The experiences of transgender and nonbinary adults in primary care: A systematic review

BACKGROUND

Transgender and nonbinary (TNB) people face barriers to primary care, which remains the main entry point for accessing gender-affirming healthcare in the UK.

OBJECTIVES

This systematic review aims to summarise the evidence regarding TNB people's experiences of primary care to inform improvements in service and patient outcomes.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic literature search was conducted across articles from 2005 to April 2023 across Ovid Medline, Ovid Embase and PsychInfo using established keywords relating to gender identity, primary care and experiences. Qualitative data were thematically analysed and quantitative data were compiled using a descriptive narrative.

RESULTS

Following eligibility criteria, 16 articles were included in this review. This review identified both facilitators and limitations and barriers experienced by TNB people related to primary care provider knowledge; the patient-provider relationship, and healthcare settings. Quantitative findings reported up to 54.4% of participants were uncomfortable discussing TNB issues with their physician. Overall findings suggest TNB people face discrimination on a systemic level utilising primary care services, though positive healthcare encounters at a local level were reported. Participants expressed a desire for primary care-led gender-affirming healthcare services, with involvement from local TNB communities.

CONCLUSION

This review demonstrates TNB people's mixed experiences of primary care alongside their recommendations for service improvement. This is the first systematically reviewed evidence on the topic, emphasising the need for clinicians and policymakers to centre the voices of the TNB community in service design and improvement.

Factors associated with the sexual transmission of Strongyloides stercoralis in men who have sex with men: A systematic review

Strongyloides stercoralis is a parasitic worm with a complex life cycle and can cause significant morbidity, including a proctocolitis and life-threatening hyperinfection syndrome. Limited reports from non-endemic areas, including in men who have sex with men (MSM), suggest sexual transmission of S. stercoralis. In this systematic review of the published literature, we aimed to explore the associated factors of S. stercoralis in MSM. We systematically searched three bibliographical databases (MEDLINE, CINAHL and EMBASE) up to November 2022. We used a two-stage process to assess eligibility: the primary author conducted an initial screen of abstracts, and then three authors conducted independent full manuscripts to determine the final eligible manuscripts. We only included manuscripts written in English that contained data on specific factors associated with sexual transmission in MSM. We used the STROBE checklist to assess the risk of bias and synthesized the narrative data using the SWiM method. Seven manuscripts were eligible for this review (four case reports, one case series, one cross-sectional study and one experimental study), which included 22 individuals from Europe and the Americas. From these studies, S. stercoralis in MSM was associated with living with HIV (including having a low CD4 count and not using antiretrovirals), having a concomitant sexually transmitted infection (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and hepatitis C) and a concomitant (sexually transmitted) protozoal infection (Entamoeba histolytica, Giardia lamblia), travel to the S. stercoralis endemic area, multiple sexual partners from endemic areas, oro-anal sexual contact and chemsex. Although limited by the number of cases in the literature, we have highlighted some possible biological and behavioural risk factors associated with the sexual transmission of S. stercoralis in MSM that could be used to both target future research and S. stercoralis public health control interventions.

Factors and presenting symptoms associated with intestinal spirochaetosis in men who have sex with men: A systematic review

The transmission dynamics and presenting symptoms of intestinal spirochaetosis (Brachyspira pilosicoli, Brachyspira aalborgi) are poorly understood but is seen more frequently in men who have sex with men (MSM) where sexual transmission may occur. We aimed to systemically review the literature to define the factors and presenting symptoms associated with intestinal spirochaetosis in MSM. We systematically searched three bibliographical databases (MEDLINE, EMBASE and Scopus) for manuscripts written in English up to November 2022. The primary author conducted an initial screen and three authors conducted independent reviews to determine the final eligible manuscripts. We only included manuscripts where there were specific data on factors and presenting symptoms associated with intestinal spirochaetosis in MSM. Fifteen manuscripts published between 1981 and 2022 met the inclusion criteria that included 188 MSM. Sexually transmitted intestinal spirochaetosis in MSM was associated with-living with HIV (including having a low CD4 count <200 mm3), having a concomitant sexually transmitted infection, a history of a sexually transmitted infection, co-infection with intestinal parasites; and sexual behaviour including oro-anal sexual contact, oro-genital contact, fisting, condom-less anal sex, receptive anal sex, multiple non-regular sexual partners and increased number of lifetime sexual partners. The presenting symptoms of MSM with intestinal spirochaetosis were diarrhoea, abdominal pain, constitutional symptoms and proctitis, including rectal pain, rectal bleeding rectal discharge, flatulence and tenesmus. We have highlighted some biological and behavioural factors and presenting symptoms associated with intestinal spirochaetosis in MSM which provide insight for clinicians, guidelines and future public health control strategies.

"HIV has taught us that you can survive anything": findings from auto-ethnographic video diaries exploring resilience among people living with HIV during the Covid pandemic in five countries

This study aimed to elucidate the intrinsic and extrinsic resilience resources among people living with HIV (PLWH) during the Covid pandemic. Autoethnographic video diaries from 29 PLWH from Argentina, UK, Philippines, Zimbabwe, and Trinidad and Tobago were included. Data were thematically analysed and validated with community partners and a video was co-produced. PLWH displayed a readiness to adopt healthy behaviours and engage in optimistic and constructive thinking about the future. Hobbies and daily activities, supportive relationships with peers living with HIV, family and friends, opportunities to mobilise and contribute to their communities in meaningful ways, supportive healthcare providers and reliable access to antiretroviral treatment helped foster psychological resilience among PLWH. The extrinsic resilience resources also supported positive physical health outcomes among PLWH through improved medication adherence.

Universal-offer HIV testing in primary care: A mixed-methods evaluation of a pilot study

BACKGROUND

Offering HIV tests to all patients undergoing blood tests in primary care has been recommended by the National Institute for Health and Care Excellence (NICE) in the UK since 2016 but has not been fully adopted. We sought to evaluate the acceptability and feasibility of such a service in primary care.

METHODS

A 3-weeks pilot of offering HIV tests to all patients undergoing blood tests was conducted in a general practice in the UK and evaluated using a mixed-methods approach. Whether patients were offered and accepted tests was recorded and any differences by patient's age and gender assessed. All patients and HCPs offering testing were approached for semi-structured interviews.

RESULTS

Two-hundred-and-51 patients (mean [range] 57.5 years [18 to 97], 58% female) attended blood test appointments with 117 being offered a HIV test (46.6%). 78.6% (n = 92) accepted testing with 91 negative results. The proportion of patients offered testing was associated with the HCP offering the test. No associations between the age or gender of the patient and their odds of being offered or accepting a test were observed. Patient semi-structured interviews (n = 13) revealed a range of previous HIV testing experiences, patients felt the "offer" of a test to be routine and non-judgemental and felt that receiving negative results via SMS was appropriate. Several participants reported not fully considering the implications of a positive result when they accepted the test. Interviews with HCPs (n = 3) identified no significant service-level barriers.

