Professor Jonathan Ross. Dr Melinda Tenant-Flowers. University Hospitals Birmingham NHS Trust. King s College Hospital NHS Foundation Trust, London

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2 THIRD JOINT CONFERENCE OF BHIVA AND BASHH 2014 Professor Jonathan Ross University Hospitals Birmingham NHS Trust Dr Melinda Tenant-Flowers King s College Hospital NHS Foundation Trust, London 1-4 April 2014, Arena and Convention Centre Liverpool

3 THIRD JOINT CONFERENCE OF BHIVA AND BASHH 2014 Dr John White Guy s and St Thomas NHS Foundation Trust, London 1-4 April 2014, Arena and Convention Centre Liverpool

4 THIRD JOINT CONFERENCE OF BHIVA AND BASHH 2014 Dr John White Guy s and St Thomas NHS Foundation Trust, London COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Dr John White Statement acts in a consultancy capacity for Diagnostics for the Real World, and as a speaker at company-sponsored events for Gilead, Becton-Dickinson, GenProbe/Hologic, and Cepheid. Date April April 2014, Arena and Convention Centre Liverpool

5 Translating recent research into clinical practice Dr John White Consultant Physician in Sexual Health & HIV Guy s and St Thomas NHS Foundation Trust 2 nd APRIL 2014

6 Translating recent research into clinical practice

7 MSM pharyngeal GC cases - GSTT 230% increase Also: 220% increase in LGV cases % increase in early syphilis last 6 months

8 Metsch LR et al. JAMA Oct 23/30, 2013 RCT to assess the effectiveness of counseling in reducing STI incidence among STD clinic patients n=5012 patients Sites included 9 STD clinics across USA

9 Metsch LR et al. JAMA Oct 23/30, Randomized to receive: brief HIV risk-reduction counseling with a rapid HIV test ($56/pt) or the rapid HIV test with information only ($23/pt) 6-mth follow up for HIV, syphilis, HSV2 (serum), genital GC/CT, TV( ) + rectal CT/GC (MSM)

10 Metsch LR et al. JAMA Oct 23/30, 2013 Results: (87% retention) incident rates: 12.3% in the counseling group 11.1% in the information-only group no overall benefit from prevention counseling observed a notable increase in STIs for MSM: 18.7% STI in counseling group vs. 12.5% in information-only group (arr, 1.41 [ ])

11 Metsch LR et al. JAMA Oct 23/30, 2013 Disappointing that counselling might not work But good for universal HIV testing: eliminate counseling in the setting of HIV screening so as to increase uptake of tests need to look for alternative effective interventions, esp MSM

12 Online survey of 2063 sexually active US MSM. Sex party attendees were more likely to be: Sex Transm Infect 2014;90:26 32 HIV-positive (28.1%), single (31.7%), have sexual compulsivity (39.2%), recently used drugs (67.8%), more partners (med=15, <90 days), and more UAI (median=3, <90 days)

13 Sex Transm Infect 2014;90: % expressed interest in free rapid HIV testing at sex parties But few considered it acceptable to see medical providers (11.7%) and peer outreach workers (9.5%) at sex parties

14 Sex Transm Infect 2014;0:1 7. included 11 studies representing sexual encounters. (USA, Canada, UK, & Australia/NZ) Odds for any UAI, seroconcordant UAI and serodiscordant UAI with strategic positioning were higher in online-initiated sexual encounters

15 Sex Transm Infect 2014;0:1 7. Singaporean heterosexual men aged years Compared online vs. brothel patrons Men seeking sex online reported significantly higher rates of oral and anal sex, STIs, lower condom use for oral sex with CSW (16.5% vs 56.6%)

16 Buri ER et al. Sex Transm Dis Vol 40;7, July 2013 n=273 aged 13 to 19 years - teen clinic in Florida. Completed ACASI, urine screening CT/GC 42 teens (15%) reported they had sex with a person they first met online though no more likely to have ever or currently have an STD

17 Centralization of PN services New staff; addition of internet/ to text messaging for PN 362 contacts were initiated compared with 133 in previous year Sex Transm Dis Vol 41;2, Feb new HIV, 11 new syphilis, and 19 known previous HIV-positive persons were identified.

