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ObjectiveA resurgence in bacterial STIs, notably syphilis, among gay, bisexual and other men who have sex with men (MSM) has been detected in England. A Canadian modelling study postulated that antiretroviral therapy (ART) may increase susceptibility to syphilis. We assess the association between ART and syphilis incidence in a comprehensive national cohort of MSM living with HIV in England.MethodsNational surveillance data were used to create a cohort of MSM attending for both HIV and STI care in England between 2009 and 2016. Survival analysis was used to calculate the incidence of infectious syphilis during periods on and off ART. Multivariable Poisson regression was used to assess the association between ART use and syphilis, after adjustment for potential confounders, including, as a proxy measure for high-risk behaviour, being diagnosed with >1 other STI prior to a syphilis diagnosis.Results19 428 HIV diagnosed MSM contributed 112 960 person-years of follow-up from 2009 to 2016. The overall rate of syphilis was 78.0 cases per 1000 person-years follow-up. Syphilis rates were higher among men receiving ART (36.8) compared with those who did not (28.4) (absolute rate difference 4.7 cases per 1000 person-years). Multivariable analysis showed no statistical association between receiving ART and syphilis. Increased risk of syphilis was found in MSM aged 25–34 (HR 1.89, 95% CI 1.43 to 2.51) and in those diagnosed with two other STIs (HR 5.83, 95% CI 5.37 to 6.32).ConclusionWhile we observed a small increase in the rate of syphilis among those on ART, when adjusting for potential confounding factors, including a proxy measure for high-risk behaviour, there was no evidence of an increased risk of syphilis in MSM receiving ART. High-risk sexual behaviour markers were the main risk factors for syphilis, and our results highlight the need for STI prevention interventions in MSM living with HIV to target these particularly high-risk sexual networks.

IntroductionHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets).Methods and analysisService evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses.Ethics and disseminationThe chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

Objectives: To provide nationally representative data on trends in HIV testing in primary care and to estimate the proportion of diagnosed HIV positive individuals known to general practitioners (GPs). Methods: We undertook a retrospective cohort study between 1995 and 2005 of all general practices contributing data to the UK General Practice Research Database (GPRD), and data on persons accessing HIV care (Survey of Prevalent HIV Infections Diagnosed). We identified all practice-registered patients where an HIV test or HIV positive status is recorded in their general practice records. HIV testing in primary care and prevalence of recorded HIV positive status in primary care were estimated. Results: Despite 11-fold increases in male testing and 19-fold increases in non-pregnant female testing between 1995 and 2005, HIV testing rates remained low in 2005 at 71.3 and 61.2 tests per 100 000 person years for males and females, respectively, peaking at 162.5 and 173.8 per 100 000 person years at 25–34 years of age. Inclusion of antenatal tests yielded a 129-fold increase in women over the 10-year period. In 2005, 50.7% of HIV positive individuals had their diagnosis recorded with a lower proportion in London (41.8%) than outside the capital (60.1%). Conclusion: HIV testing rates in primary care remain low. Normalisation of HIV testing and recording in primary care in antenatal testing has not been accompanied by a step change in wider HIV testing practice. Recording of HIV positive status by GPs remains low and GPs may be unaware of HIV-related morbidity or potential drug interactions.

Background/introduction As in many other western countries, men who have sex with men (MSM) are most affected by HIV in the UK. Aim(s)/objectives To describe 15-year trends in HIV among MSM to inform prevention strategies. Methods National HIV surveillance data were linked to national register deaths and HIV testing data from sexually transmitted infection (STI) clinics. Multivariable analyses revealed predictors of late diagnosis (800 men have been diagnosed late annually since 2004. HIV testing in STI clinics in England increased, 10,900 to 102,600. One-year death rates among new diagnoses declined (4.6% to 0.9%) due to fewer deaths among late presenters (4.4% to 1.8%). Older age (>50) and living outside London were predictors of late presentation, while older age and late presentation were predictors of one-year mortality. Discussion/conclusion In its third decade, the HIV epidemic among UK MSM has continued to diversify. Increases in new diagnoses reflect both increased testing and ongoing transmission. Despite improvements in patient outcomes, >800 men present late each year; death rates remain high and preventable. Culturally appropriate prevention and testing strategies require strengthening to reduce HIV transmission and late diagnosis.