CONCLUSIONS

Offering HIV tests to patients undergoing blood tests in primary care is feasible and acceptable. The principal barrier to uptake was HCPs not offering testing.

Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment

OBJECTIVES

Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa.

METHODS

Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities.

RESULTS

We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12).

CONCLUSIONS

Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

Medical student anxiety in caring for dying patients and their family: a cross-sectional study

OBJECTIVES

To investigate the level of medical student anxiety in caring for a dying patient and their family and identify influencing factors.

METHODS

We conducted a cross-sectional survey in a UK medical school to measure medical student anxiety using a validated Thanatophobia Scale questionnaire.

RESULTS

In total, 332 questionnaires were completed. Mean thanatophobia score was 19.5 (SD 7.78, range 7-49). Most respondents were female (67.4%) and did not have a previous undergraduate degree (56%). Median student age was 22 years (IQR 20-24). Year of study influenced anxiety level, with second year students displaying an increase in mean thanatophobia score of 6.088 (95% CI 3.778 to 8.398, p<0.001). No significant differences were observed between final year and first year thanatophobia scores. For each 1-year increase in student age, mean thanatophobia score reduced by -0.282 (95% CI -0.473 to -0.091, p=0.004). Degree status and gender identity did not significantly affect thanatophobia score.

CONCLUSION

A degree of thanatophobia exists among medical students, with no significant improvement observed by completion of training. Recognising this anxiety to care for the dying earlier in undergraduate curricula will give educators the opportunity to address students' fears and concerns and better prepare our future doctors for their role in caring for our dying patients and their families.

"But can chatbots understand sex?" Attitudes towards artificial intelligence chatbots amongst sexual and reproductive health professionals: An exploratory mixed-methods study

BACKGROUND

Artificial Intelligence (AI)-enabled chatbots can offer anonymous education about sexual and reproductive health (SRH). Understanding chatbot acceptability and feasibility allows the identification of barriers to the design and implementation.

METHODS

In 2020, we conducted an online survey and qualitative interviews with SRH professionals recruited online to explore the views on AI, automation and chatbots. Qualitative data were analysed thematically.

RESULTS

Amongst 150 respondents (48% specialist doctor/consultant), only 22% perceived chatbots as effective and 24% saw them as ineffective for SRH advice [Mean = 2.91, SD = 0.98, range: 1-5]. Overall, there were mixed attitudes towards SRH chatbots [Mean = 4.03, SD = 0.87, range: 1-7]. Chatbots were most acceptable for appointment booking, general sexual health advice and signposting, but not acceptable for safeguarding, virtual diagnosis, and emotional support. Three themes were identified: "Moving towards a 'digital' age'", "AI improving access and service efficacy", and "Hesitancy towards AI".

CONCLUSIONS

Half of SRH professionals were hesitant about the use of chatbots in SRH services, attributed to concerns about patient safety, and lack of familiarity with this technology. Future studies should explore the role of AI chatbots as supplementary tools for SRH promotion. Chatbot designers need to address the concerns of health professionals to increase acceptability and engagement with AI-enabled services.

Bisexual People Experience Worse Health Outcomes in England: Evidence from a Cross-Sectional Survey in Primary Care

Persistent inequalities in relation to health outcomes continue to exist among patients identifying as lesbian, gay, and bisexual (LGB), and very little is known about outcomes specific to bisexual populations. This study's aim was to compare the health of individuals identifying as LGB with heterosexual counterparts within primary care in England. Cross-sectional survey data from the year 10 (2015/2016) English General Practice Patient Survey (GPPS) dataset, which consisted of 836,312 responses (38.9% response rate), including 23,834 people who identified as gay, lesbian, bisexual or "other" was analyzed. Health outcomes were assessed through self-reported quality of life, physical and mental health, and confidence in managing own health. Multifactorial logistic regression (adjusting for age, ethnic group, working status, and socioeconomic status) were conducted. Long-term physical and mental health problems were more than twice as likely to be reported for people within LGB groups compared to the heterosexual group for both genders, except bisexual women where the odds were more than four times greater (OR = 4.275, 95% CI, 3.896, 4.691; p < .001). Bisexual women were half as likely to report the absence of a long-term health problem (OR = 0.452, 95% CI 0.419, 0.488; p < .001). LGB groups across both genders, reported a higher proportion of individuals that did not feel confident in managing their health and experienced significantly worse quality of life compared to heterosexuals. LGB patients consistently report poorer health outcomes than heterosexual patients. Bisexual people of both genders consistently experienced worse physical and mental health outcomes compared with the other recorded sexual orientations.

Antimicrobial resistance in sexually transmitted Shigella in men who have sex with men: A systematic review

BACKGROUND

Outbreaks of sexually transmitted Shigella flexneri and Shigella sonnei in men who have sex with men (MSM) are a major public health issue. While most cases can be managed conservatively, a minority require antimicrobial treatment. Recent reports have highlighted increasing antimicrobial resistant (AMR) strains of Shigella spp. in men who have sex with men. We aimed to systematically review antimicrobial resistance (and decreased antimicrobial sensitivity) in sexually transmitted shigella in men who have sex with men, focussing on macrolides, quinolones, and third generation cephalosporins.

METHODS

We systematically searched 4 bibliographical databases (EMBASE, medline, EMCARE and CINAHL) from January 2011 to November 2021. We used a 2-stage process to assess eligibility: the primary author conducted an initial screen and then 3 authors conducted independent full-text reviews to determine the final eligible manuscripts. We only included manuscripts in English which included men who have sex with men with sexually transmitted shigella where data on antimicrobial resistance was available.

RESULTS

Thirty-nine manuscripts met the inclusion criteria. A majority of the manuscripts (N = 34) described reduced susceptibility or antimicrobial resistant to macrolides, quinolones and third generation cephalosporins in circulating strains of shigella within sexual networks of men who have sex with men. Extensively drug resistant outbreaks of shigella in men who have sex with men have been reported containing genetic markers of ceftriaxone resistance (e.g. BlaCTX-M27) where isolates also contained markers of reduced susceptibility, and antimicrobial resistant to macrolides and quinolones.

CONCLUSION

There is little role for macrolides, quinolones or third generation cephalosporins in the management of sexually transmitted shigella in men who have sex with men. More research is needed to develop novel strategies for shigella control in men who have sex with men, as antimicrobial options are diminishing.

How are young people's mental health related to their sexual health and substance use? A systematic review of UK literature

OBJECTIVES

The transition from childhood to adulthood is complex and presents challenges to young people's mental health. Mental health impacts and is impacted by a range of contextual and personal factors. Adolescence and young adulthood also coincide with increased experimentation with sex, sexuality and substance use. Addressing the mental health, sexual health and substance-use challenges experienced by young people therefore necessitates an understanding of how these elements relate to one another. By collecting and analysing existing literature, this review aims to identify associations between young people's mental health and sexual health, their mental health and substance use and any resulting gaps-in-knowledge.

