of treponemal IgM should increase its sensitivity for detecting cases of primary syphilis.

The prevalence of proline iminopeptidase negative Neisseria gonorrhoeae throughout England and Wales

BACKGROUND

The accurate laboratory identification of Neisseria gonorrhoeae is an essential element of the diagnosis of gonorrhoea and is particularly important for medicolegal cases. The detection of proline iminopeptidase (Pip) activity is widely used as a marker for gonococci, although Pip negative N gonorrhoeae isolates have been shown to generate false negative identifications when using biochemical kits. This study aimed to determine the frequency of Pip negative gonococci in England and Wales.

METHODS

A total of 2055 isolates were collected from consecutive patients attending 26 genitourinary medicine centres as part of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). Upon receipt the identity of all isolates was confirmed using N gonorrhoeae specific monoclonal antibodies and the Pip status was determined using the Gonochek II kit.

RESULTS

The overall prevalence of Pip negative isolates was found to be 4.33%. Significant geographical variation was observed between isolates from centres outside London (p< or =0.001). Variation was also observed within London between the nine different clinics submitting isolates (p = 0.025). There was also a higher frequency of these isolates among men who have sex with men (p< or =0.001), which may account for geographical variations.

CONCLUSION

Pip negative N gonorrhoeae isolates are a very serious cause for concern as currently all biochemical test kits available within the United Kingdom require the presence of the Pip enzyme for an unambiguous identification of this pathogen. Raising awareness of the current prevalence of Pip negative N gonorrhoeae isolates is critical for the successful control of gonorrhoea.

Who pays for sex? An analysis of the increasing prevalence of female commercial sex contacts among men in Britain

BACKGROUND

In the United Kingdom the incidence of sexually transmitted infections (STI) and risky sexual behaviours is increasing. The role of commercial sex in this trend is poorly understood. Little is known about the men who pay for sex. We examined the epidemiology of female commercial sex contacts reported by men in 1990 and 2000.

METHODS

National probability sample surveys of sexual attitudes and lifestyles (Natsal) of men aged 16-44 resident in Britain in 1990 (n = 6000) and 2000 (n = 4762).

RESULTS

The proportion of men who reported paying women for sex in the previous 5 years increased from 2.0% (95% CI 1.6 to 2.5) in 1990 to 4.2% in 2000 (95% CI 3.6 to 4.9). In both surveys, paying for sex was more frequent in men aged between 25 years and 34 years, who were never or previously married, and who lived in London. There was no association with ethnicity, social class, homosexual contact, or injecting drug use. Men who paid for sex were more likely to report 10 or more sexual partners in the previous 5 years; only a minority of their lifetime sexual partners (19.3%) were commercial. They were more likely to meet partners abroad and to report previous STI. Only 15% reported having had an HIV test.

CONCLUSION

The proportion of men who reported paying for heterosexual sex has increased, and these men have multiple commercial and non-commercial partners. Their higher rates of STI and low level of HIV testing suggest the need for prevention interventions for clients as well as sex workers.

An agenda for future research on HIV and sexual behaviour among African migrant communities in the UK

The epidemiology of the recent rise in HIV cases in Britain highlights the need for more research among the heterosexual African migrant population. New research should not, however, only extend the limited number of studies that describe observable patterns in sexual health but should also seek to determine their underlying social causation. To achieve this, both methodological and ontological shifts are necessary in the existing research paradigm; we advocate that a broad range of qualitative techniques be deployed both to uncover the empirical details of specifically African sexual behaviours and to highlight and explore the 'relational' nature of sexual decision-making. Rather than fixing on individuals, analysis must situate them within the broader discursive and material frames that structure the boundaries of decision-making. In addition, researchers need to utilise the parallel literature on the social embeddedness of HIV in Africa to inform analysis of the British context. It would then be possible to address the crucial question of whether the social conditions known to cause high-risk behaviours and facilitate transmission in Africa persist, or are transformed, after migration to the UK. A key, and neglected, dimension of this is the role of spatial context in relational sexual decision-making and the constitution of social relationships in particular arenas. This needs further thought, particularly in relation to domestic space and gender identities. We believe that the research agenda proposed herein has much to contribute to interventions and service provision. Nevertheless, we are mindful of the need for self-reflexivity about our role in the production of powerful knowledges about sex. Our final proposal is that researchers seek ways to work with, not on, African communities in order to facilitate their own informed management of sexual health.

Provision of chlamydia testing in a nationwide service offering termination of pregnancy: with data capture to monitor prevalence of infection

OBJECTIVES

To establish a methodology by which all women attending for termination of pregnancy (TOP) at British Pregnancy Advisory Service (BPAS) branches may be approached to participate in Chlamydia trachomatis screening. To examine the feasibility of monitoring C trachomatis prevalence and the impact of charging for screening on the uptake rate in this population.

METHODS

Patients attending for TOP at participating BPAS branches were offered a test for chlamydia infection and asked to complete a questionnaire. Urine samples from participants were tested using a nucleic acid amplification test (NAAT).

RESULTS

1001 women provided a urine sample, a 77% response rate among those participating in the study. Factors significantly associated with taking up chlamydia screening included symptoms, previous TOP, parity, and no previous chlamydial test. Overall prevalence of genital chlamydial infection was 7.5%, with highest age specific prevalences occurring among attendees aged 20-24 years (11.5%) and under 20 years (10.8%). In univariate analysis, chlamydia positivity was significantly associated with respondent age and previous diagnosis with chlamydia. Only 35% of women who had the screening test would have done so had they been asked to pay the pound 20 clinical, administrative, and laboratory costs of the examination.

CONCLUSIONS

We have demonstrated the feasibility of routine chlamydia screening and the potential for prospective prevalence monitoring across the nationwide BPAS service. In most cases the chlamydia result was available within the clinical contact period for the TOP. Charging patients directly for the test could reduce uptake of chlamydia screening to levels unsatisfactory for both the public health and prevalence monitoring purposes.