Introduction In England, 80% of HIV diagnoses are in sexually transmitted infection (STI) clinics. Since 2009, Public Health England offered testing for recent HIV infection. Aim To estimate HIV incidence among STI clinic attendees in 2012. Methods The AxSYM avidity assay, modified to determine antibody avidity, was conducted on aliquots of newly diagnosed persons and results linked to the national HIV database. An incident case was defined as avidity Results Of 212 STI clinics in England, 150(71%) submitted specimens for recent infection testing, comprising 3,930 persons newly diagnosed; 50% were MSM. The number of HIV tests/diagnosis was 210 for all clinic attendees, 38 for MSM, 403 for all heterosexuals and 46 for black African heterosexuals. HIV incidence was 0.15% (95% C.I. 0.13–0.18%) for all attendees, 1.22% (95% C.I. 1.07–1.42%) for MSM, 1.41% (95% C.I. 1.21%-1.66%) for MSM in London, 0.03% (95% C.I. 0.02–0.04%) for heterosexuals and 0.13% (0.05–0.22%) for black African heterosexuals. Discussion/conclusion Testing for recent HIV infection combined with routinely collected clinical data provides robust and timely national estimates of HIV incidence. HIV incidence among MSM and black African heterosexuals attending STI clinics was 40 and nine times higher respectively than among all heterosexuals, and exceeds the WHO-defined elimination threshold of 0.1%.

Background Mortality from AIDS has dramatically reduced since the introduction of effective antiretroviral therapy, Nevertheless, HIV infected individuals remain at higher risk of early death. We investigate all causes of deaths among HIV diagnosed adults reported nationally in the HAART era. Methods Analyses of data from national HIV surveillance linked to the Office National Statistics. Deaths among all adults (≥15) diagnosed between 1997 and 2008 in England and Wales (E&W) were reviewed and grouped by cause of death (COD) and risk information. Death rates were calculated using a census of all persons accessing HIV care in 2008 (SOPHID). Results The crude mortality rate among HIV-infected individuals (15−59 yrs) fell from 21.8 to 8.2 per 1000 persons living with diagnosed HIV in 2008. A total of 3640 (5.6%) persons diagnosed over the 12-year period were reported to have died [3544 had a cause of death]. The overall median age at death was 41 yearss [IQR: 35−50 years]. AIDS related mortality accounted for 56% of all deaths: 51% among MSM, 61% among heterosexuals and 34% among IDUs. AIDS-related respiratory infection (including PCP) was the most common COD in MSM and heterosexuals whereas external causes were the most common COD among IDUs. Non AIDS mortality increased sixfold since 1997 (36−226), with particular increases in cardio/cerebrovascular disease, non-AIDS defining malignancies and external causes. Infectious diseases (mostly respiratory) was the most common underlying cause of non AIDS deaths for MSM and heterosexuals aged 15−59: (38% and 36% respectively) and also high among IDUs (35%). External causes (mostly due to overdose and suicide) was the most common COD among IDUs (36%) and high among MSM (19%). Cardio/cerebrovascular disease and non AIDS malignancies accounted for 16% and 11% of non-AIDS deaths (15−59 years) respectively. Three quarters (76%) of all AIDS deaths and 47% of non AIDS deaths occurred within a year of diagnosis. Conclusion Overall mortality rates in HIV positive persons have substantially declined in the HAART era but remain high compared to the general population. Clinical AIDS associated with late presentation continues to account for the majority of deaths. Our analyses also reveal that a disproportionate number of deaths are due to infectious diseases, overdose and suicide occur in this population, many of which may be preventable. Surveillance of non-AIDS causes of death is critical in the HAART era.