CONTENT

Seven electronic databases were searched between March and May 2021 and updated in May 2022 with terms collated under the categories of "young people", "mental health", "sexual health" and "substance use". English-language articles, presenting data from the UK & Ireland, on young people aged 16-24 years inclusive were screened and subjected to a selection process in accordance with PRISMA guidelines (preregistered on PROSPERO, ref. number CRD42021245096). The quality of the resulting articles were assessed using the Mixed Methods Appraisal Tool (MMAT) and findings were tabulated through a data extraction process.

SUMMARY

27 articles were included in the review. Various mental health indices such as depression, anxiety, self-harm, psychotic-like experiences, hypomanic symptoms and binge-purge type eating disorders were found to be associated with higher use of substances such as alcohol, cannabis, ecstasy and generalised drug use. Additionally, mental health indices such as depression, anxiety and self-harm were found to be associated with sex before age 16 and/or unprotected sex at age 16, positive Chlamydia infection and higher levels of sexual activity at a younger age. Overall, cross-sectional associations were stronger than the longitudinal associations presented in the articles.

OUTLOOK

This review into the specific relations between young people's mental health, sexual health and substance use has revealed the complex and bi-directional nature of these associations, with some conditions and substances having been more extensively investigated (e.g., alcohol and depression/anxiety) as opposed to the relations between young people's sexual health and mental health which is lacking in the UK and Irish context. The findings can help inform mental health related policies and service provisions targeted at young people in the UK and Ireland. Areas for future work are suggested.

Care of the dying - medical student confidence and preparedness: mixed-methods simulation study

OBJECTIVES

Of all doctors, Foundation Year 1 trainees spend the most time caring for dying patients yet report poor preparation and low confidence in providing this care. Despite documented effectiveness of simulation in teaching end-of-life care to undergraduate nurses, undergraduate medicine continues to teach this subject using a more theoretical, classroom-based approach. By increasing undergraduate exposure to interactive dying patient scenarios, simulation has the potential to improve confidence and preparedness of medical students to care for dying patients. The main study objective was to explore whether simulated experience of caring for a dying patient and their family can improve the confidence and preparedness of medical students to provide such care.

METHODS

A mixed-methods interventional study simulating the care of a dying patient was undertaken with serial measures of confidence using the Self Efficacy in Palliative Care (SEPC) tool. Significance testing of SEPC scores was undertaken using paired t-tests and analysis of variance. Post-simulation focus groups gathered qualitative data on student preparedness. Data were transcribed using NVivo software and interpreted using Thematic Analysis.

RESULTS

Thirty-eight 4th-year students participated. A statistically significant post-simulation increase in confidence was seen for all SEPC domains, with sustained confidence observed at 6 months. Focus group data identified six major themes: current preparedness, simulated learning environment, learning complex skills, patient centredness, future preparation and curriculum change.

CONCLUSION

Using simulation to teach medical students how to care for a dying patient and their family increases student confidence and preparedness to provide such care.

Factors related to condomless anal intercourse between men who have sex with men: results from a European bio-behavioural survey

Background

Relationship status is an important factor associated with condomless anal intercourse (CAI) amongst men who have sex with men (MSM).

Methods

A multi-centre bio-behavioural survey with MSM was conducted in 13 European cities (n = 4901) exploring factors associated with CAI via bivariate and multivariate multilevel logistic regression analyses.

Results

Likelihood of CAI with casual partners was associated with being ‘out’ to a majority (AOR = 1.19;95% CI 1,1.42); knowing their HIV status (AOR = 1.86; 95% CI 1.25,2.76); using substances (1–2 AOR = 1.39; 95% CI 1.16,1.63, 2+ AOR = 1.81; 95% CI 1.35,2.42); being older (AOR = 0.98; 95% CI 0.97,0.99); successful sero-communication (AOR = 0.79; 95% CI 0.67,0.94); and, not having a recent HIV test (AOR = 0.78; 95% CI 0.66,0.92). CAI with steady partners was associated with successful sero-communication (AOR = 2.72; 95% CI 2.72,3.66); not having a recent HIV test (AOR = 1.26; 95% CI 1.09,1.46), and; being older (AOR = 0.99; 95% CI 0.98,0.99).

Conclusions

Understandings of partner type and/or relationship status in relation to CAI amongst MSM can potentially play an important role in the development of culturally appropriate HIV/STI prevention and risk-reduction efforts targeting at-risk MSM. Our results speak to the need to consider segmented and tailored public health and health promotion initiatives for MSM with differing CAI behaviours and relationship profiles.

Sexual healthcare professionals' views on the rapid provision of remote services at the beginning of COVID-19 pandemic: A mixed-methods study

Introduction: The COVID-19 pandemic and social distancing measures forced sexual health services to engage with patients remotely. We aimed to understand perceived barriers and facilitators to the provision of digital sexual health services during the first months of the pandemic. Methods: An online survey and qualitative interviews with UK sexual healthcare professionals recruited online and via snowball sampling were conducted in May–July 2020. Results: Amongst 177 respondents (72% female, 86% White, mean age = 46, SD = 9), most utilised telephone and email as their main communication channels; however, their perceived effectiveness varied (94% and 66%, respectively). Most agreed that staff needed additional training (89%), the available technology was not adequate (66%) and health professionals were hesitant to provide online consultations (46%). They had positive attitudes towards digitalisation, improving service quality and cost-effectiveness but were concerned about exacerbating health inequalities. Discussion: The study identifies a need for clear guidelines and training around the use of digital tools as well as a demand for investment in hardware and software required for the provision of remote services. Future research needs to explore the acceptability, safety and effectiveness of various digital tools to narrow health inequalities in sexual health service users.

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework

BACKGROUND

Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.

METHODS

In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.

RESULTS

Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).

CONCLUSION

Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education

BACKGROUND

Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals are more likely to have negative healthcare experiences and worse health outcomes when compared with their heterosexual and cisgender counterparts. A key recommendation of the 2018 Stonewall-commissioned "LGBT in Britain" report was that the curricula, standards, and training provided by medical schools should be reviewed in order to encompass mandatory teaching about LGBT health inequalities and discrimination, LGBT-inclusive care and the use of appropriate language. The aim of our study was to conduct an in-depth national review of the content of LGBT teaching within the curricula of UK Medical Schools.

METHODS

Course leads at all 37 UK Medical Schools with students currently enrolled in a primary undergraduate medical training course were asked between December 2019-March 2020 to complete a cross-sectional online survey comprised of 30 questions; divided into three sections relating to the current LGBT teaching (Part 1), any planned or future LGBT teaching (Part 2), and the opinions of the survey respondent about the coverage of LGBT topics (Part 3) at their institution. Responses were analysed using descriptive statistics.