18 Hunter P. et al. Public Health Reports; 2014 Supp 1;Vol 129 Investigation of syphilis outbreak in young black MSM in US

19 Hunter P. et al. Public Health Reports; 2014

20 John White updated his profile picture

21 Chesson HW et al, Sex Transm Dis Vol 40;5, May 2013 Modelling study; based on San Fran data Screening & treating MSM for rectal CT/GC may help reduce increased biological susceptibility to HIV identify men at increased risk for HIV

22 Chesson HW et al, Sex Transm Dis Vol 40;5, May 2013 Cost per QALY gained was $16,300 in the static model In the dynamic model, the cost per QALY gained was less than $0, meaning that rectal screening was costsaving assumed all rectal CT/GC infections detected would be treated successfully immediately upon detection lots of assumptions but important in MSM

23 Retrospective cohort of male patients diagnosed with rectal chlamydia Sex Transm Dis Feb;41(2): (culture); APTIMA Combo 2 Treated with azithromycin (1 g stat) or doxycycline (100 mg bd 7 days)

24 n=1835 cases of rectal chlamydia Sex Transm Dis Feb;41(2): /1231 (33%) of AZI and 95/249 (38%) of DOXY men had a repeat test within 14 to 180 days (median 84 days; P = 0.12) DOXY men more likely to have a symptomatic infection and diagnosis of proctitis (both P<0.01)

25 Treatment with AZI significantly associated with a 5-fold higher risk of persistent/recurrent infection at 14 to 90 days after treatment c.f. DOXY Overall failure rates at days: 88/407 (21.6%) AZI-treated 8/95 (8.4%) DOXY-treated (p=0.002) Sex Transm Dis Feb;41(2):79-85

26 Azithromycin for rectal CT There have been no RCTs for antibiotic therapy of rectal CT Observations of poorer outcome with Azi 1g FIVE papers now If meta-analysis: Azi 1g 505/628 = 80.4% (95%CI ) Doxy 288/300 = 96.0% (95%CI ) Are RCTs really needed??? MSM good with pills

27 Int J STD AIDS : 822 n=143 MG+ve specimens: fluoroquinolone mutations in 15% and macrolide mutations in 43% n=30 men with MG+ve NGU 25 heterosexual; 4 MSM; 1 bisexual 2 partners (cervical MG); 1 MSM (rectal MG) 4 cases of moxifloxacin treatment failure

28 UK MSM data The Lancet Infectious Diseases 2014; 14:16-17

29 Of all patients from 17 states infected with azithromycin-resistant Shigella 36 S. flexneri, 18 S. sonnei, 1 S. boydii 80% men; 79% MSM, 81% HIV-positive MMWR Morb Mortal Wkly Rep Feb 14;63(6): % resistant to >5 classes; 4% cipro-resistant

30 Sex Transm Infect 2013;89: iv47 iv51 Core groups breed and spread resistant organisms MSM have been critical to the spread of GC resistant to cefixime and ceftriaxone Most important core group in UK Crucial to consider differently when treating

31 45% of NGU cases have no identified etiology. Novel bacteria recently associated with BV in women may be involved Cases (n = 157) with NGU (GC, CT, TV, MG, UU2-negative) vs. controls (n = 102) Urine tested by qpcr for BVABs Sex Transm Dis Vol 40;12, Dec 2013

32 Sex Transm Dis Vol 40;12, Dec 2013 Leptotrichia/Sneathia spp. were significantly associated with urethritis 24/157 (15.3%) vs. 6/102 (5.9%), P = 0.03 BVAB-2 was more common in cases BVAB-3 & Megasphaera only in men with NGU Atopobium spp. not associated with NGU

33 Sex Transm Dis Vol 40;12, Dec 2013 Among treated cases, doxycycline was more effective than azithromycin for clinical cure of men with Leptotrichia/Sneathia spp. (9/10 vs. 7/12, P = 0.16) and BVAB-2 (3/3 vs. 0/3, P = 0.10)

34 Prospective study followed women for 1 year after choosing: copper T380 IUD or oral LNG for EC n=542 women who presented for EC <120h - Salt Lake City, US 215 (40%) chose the copper IUD IUD insertion failed in 42 women (19%) 327 (60%) chose oral LNG 1-year F/U rate was 82% 64% of IUD users still had their IUDs at 1 year Turok DK, et al Contraception Mar;89(3)

35 1-year cumulative pregnancy rates: By type of EC method actually received: 5.2% for copper IUD users vs. 12.3% for oral LNG users HR 0.42 ( , p=.017) Turok DK, et al Contraception Mar;89(3)

36 Promotion of IUD for EC warranted Turok DK, et al Contraception Mar;89(3) But what are our failed insertion rates? if we tell our patients that 1 in 5 emiud insertions fail how many would still go for it??

37 Participants were customers (63% males) in a barroom in Grenoble, France. Randomized to alcoholic or placebo drink

38 Participants drank, then rated how attractive, bright, original, and funny they felt at the moment estimated blood alcohol level using a breathalyser evaluated by independent judges

39 Conclusion: when people drink alcohol, they evaluate themselves as more attractive (or at least, less unattractive), but this selfperception appears to be an illusion. quantity of alcohol ingested was not related to self-perceived attractiveness

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