Introduction Tuberculosis (TB) rates in the UK are amongst the highest in Western Europe and HIV-TB co-infection (HIV-TB) contributes significantly to the burden of TB in the UK. Globally, HIV-TB is associated with significant morbidity and mortality, in particular where there is delayed diagnosis. Analysis of setting-specific survival can inform local healthcare policy. Here we report the outcome of individuals diagnosed with HIV in the UK, with particular emphasis on TB co-infection.Methodology We examined deaths among a retrospective national cohort of adults (15 years +) diagnosed with HIV infection between 2000–2008 linked to the national TB databases and death records from the Office of National Statistics to mid-2010. Hazard ratios (HR) estimates using uni- and multi-variable Cox regression modelling were calculated to compare all-cause and AIDS-specific mortality by key demographic and clinical markers.Results A total of 1,880 (4.3%) deaths were observed among 44,050 HIV-diagnosed adults during 149,663 person-years of follow-up. 3,188 (7.2%) adults developed TB and HIV-TB cases accounted for 341 (18.1%) of all deaths of whom 270 (79.2%) were late presenters (CD4

Background In the UK the primary objective of RITA has been to measure HIV incidence. The UK is the first country to routinely return results to patients and with over 7000 tests returned to clinicians so far, RITA is now seen as part of baseline HIV clinical care in participating centres. Objectives To evaluate patients9 experience of receiving a RITA result, including effects on identifying likely timing of infection, partner notification and relationships. Methods Five HIV centres in England asked their patients to complete a questionnaire on their experience of receiving a “recently infected” RITA result soon after their HIV diagnosis. Results Forty patients with newly diagnosed HIV and a “recent” RITA result completed the questionnaire (93% MSM). The majority (30/40, 75%) said that receiving the recent RITA result was helpful; 10 were unsure how helpful it was, and no participants found it unhelpful. 24 patients (60%) reported RITA helped identify partners who may be at risk of HIV and 24 (62%) felt it helped them to better understand how they may have been infected. Most (35, 88%) either felt neutral or “not more upset” when they learnt that they were likely recently infected. Of those in a relationship 33/37 (89%) reported RITA testing had not caused any relationship problems. Conclusion The majority of patients receiving recent RITA results found this information helpful and no-one found it unhelpful. The result was felt to be useful in increasing an understanding of the likely timing of infection and for identifying “at risk” partners.

Background Testing for recent infection with HIV has been part of routine national surveillance in the UK since 2009. These data can be used to estimate HIV seroincidence in populations. For these estimates to be accurate, HIV testing behaviour must be independent of HIV acquisition risk. This is unlikely to be true, as much testing may be motivated or clinically indicated. Aims To identify demographic and behavioural differences between individuals diagnosed with recent ( Methods Recent Infection Testing Algorithm (RITA) results were linked to Genitourinary Medicine Clinic Activity Dataset attendance records (providing data on attendance and sexual health) for the year preceding the date of RITA test and/or HIV diagnosis. Univariate analyses were performed examining age, sexual orientation, GUM clinic attendances, and STI history, to identify predictors of being diagnosed at early stages of HIV infection. Results Preliminary analyses show that among 628 newly diagnosed HIV-positive individuals, 14% (85/628) were diagnosed with recent HIV infection. Being diagnosed with a recent HIV infection was positively associated with younger age, men who have sex with men and having been diagnosed with any bacterial STI in the year preceding the HIV diagnosis (see Abstract O14 table 1). Those visiting a sexual health clinic more than twice in the previous year were also more likely to be diagnosed at early stages of HIV infection. Conclusions Important behavioural and demographic differences exist between individuals diagnosed with recent vs established HIV infections. Such differences must be considered when deriving incidence estimates among key at-risk groups. Further work to examine these trends among all RITA results, in particular the relationship with HIV testing patterns, is ongoing.

Background Endemic HIV transmission in men who have sex with men (MSM) is a major concern in England. Since 2008, a new national anonymised genitourinary medicine (GUM) clinic reporting system provides follow-up data on clinic attendees. Objective To calculate HIV seroconversion rates and identify predictors of acquisition in MSM clinic attendees to inform the development of further HIV prevention initiatives. Methods National cohort of MSM who tested HIV negative at a GUM clinic in England in 2009 and had a follow-up test within 1 year were included in these analyses. HIV seroconversion rates (per 100 person-years (py)) with 95% CI were calculated by subgroups and risk markers. HR with 95% CI are reported for significant (p Results Among the 15 500 men who attended in 2009, there were 277 seroconversions, giving an overall incidence of 2.7/100 py (95% CI 2.4 to 3.1). Incidence was higher among MSM aged 35–49 years (3.4/100 py), of black ethnicity (4.1/100 py) and with a previous gonorrhoea or chlamydia infection (8.6/100 py and 9/100 py, respectively). In multivariable analysis, risk of acquiring HIV was higher among MSM with a previous gonorrhoea (HR: 2.4, 95% CI 1.4 to 4.1) or chlamydia infection (HR: 3.0, 95% CI 2.0 to 4.7) or who received treatment as a STI contact (HR: 1.8, 95% CI 1.1 to 2.9). Age predicted HIV acquisition in 30% of new infections and clinical risk markers from the previous year another 10%. Conclusions Annual HIV incidence among MSM re-attending GUM clinics is very high at almost 3%. None of the clinical risk factors were important predictors of HIV acquisition. Therefore more discriminatory behavioural information is required to identify MSM at higher risk of HIV and facilitate better triaging of HIV prevention measures in GUM clinics.