RESULTS

Questionnaires were received from 19/37 institutions (response rate: 51%). The median estimated number of hours of LGBT-teaching across the entire undergraduate course was 11.0 (IQR: 12.25). Teaching on LGBT mental health, gender identity, sexual orientation, awareness of LGBT-health inequalities, and LGBT discrimination in healthcare were reported by almost all respondents, whilst maternity and childbirth, chronic disease and LGBT adolescent health were least represented within the curriculum. Almost all (18 medical schools; 95%) responding institutions were considering implementing new LGBT teaching within the next three academic years. A lack of space within the curriculum is a universally reported barrier to the implementation of LGBT teaching. Only 5 (26%) survey respondents consider their institution's current coverage of LGBT topics to be "Good" or "Very good".

CONCLUSION

Our study demonstrates a significant variation in the amount and breadth of content within the undergraduate curricula of UK medical schools. Recommendations for increasing the quantity and quality of LGBT content are provided, based upon areas of good practice.

Sexual health promotion in people with severe mental illness: the RESPECT feasibility RCT

BACKGROUND

People with serious mental illness have sexual health needs, but there is limited evidence regarding effective interventions to promote their sexual health.

OBJECTIVES

To develop a sexual health promotion intervention for people with serious mental illness, and to conduct a feasibility trial in order to establish the acceptability and parameters for a fully powered trial.

DESIGN

A two-armed randomised controlled, open feasibility study comparing usual care alone with usual care plus the adjunctive intervention.

SETTING

Five community mental health providers in Leeds, Barnsley, Brighton and London.

PARTICIPANTS

Adults aged ≥ 18 years with serious mental illness and receiving care from community mental health teams.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to usual care plus the RESPECT (Randomised Evaluation of Sexual health Promotion Effectiveness informing Care and Treatment) intervention (three sessions of 1 hour) (intervention arm) or usual care only (control arm). The intervention was an interactive manualised package of exercises, quizzes and discussion topics focusing on knowledge, motivation and behavioural intentions to adopt safer sexual behaviours.

MAIN OUTCOME MEASURES

Feasibility parameters including establishing the percentage of people who were eligible, consented and were retained in each arm of the trial, retention for the intervention, as well as the completeness of the data collection. Data were collected on knowledge, motivation to adopt safer sexual behaviour, sexual behaviour, sexual stigma, sexual health service use and quality of life. Data were collected at baseline and then at 3 months and 6 months post randomisation.

RESULTS

Of a target of 100 participants, 72 people participated in the trial over 12 months. Of the 36 participants randomised to the intervention arm, 27 received some of the intervention (75.0%). At 3 months, 59 of the 72 participants completed follow-up questionnaires (81.9%) (30 participants from the intervention arm and 29 participants from the control arm). Only the first 38 participants were followed up at 6 months. However, data were collected on 29 out of 38 participants (76.3% retention): 13 in the intervention arm and 16 in the control arm. No adverse events were reported. Participant feedback confirmed that both the design and the intervention were acceptable. The economic analysis indicated high completion rates and completeness of data among participants who continued the trial.

CONCLUSIONS

Despite the limitations, the findings suggest that it is both acceptable and feasible to undertake a sexual health promotion study for people with serious mental illness.

FUTURE WORK

A fully powered randomised controlled trial would be required to establish the clinical effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15747739.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 65. See the NIHR Journals Library website for further project information.

Acceptability of artificial intelligence (AI)-enabled chatbots, video consultations and live webchats as online platforms for sexual health advice

OBJECTIVES

Sexual and reproductive health (SRH) services are undergoing a digital transformation. This study explored the acceptability of three digital services, (i) video consultations via Skype, (ii) live webchats with a health advisor and (iii) artificial intelligence (AI)-enabled chatbots, as potential platforms for SRH advice.

METHODS

A pencil-and-paper 33-item survey was distributed in three clinics in Hampshire, UK for patients attending SRH services. Logistic regressions were performed to identify the correlates of acceptability.

RESULTS

In total, 257 patients (57% women, 50% aged <25 years) completed the survey. As the first point of contact, 70% preferred face-to-face consultations, 17% telephone consultation, 10% webchats and 3% video consultations. Most would be willing to use video consultations (58%) and webchat facilities (73%) for ongoing care, but only 40% found AI chatbots acceptable. Younger age (<25 years) (OR 2.43, 95% CI 1.35 to 4.38), White ethnicity (OR 2.87, 95% CI 1.30 to 6.34), past sexually transmitted infection (STI) diagnosis (OR 2.05, 95% CI 1.07 to 3.95), self-reported STI symptoms (OR 0.58, 95% CI 0.34 to 0.97), smartphone ownership (OR 16.0, 95% CI 3.64 to 70.5) and the preference for a SRH smartphone application (OR 1.95, 95% CI 1.13 to 3.35) were associated with video consultations, webchats or chatbots acceptability.

CONCLUSIONS

Although video consultations and webchat services appear acceptable, there is currently little support for SRH chatbots. The findings demonstrate a preference for human interaction in SRH services. Policymakers and intervention developers need to ensure that digital transformation is not only cost-effective but also acceptable to users, easily accessible and equitable to all populations using SRH services.

Nonclinical Sexual Health Support for HIV, Viral Hepatitis, and Other Sexually Transmitted Infections in Gay, Bisexual, and Other Men Who Have Sex With Men: Protocol for a European Community Health Worker Online Survey (ECHOES)

BACKGROUND

The term "community health worker" (CHW) can apply to a wide range of individuals providing health services and support for diverse populations. Very little is known about the role of CHWs in Europe working in nonclinical settings who promote sexual health and prevent HIV and other sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM).

OBJECTIVE

This paper describes the development and piloting of the first European Community Health Worker Online Survey (ECHOES) as part of the broader European Union-funded ESTICOM (European Surveys and Trainings to Improve MSM Community Health) project. The questionnaire aimed to assess the knowledge, attitudes, and practices of CHWs providing sexual health services to gay, bisexual, and other MSM in European settings.

METHODS

ECHOES comprises three superordinate domains divided into 10 subsections with 175 items (routed) based on a scoping exercise and literature review, online prepiloting, and Europe-wide consultation. Additional piloting and cognitive debriefing interviews with stakeholders were conducted to identify comprehension issues and improve the clarity, intelligibility, accessibility, and acceptability of the survey. Psychometric properties, including internal consistency of the standardized scales used as part of the survey were examined. The final survey was available to 33 countries in 16 languages.

RESULTS

Recruitment closed on January 31, 2018. Data from 1035 CHWs were available for analysis after application of the exclusion criteria. The findings of the ECHOES survey and the wider ESTICOM project, are now available from the ESTICOM website and/or by contacting the first author.

CONCLUSIONS

The findings of this survey will help characterize, for the first time, the diverse role of CHWs who provide sexual health services to gay, bisexual, and other MSM in Europe. Importantly, the data will be used to inform the content and design of a dedicated training program for CHWs as part of the larger ESTICOM project and provide recommendations for MSM-specific strategies to improve sexual health in general and to reduce the incidence and prevalence of HIV, viral hepatitis, and other STIs in particular.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/15012.

Healthcare provider and service user perspectives on STI risk reduction interventions for young people and MSM in the UK

OBJECTIVE

Behavioural interventions have been shown to reduce sexual behaviours associated with increased risk of sexually transmitted infections in young people (<25 years) and men who have sex with men (MSM) internationally, but evidence from England is limited. We aimed to explore service provider and user experiences and perspectives on behavioural interventions to reduce sexual behaviour risks, and the use of automated methods to triage individuals to these services.

METHODS

We conducted a sequential mixed methods study with sexual health service providers and users in 2015/2016. Qualitative interviews with providers and service users (heterosexual young people and MSM) in London and Brighton allowed us to explore a range of experiences and expectations. A subsequent national web-survey of service providers measured the feasibility of delivery within existing resources and preferences for intervention attributes.

RESULTS

We conducted 35 service user (15 heterosexual young people; 20 MSM) and 26 provider interviews and had 100 web-survey responses. We found considerable heterogeneity in prevention services offered. Service users and providers were broadly supportive of tailoring interventions offered, but service users raised concerns about automated, data-driven triage, particularly around equity and fairness of service delivery. Digital technologies, including social media or apps, were appealing to providers, being less resource intensive. However, one-to-one talking interventions remained popular with both service users and providers, being familiar, trustworthy and personal. Key tensions between desirability of interventions and availability of resources to deliver them were acknowledged/recognised by providers and users.

CONCLUSION

Overall, behavioural interventions to reduce sexual behaviour risks were viewed favourably by service providers and users, with key considerations including: privacy, personalisation and convenience. However, introducing desirable targeted interventions within heterogeneous sexual health settings will require resources to adapt interventions and research to fully understand the barriers and facilitators to use within routine services.

Medical student confidence in care of the dying and their family: a systematic review

BACKGROUND

The General Medical Council expects medical graduates to care for dying patients with skill, clinical judgement and compassion. UK surveys continually demonstrate low confidence and increasing distress amongst junior doctors when providing care to the dying.

AIM

This systematic review aims to determine what has been evidenced within worldwide literature regarding medical undergraduate confidence to care for dying patients.

DESIGN

A systematic electronic search was undertaken. Data extraction included measurements of baseline confidence, associated assessment tools and details of applied educational interventions. Pre/postintervention confidence comparisons were made. Factors influencing confidence levels were explored.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, ISI Web of Science, ERIC, PsycINFO, British Education Index and Cochrane Review databases were accessed, with no restrictions on publication year. Eligible studies included the terms 'medical student', 'confidence' and 'dying', alongside appropriate MeSH headings. Study quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Fifteen eligible studies were included, demonstrating a diversity of assessment tools. Student confidence was low in provision of symptom management, family support, and psycho-spiritual support to dying patients. Eight interventional studies demonstrated increased postinterventional confidence. Lack of undergraduate exposure to dying patients and lack of structure within undergraduate palliative care curricula were cited as factors responsible for low confidence.

CONCLUSION

This review clarifies the objective documentation of medical undergraduate confidence to care for the dying. Identifying where teaching fails to prepare graduates for realities in clinical practice will help inform future undergraduate palliative care curriculum planning.

PROSPERO REGISTRATION NUMBER

CRD42019119057.

Sexual health promotion in people with severe mental illness: the RESPECT feasibility RCT

BACKGROUND

People with serious mental illness have sexual health needs, but there is limited evidence regarding effective interventions to promote their sexual health.

OBJECTIVES

To develop a sexual health promotion intervention for people with serious mental illness, and to conduct a feasibility trial in order to establish the acceptability and parameters for a fully powered trial.

DESIGN

A two-armed randomised controlled, open feasibility study comparing usual care alone with usual care plus the adjunctive intervention.

SETTING

Five community mental health providers in Leeds, Barnsley, Brighton and London.

PARTICIPANTS

Adults aged ≥ 18 years with serious mental illness and receiving care from community mental health teams.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to usual care plus the RESPECT (Randomised Evaluation of Sexual health Promotion Effectiveness informing Care and Treatment) intervention (three sessions of 1 hour) (intervention arm) or usual care only (control arm). The intervention was an interactive manualised package of exercises, quizzes and discussion topics focusing on knowledge, motivation and behavioural intentions to adopt safer sexual behaviours.

MAIN OUTCOME MEASURES

Feasibility parameters including establishing the percentage of people who were eligible, consented and were retained in each arm of the trial, retention for the intervention, as well as the completeness of the data collection. Data were collected on knowledge, motivation to adopt safer sexual behaviour, sexual behaviour, sexual stigma, sexual health service use and quality of life. Data were collected at baseline and then at 3 months and 6 months post randomisation.

RESULTS

Of a target of 100 participants, 72 people participated in the trial over 12 months. Of the 36 participants randomised to the intervention arm, 27 received some of the intervention (75.0%). At 3 months, 59 of the 72 participants completed follow-up questionnaires (81.9%) (30 participants from the intervention arm and 29 participants from the control arm). Only the first 38 participants were followed up at 6 months. However, data were collected on 29 out of 38 participants (76.3% retention): 13 in the intervention arm and 16 in the control arm. No adverse events were reported. Participant feedback confirmed that both the design and the intervention were acceptable. The economic analysis indicated high completion rates and completeness of data among participants who continued the trial.

CONCLUSIONS

Despite the limitations, the findings suggest that it is both acceptable and feasible to undertake a sexual health promotion study for people with serious mental illness.

FUTURE WORK

A fully powered randomised controlled trial would be required to establish the clinical effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15747739.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 65. See the NIHR Journals Library website for further project information.

UK healthcare professionals' uncertainties, barriers and facilitators to the introduction of targeted human papillomavirus vaccination for men who have sex with men

BACKGROUND

Female-only human papillomavirus (HPV) vaccination will fail to protect men who have sex with men (MSM) against HPV and its sequelae (i.e. genital warts and anal cancers). In the absence of gender-neutral HPV vaccination, targeted vaccination at sexual health clinics for MSM offers a valuable preventive opportunity. This study aimed to identify sexual healthcare professionals' (HCPs) perceived barriers and facilitators for MSM-targeted HPV vaccination.

METHODS

Nineteen telephone interviews with UK-based self-referred HCPs (13 doctors, three nurses, three health advisers) were conducted in October and November 2014. The interviews were recorded and transcribed verbatim. Data were analysed thematically by two researchers.

RESULTS

HCPs were unsure about selection criteria, acceptable healthcare settings and the source of vaccination funding for the introduction of MSM-targeted HPV vaccination. Lack of political and public support, MSMs' limited access to HPV vaccination and disclosure of sexual orientation to HCPs, identification of eligible MSM, patients' poor HPV awareness and motivation to complete HPV vaccination were perceived as significant barriers. HCPs believed that the introduction of official guidelines on HPV vaccination for MSM, awareness campaigns and integrated clinic procedures could improve vaccination coverage.