Background A test for recent infection (avidity test) is offered for all patients newly diagnosed with HIV in England and Wales as part of an HIV incidence surveillance programme. The UK is currently the only country to return these results to individual patients. Objectives To determine the acceptability and patient experience of receiving a RITA test result soon after HIV diagnosis. Methods This was a qualitative study using semi-structured interviews. 14 people recently diagnosed with HIV who had a RITA result consented to participate. Analyses were based on the framework method using N-Vivo software. Interviews were transcribed, coded and emergent themes identified. Results All participants agreed that the more information available to them about the possible duration of infection the better. Unsurprisingly the HIV diagnosis and the emotions and practical issues associated with it had far more impact than the RITA result. None of the participants experienced any problems with former partners as a consequence of their RITA result although some could see the theoretical potential for such problems. “Recently infected” RITA results were felt to be potentially useful for identifying “at risk” partners. However partner notification was not altered in the study group because the individuals concerned had other reasons to suspect recent infection. Other major themes identified were the perceived stigma; the difficulty of sharing the diagnosis of HIV with family and friends; and the many conflicting emotions that people had to deal with at diagnosis including anger, grief, self-blame, fear and depression. Conclusion RITA testing is a potentially useful epidemiological tool. These interviews demonstrated that receiving a RITA result, while useful to some people, is a minor issue compared with dealing with the HIV result itself. Reassuringly none of the participants reported negative outcomes from receiving the RITA result.

OBJECTIVES\ud \ud To estimate life expectancy for people with HIV undergoing treatment compared with life expectancy in the general population and to assess the impact on life expectancy of late treatment, defined as CD4 count

Background Tuberculosis (TB) and HIV/AIDS are global public health problems with considerable mutual interaction. Data on national TB-HIV co-infection trends are essential to plan and evaluate TB-HIV control measures. We compared the burden of co-infection and how this is monitored in surveillance systems in England with the rest of Europe. Methods A systematic search of academic and grey literature identifying studies reporting data on TB-HIV co-infection in EU/EEA countries. A questionnaire survey among EU/EEA countries9 TB surveillance leads, regarding surveillance methods, data and proportion of cases tested for HIV. For England, Wales and Northern Ireland, cases reported to Enhanced Tuberculosis Surveillance matched to national HIV/AIDS case reports. Results A total of 55 papers were identified providing estimates on the proportion of TB patients co-infected with HIV. From 30 EU/EEA countries 25 TB questionnaires were returned. This gave prevalence data for 23 countries. In England, the prevalence of HIV co-infection among TB patients rose from 5% in 2000 to 8% in 2005, with a peak at 9% in 2003–2004. These figures are at the higher end of what is observed in Europe. France, Iceland and Portugal (11–15%) had higher co-infection levels, while similar levels were found for Estonia and Malta (9%). Very low levels were reported from central European countries (0–1%). A rise in co-infection levels was seen in Estonia, Latvia, Lithuania, the UK and Belgium, while decreases were seen in Spain and Portugal. The burden was higher in countries reporting high levels of HIV testing and countries with a higher HIV burden. Information on TB patients9 HIV status was collected in 19/25 TB surveillance systems responding to the survey. While 17 countries rely on clinician reporting, in England and Finland, data are obtained by matching to national HIV/AIDS surveillance data due to confidentiality concerns. Conclusion Levels of TB-HIV co-infection vary widely across EU countries, with the UK being at the higher end. Our data suggest that TB-HIV surveillance appears patchy and needs strengthening to better inform control policies and clinical practice.