CONCLUSION

HCPs recognised a need to protect MSM against HPV. However, several challenges and obstacles associated with the introduction of MSM-targeted HPV vaccination in the UK were reported. HCPs' perspectives and concerns need to be addressed when developing policies and guidelines for a potential MSM-targeted HPV vaccination. Future research needs to examine whether negative views of HCPs towards MSM-targeted HPV vaccination are associated with lower HPV vaccine uptake and completion rates in MSM.

Acceptability and feasibility of using digital vending machines to deliver HIV self-tests to men who have sex with men

OBJECTIVE

Technology-based approaches to distribute HIV self-tests (HIVST) have the potential to increase access to HIV testing in key populations. We evaluate the acceptability and feasibility of using vending machines (VMs) in a community setting to distribute HIVST to men who have sex with men at high-risk of HIV.

METHODS

First, a predevelopment survey of targeted potential users explored attitudes towards HIVST and the use of a VM to deliver HIVST. Second, participatory design workshops between designers and community volunteers informed the production of a bespoke VMs dispensing free BioSureHIVST. Uptake of HIVST and user experiences were evaluated using information supplied directly from the machines interface (number of tests dispensed, user demographics), an online questionnaire and semistructured interviews.

RESULTS

The predevelopment survey found that 32% of 232 sauna users had never tested for HIV, despite high-risk behaviours. A total of 265 testing kits were dispensed: mean age 31 range (18-70); 4%(n = 7) had never tested for HIV before and 11% (n = 22) had tested within the last 1-5 years. Uptake of tests was significantly higher via the VMs compared with outreach testing by community workers in the same venue during a comparable period (34 vs 6 tests per month). Qualitative interviews and online questionnaires demonstrated high acceptability for this intervention, which was considered accessible and appropriately targeted.

CONCLUSIONS

VMs to distribute HIVST was feasible and acceptable. This intervention could be used in different settings to improve access to HIV testing for key populations.

Sexual risk reduction interventions for patients attending sexual health clinics: a mixed-methods feasibility study

BACKGROUND

Sexually transmitted infections (STIs) continue to represent a major public health challenge. There is evidence that behavioural interventions to reduce risky sexual behaviours can reduce STI rates in patients attending sexual health (SH) services. However, it is not known if these interventions are effective when implemented at scale in SH settings in England.

OBJECTIVES

The study (Santé) had two main objectives - (1) to develop and pilot a package of evidence-based sexual risk reduction interventions that can be delivered through SH services and (2) to assess the feasibility of conducting a randomised controlled trial (RCT) to determine effectiveness against usual care.

DESIGN

The project was a multistage, mixed-methods study, with developmental and pilot RCT phases. Preparatory work included a systematic review, an analysis of national surveillance data, the development of a triage algorithm, and interviews and surveys with SH staff and patients to identify, select and adapt interventions. A pilot cluster RCT was planned for eight SH clinics; the intervention would be offered in four clinics, with qualitative and process evaluation to assess feasibility and acceptability. Four clinics acted as controls; in all clinics, participants would be consented to a 6-week follow-up STI screen.

SETTING

SH clinics in England.

PARTICIPANTS

Young people (aged 16-25 years), and men who have sex with men.

INTERVENTION

A three-part intervention package - (1) a triage tool to score patients as being at high or low risk of STI using routine data, (2) a study-designed web page with tailored SH information for all patients, regardless of risk and (3) a brief one-to-one session based on motivational interviewing for high-risk patients.

MAIN OUTCOME MEASURES

The three outcomes were (1) the acceptability of the intervention to patients and SH providers, (2) the feasibility of delivering the interventions within existing resources and (3) the feasibility of obtaining follow-up data on STI diagnoses (primary outcome in a full trial).

RESULTS

We identified 33 relevant trials from the systematic review, including videos, peer support, digital and brief one-to-one sessions. Patients and SH providers showed preferences for one-to-one and digital interventions, and providers indicated that these intervention types could feasibly be implemented in their settings. There were no appropriate digital interventions that could be adapted in time for the pilot; therefore, we created a placeholder for the purposes of the pilot. The intervention package was piloted in two SH settings, rather than the planned four. Several barriers were found to intervention implementation, including a lack of trained staff time and clinic space. The intervention package was theoretically acceptable, but we observed poor engagement. We recruited patients from six clinics for the follow-up, rather than eight. The completion rate for follow-up was lower than anticipated (16% vs. 46%).

LIMITATIONS

Fewer clinics were included in the pilot than planned, limiting the ability to make strong conclusions on the feasibility of the RCT.

CONCLUSION

We were unable to conclude whether or not a definitive RCT would be feasible because of challenges in implementation of a pilot, but have laid the groundwork for future research in the area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16738765.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 12. See the NIHR Journals Library website for further project information.

What is the extent of repeat prescriptions for post-exposure prophylaxis for HIV after sexual exposure among men who have sex with men in the UK?

People who repeatedly present for post-exposure prophylaxis (PEP) for prevention of HIV following a high-risk sexual exposure are of concern according to the British HIV Association PEP guidelines. The aim of this audit was to determine the extent of repeat PEP prescriptions for men who have sex with men (MSM) by conducting a retrospective review of patient notes from a 5-year period at one genitourinary medicine clinic. Over the 5 years, 107 of 929 MSM (11.5%; 95% confidence interval: 9.45-13.55) received more than one PEP prescription (repeat range 1-8; mean=3.3, s.d.=1.44). Forty percent of these had received three or more PEP prescriptions. Seven of the 107 became HIV positive. Patients need to be offered and encouraged to take up behavioural risk reduction interventions at the time of each PEP prescription.

Men who have sex with men who do not access sexual health clinics nor disclose sexual orientation are unlikely to receive the HPV vaccine in the UK

BACKGROUND

Men who have sex with men (MSM) are recommended the Human Papillomavirus (HPV) vaccination due to their higher risk of genital warts and anal cancer.

PURPOSE

To examine HPV vaccine acceptability amongst MSM in the UK.

METHODS

Using advertisements via Facebook, MSM were recruited to an online survey measuring motivations for HPV vaccination. Logistic regression was performed to identify predictors of HPV vaccine acceptability.

RESULTS

Out of 1508 MSM (median age = 22, range: 14-63 years) only 19% knew about HPV. Overall, 55% of MSM were willing to ask for the HPV vaccine and 89% would accept it if offered by a healthcare professional (HCP). Access to sexual health clinics (SHCs) [OR = 1.82, 95% CI 1.29-2.89], the disclosure of sexual orientation to a HCP [OR = 2.02, CI 1.39-3.14] and HIV-positive status [OR = 1.96, CI 1.09-3.53] positively predicted HPV vaccine acceptability. After receiving information about HPV, perceptions of HPV risk [OR = 1.31, CI 1.05-1.63], HPV infection severity [OR = 1.89, CI 1.16-3.01), HPV vaccination benefits [OR = 1.61, CI 1.14-3.01], HPV vaccine effectiveness [OR = 1.54, CI 1.14-2.08], and the lack of perceived barriers to HPV vaccination [OR = 4.46, CI 2.95-6.73] were also associated with acceptability.

CONCLUSIONS

Although nearly half of MSM would not actively pursue HPV vaccination, the vast majority would accept the vaccine if recommended by HCPs. In order to achieve optimal uptake, vaccine promotion campaigns should focus on MSM who do not access SHCs and those unwilling to disclose their sexual orientation.

Designing a brief behaviour change intervention to reduce sexually transmitted infections: a discrete choice experiment

To understand whether people attending sexual health (SH) clinics are willing to participate in a brief behavioural change intervention (BBCI) to reduce the likelihood of future sexually transmitted infections (STIs) and to understand their preferences for different service designs, we conducted a discrete choice experiment (DCE) with young heterosexual adults (aged 16-25 years), and men who have sex with men (MSM) aged 16 or above, attending SH clinics in England. Data from 368 participants showed that people particularly valued BBCIs that involved talking (OR 1.45; 95%CI 1.35, 1.57 compared with an 'email or text'-based BBCIs), preferably with a health care professional rather than a peer. Findings also showed that 26% of respondents preferred 'email/texts' to all other options; the remaining 14% preferred not to participate in any of the offered BBCIs. These results suggest that most people attending SH clinics in England are likely to participate in a BBCI if offered, but the type/format of the BBCI is likely to be the single important determinant of uptake rather than characteristics such as the length and the number of sessions. Moreover, participants generally favoured 'talking'-based options rather than digital alternatives, which are likely to require the most resources to implement.

Syndemics of stigma, minority-stress, maladaptive coping, risk environments and littoral spaces among men who have sex with men using chemsex

There has been a steep rise in the use of drugs during sex (chemsex) by some men who have sex with men in economically developed countries, with associated increases in sexual risk for HIV and other STIs. This paper presents data from telephone interviews with 15 men attending sexual health clinics for post-exposure prophylaxis following a chemsex-related risk for HIV and discusses some of the theoretical approaches that have been employed to understand chemsex and inform interventions. Interviews were conducted as part of a larger intervention study, which used an adapted version of motivational Interviewing to explore risk behaviour and support change. Participants conceptualised their chemsex and HIV-related risks in a psycho-social context, highlighting the influences of psycho-socio-cultural challenges of homophobic marginalisation and the 'gay scene' on behaviour. Multiple influences of stigma, marginalisation, minority stress and maladaptive coping (including drug-use) contribute to syndemic 'risk-environments' and 'littoral spaces' in which chemsex and risk behaviours are played out.

Genetic predisposition to obesity, restrained eating and changes in body weight: a population-based prospective study

OBJECTIVES

There is no consensus on whether cognitive control over food intake (that is, restrained eating) is helpful, merely ineffective or actually harmful in weight management. We examined the interplay between genetic risk of obesity, restrained eating and changes in body weight and size.

METHODS

Participants were Finnish aged 25-74 years who attended the DIetary, Lifestyle and Genetic determinants of Obesity and Metabolic syndrome study at baseline in 2007 and follow-up in 2014. At baseline (n=5024), height, weight and waist circumference (WC) were measured in a health examination and participants self-reported their weight at age 20 years. At follow-up (n=3735), height, weight and WC were based on measured or self-reported information. We calculated 7-year change in body mass index (BMI) and WC and annual weight change from age 20 years to baseline. Three-Factor Eating Questionnaire-R18 was used to assess restrained eating. Genetic risk of obesity was assessed by calculating a polygenic risk score of 97 known BMI-related loci.

RESULTS

Cross-lagged autoregressive models indicated that baseline restrained eating was unrelated to 7-year change in BMI (β=0.00; 95% confidence interval (CI)=-0.01, 0.02). Instead, higher baseline BMI predicted greater 7-year increases in restrained eating (β=0.08; 95% CI=0.05, 0.11). Similar results were obtained with WC. Polygenic risk score correlated positively with restrained eating and obesity indicators in both study phases, but it did not predict 7-year change in BMI or WC. However, individuals with higher genetic risk of obesity tended to gain more weight from age 20 years to baseline, and this association was more pronounced in unrestrained eaters than in restrained eaters (P=0.038 for interaction).

CONCLUSIONS

Our results suggest that restrained eating is a marker for previous weight gain rather than a factor that leads to future weight gain in middle-aged adults. Genetic influences on weight gain from early to middle adulthood may vary according to restrained eating, but this finding needs to be replicated in future studies.

Patients' perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study

The objective of this study was to identify the aspects of healthcare that are most valued by people with HIV and to describe their concerns and preferences for the future delivery of services for non-HIV-related illness. Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, gender, sexual orientation and ethnicity. Data were analysed using Framework Analysis. The results showed that among the 74 respondents (61% male), a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners to manage patient confidentiality or deal appropriately with the emotional and social challenges of living with HIV. Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services and increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV.

Perceptions of HPV and attitudes towards HPV vaccination amongst men who have sex with men: A qualitative analysis

OBJECTIVES

Men who have sex with men (MSM) are at risk of genital warts and anal cancer due to human papillomavirus (HPV) infection. This study explores MSMs' perceptions of HPV and HPV vaccination prior to the introduction of this programme.

DESIGN

Focus groups and one-to-one interviews with self-identified MSM were conducted between November 2014 and March 2015 in Brighton, UK.

METHODS

Participants were recruited from community-based lesbian-gay-bisexual-transgender (LGBT) venues and organizations. Discussions were recorded, transcribed verbatim, and analysed using framework analysis.

RESULTS

Thirty-three men took part (median age 25 years, IQR: 21-27), most of whom (n = 25) did not know about HPV, anal cancer (31), or HPV vaccination (26). While genital warts and anal cancer were perceived as severe, men did not perceive themselves at risk of HPV. All MSM would accept the HPV vaccine if offered by a health care professional. The challenges of accessing sexual health services or openly discussing same-sex experiences with health care professionals were perceived as barriers to accessing HPV vaccination. Two participants were concerned that selective HPV vaccination could increase stigma and prejudice against MSM, comparable to the AIDS epidemic. Ten MSM were unsure about the effectiveness of HPV vaccination for sexually active men and were in favour of vaccinating all adolescent boys at school.

CONCLUSIONS

Most MSM have poor knowledge about HPV and associated anal cancer. Despite the lack of concern about HPV, most MSM expressed willingness to receive HPV vaccination. There is a need for health education about the risks of HPV and HPV-related diseases so that MSM can appraise the benefits of being vaccinated. Concerns about HPV vaccine effectiveness in sexually active men and possible stigmatization need to be addressed to optimize HPV vaccine acceptability. Statement of contribution What is already known on this subject? Men who have sex with men (MSM) have poor knowledge about HPV and HPV-related diseases. Perceived risk of HPV and attitudes towards HPV vaccination are associated with HPV vaccine acceptability amongst MSM in the United States. There is a gap between acceptability and uptake of HPV vaccination amongst MSM. What does this study add? Due to concerns about compromised effectiveness of the HPV vaccine in sexually active men, most MSM would recommend vaccination of all adolescent boys. Restricted access to sexual health services and the inability to discuss same-sex experiences were perceived as barriers to HPV vaccination. While the HPV vaccine is acceptable amongst MSM, the motivation to be vaccinated and complete the three-dose series might be low.

Which aspects of health care are most valued by people living with HIV in high-income countries? A systematic review

BACKGROUND

Increasing numbers of people with HIV are living into older age and experiencing comorbidities. The development of new models of care to meet the needs of this population is now a priority. It is important that the views and preferences of patients inform the development of services in order to maintain high levels of patient satisfaction and engagement. The aim of this systematic review was to determine which aspects of healthcare are particularly valued by people living with HIV.

METHODS

We searched electronic databases and reference lists of relevant articles. The search strategy was developed to identify articles reporting on HIV positive patients' perceptions, evaluations or experiences of healthcare services and factors associated with satisfaction with care. Peer-reviewed papers and conference abstracts were included if the study reported on aspects of health care that were valued by people living with HIV, data were collected during the era of combination therapy (from 1996 onwards), and the paper was published in English. A thematic approach to data synthesis was used.

RESULTS

Twenty-three studies met the inclusion criteria. Studies used both qualitative and quantitative methods. Six studies specifically reported on relative importance to patients of different aspects of care. The valued aspects of care identified were grouped into seven themes. These highlighted the importance to patients of: a good health care professional-patient relationship, HIV specialist knowledge, continuity of care, ease of access to services, access to high quality information and support, effective co-ordination between HIV specialists and other healthcare professionals, and involvement in decisions about treatment and care. We were unable to determine the relative importance to patients of different aspects of care because of methodological differences between the studies.

CONCLUSIONS

This review identified several attributes of healthcare that are valued by people living with HIV, many of which would be relevant to any future reconfiguration of services to meet the needs of an ageing population. Further research is required to determine the relative importance to patients of different aspects of care.

Investigating factors for increased gonorrhoea re-infection in men who have sex with men attending a genitourinary clinic: a qualitative study

The number of confirmed cases of gonorrhoea increased by one-third in England from 2013 to 2014 and the incidence increased by 32% in men who have sex with men (MSM). In our clinic, annual incidence increased by 28.8% (2013) and re-infection (second infection within one-year of initial infection) rose from 6.7% as a proportion of total infections (2009) to 19.4% (2013). The aim of this study was to explore reasons for repeat gonorrhoea infections among MSM. We interviewed 16 MSM about knowledge and awareness of gonorrhoea, antibiotic resistance and attitudes towards safe sex. We used qualitative methods to investigate the potential causes for the rise in gonorrhoea re-infection. Mobile applications were used to meet casual sex partners and arrange impromptu group-sex parties with partner anonymity making contact tracing difficult. The use of recreational drugs was widespread. It was suggested that new technologies could also be used to increase awareness of STI trends and services for at-risk individuals. Participants were concerned about global antibiotic resistance, but felt that behaviour would not change unless there was local evidence of this. Despite knowing gonorrhoea prevalence was high, participants felt their behaviour was unlikely to change and frequently felt resigned to repeat infections. The use of geosocial networking applications to arrange sexual encounters may be contributing to a rise in STIs, as well as recreational drugs, alcohol and sex parties. Networking applications could increase awareness and advertise testing opportunities. In some cases, risk-taking behaviours are unlikely to change, and for these men, regular sexual health screens should be encouraged to detect and treat infections earlier and reduce onward spread.

Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review

BACKGROUND

Sexually transmitted infections (STIs) are more common in young people and men who have sex with men (MSM) and effective in-service interventions are needed.

METHODS

A systematic review of randomized controlled trials (RCTs) of waiting-room-delivered, self-delivered and brief healthcare-provider-delivered interventions designed to reduce STIs, increase use of home-based STI testing, or reduce STI-risk behavior was conducted. Six databases were searched between January 2000 and October 2014.

RESULTS

17,916 articles were screened. 23 RCTs of interventions for young people met our inclusion criteria. Significant STI reductions were found in four RCTs of interventions using brief one-to-one counselling (2 RCTs), video (1 RCT) and a STI home-testing kit (1 RCT). Increase in STI test uptake was found in five studies using video (1 RCT), one-to-one counselling (1 RCT), home test kit (2 RCTs) and a web-based intervention (1 RCT). Reduction in STI-risk behavior was found in seven RCTs of interventions using digital online (web-based) and offline (computer software) (3 RCTs), printed materials (1 RCT) and video (3 RCTs). Ten RCTs of interventions for MSM met our inclusion criteria. Three tested for STI reductions but none found significant differences between intervention and control groups. Increased STI test uptake was found in two studies using brief one-to-one counselling (1 RCT) and an online web-based intervention (1 RCT). Reduction in STI-risk behavior was found in six studies using digital online (web-based) interventions (4 RCTs) and brief one-to-one counselling (2 RCTs).

CONCLUSION

A small number of interventions which could be used, or adapted for use, in sexual health clinics were found to be effective in reducing STIs among young people and in promoting self-reported STI-risk behavior change in MSM.

Understanding HIV-positive patients' preferences for healthcare services: a protocol for a discrete choice experiment

INTRODUCTION

While the care of HIV-positive patients, including the detection and management of comorbidities, has historically been provided in HIV specialist outpatient clinics, recent years have seen a greater involvement of non-HIV specialists and general practitioners (GPs). The aim of this study is to determine whether patients would prefer to see their GP or HIV physician given general symptoms, and to understand what aspects of care influence their preferences.

METHODS/ANALYSIS

We have developed and piloted a discrete choice experiment (DCE) to better understand patients' preferences for care of non-HIV-related acute symptoms. The design of the DCE was informed by our exploratory research, including the findings of a systematic literature review and a qualitative study. Additional questionnaire items have been included to measure demographics, service use and experience of non-HIV illnesses and quality of life (EQ5D). We plan to recruit 1000 patients from 14 HIV clinics across South East England. Data will be analysed using random-effects logistic regression and latent class analysis. ORs and 95% CIs will be used to estimate the relative importance of each of the attribute levels. Latent class analysis will identify whether particular groups of people value the service attribute levels differently.

ETHICS/DISSEMINATION

Ethical approval for this study was obtained from the Newcastle and North Tyneside Research Ethics Committee (reference number 14/NE/1193). The results will be disseminated at national and international conferences and peer-reviewed publications. A study report, written in plain English, will be made available to all participants. The Patient Advisory Group will develop a strategy for wider dissemination of the findings to patients and the public.

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND

Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patient's behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system.

OBJECTIVE

We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice.

DESIGN

Cluster randomised controlled trial.

SETTING

General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system.

INTERVENTIONS

Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral.

MAIN OUTCOME MEASURES

(1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months.

RESULTS

As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions.

CONCLUSIONS

External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24160819.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.