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A 39-year-old HIV-positive black African woman with previously treated cerebral toxoplasmosis experienced a foetal intra-uterine death due to congenital toxoplasmosis. This case demonstrates the complexities of screening for maternal toxoplasmosis in the context of pregnancy and HIV infection-related cell-mediated immunosuppression. Additionally, the case highlights the challenges in providing effective preventative and therapeutic drug options for congenital toxoplasmosis.

Background Studies have shown high rates of concurrent rectal CT in women with urogenital infection. Extra-genital STI testing in women is is not routine, and would be cost-prohibitive for all women. Pooling of samples from different anatomical sites is an effective method of testing for bacterial STIs, however is most commonly used in men who have sex with men. Before implementing pooled sampling within our services we performed a small validation comparing triple site sampling with pooled sampling for detection of CT and Neisseria gonorrhoea (NG) in women Methods This validation was performed at a level 3 genito-urinary medicine clinic in London from January – March 2018. Patients were both symptomatic and asymptomatic. Samples were taken by either clinician or patient. All samples were tested using Aptima Combo 2 nucleic acid amplification tests. Results 99 cisgender women were included with a median age of 22. 56 women (57%) had symptoms that could indicate an acute STI. None reported rectal symptoms 19 patients tested positive for CT at any site (19% prevalence). Genital only (2) rectal only (7) pharynx only (1) genital + rectal (6) triple site (3). Pooled sampling detected CT RNA in 18/19 patients (95%) and was equivocal in 1/19 patients (sensitivity 95% specificity 100%). Conclusion We demonstrated high prevalence of extra-genital CT infection in women. 2/19 had genital infection alone; genital sampling would miss 8/19 (42%) of CT infection. In this small evaluation, pooled sampling has been shown to be sensitive and specific for detection of CT. 16/19 women (84%) had rectal CT. Our study is limited by size and inconsistent documentation of receptive anal sex, however evidence shows this to be a poor predictor of rectal CT infection. We limited our sample to a high prevalence population so our results may not be generalizable to lower prevalence groups. Disclosure No significant relationships.

Objectives The aim of the study was to identify differences in infant outcomes, virological efficacy, and preterm delivery (PTD) outcome between women exposed to lopinavir/ritonavir (LPV/r) and those exposed to atazanavir/ritonavir (ATV/r). Methods A retrospective case note review was carried out. The case notes of 493 women who conceived while on LPV/r or ATV/r or initiated LPV/r or ATV/r during pregnancy and who delivered between 1 September 2007 and 30 August 2012 were reviewed. Data collected included demographics, antiretroviral use, HIV markers, and pregnancy and infant outcomes. Infant outcomes, virological efficacies and PTD rates for LPV/r and ATV/r were compared. Results A total of 306 women received LPV/r (82 conceiving while on the drug and 224 commencing it post-conception) and 187 received ATV/r (96 conceiving while on the drug and 91 commencing it post-conception). Comparing the two protease inhibitors (PIs), viral suppression rates were similar and, in women starting antiretroviral therapy (ART) post-conception, the median times to first undetectable HIV viral load were not significantly different (P = 0.64). PTD rates did not differ by therapy overall (ATV/r, 13%; LPV/r, 14%) or when considering the timing of first exposure (conceiving on ART, P = 0.81; commencing ART in pregnancy, P = 0.08). Poor fetal outcomes were very uncommon. There were two transmissions, giving a mother-to-child transmission (MTCT) rate of 0.4% (95% confidence interval 0.05–1.5%). Conclusions Both ART regimens were well tolerated and successful in preventing MTCT. No significant differences in tolerability or in pregnancy or infant outcomes were observed, which supports the provision of a choice of PI in pregnancy.

OBJECTIVES: To document postpartum disease-free survival of HIV-infected women taking antiretroviral therapy (ART) during pregnancy. METHODS: Laboratory and clinical data were collected on all HIV-infected pregnant women delivering from 1998 to 2002 and followed up until September 2004 at 6 hospitals in London. Mothers were grouped according to receipt of zidovudine monotherapy (ZDVm), highly active antiretroviral therapy (HAART) given during and continued after pregnancy (cHAART), and short-term HAART given during pregnancy and discontinued on delivery (START). RESULTS: Eight-five women took ZDVm, 155 took cHAART, and 71 took START. The mean follow-up for all mothers was 33 months, with a total of 847 person-years. At the first antenatal clinic (ANC) visit, 72% of women were in Centers for Disease Control and Prevention (CDC) stage A, 85% were treatment naive, and the ZDVm group had a median HIV viral load (VL) 10-fold less than those mothers who started HAART during pregnancy. At last follow-up, 1 patient had died and 6 (1.9%) had progressed to CDC stage C; 62% of all women, including a quarter of the ZDVm group, were receiving HAART for their own health; and 83% of all mothers had a VL

Introduction.There are few data regarding the tolerability, safety, or efficacy of antenatal atazanavir. We report our clinical experience of atazanavir use in pregnancy.Methods.A retrospective medical records review of atazanavir-exposed pregnancies in 12 London centres between 2004 and 2010.Results.There were 145 pregnancies in 135 women: 89 conceived whilst taking atazanavir-based combination antiretroviral therapy (cART), “preconception” atazanavir exposure; 27 started atazanavir-based cART as “first-line” during the pregnancy; and 29 “switched” to an atazanavir-based regimen from another cART regimen during pregnancy. Gastrointestinal intolerance requiring atazanavir cessation occurred in five pregnancies. Self-limiting, new-onset transaminitis was most common in first-line use, occurring in 11.0%. Atazanavir was commenced in five switch pregnancies in the presence of transaminitis, two of which discontinued atazanavir with persistent transaminitis. HIV-VL < 50 copies/mL was achieved in 89.3% preconception, 56.5% first-line, and 72.0% switch exposures. Singleton preterm delivery (Conclusions.These data suggest that atazanavir is well tolerated and can be safely prescribed as a component of combination antiretroviral therapy in pregnancy.

Background/introduction Screening for HIV and hepatitis B (HBV) is recommended for MSM attending GUM clinics. Hepatitis C testing is recommended for all HIV positive MSM. However, the PROUD pilot study reported an HCV incidence of 3.1% in high-risk, HIV negative MSM. Aim(s)/objectives To report on proportion tested and prevalence of blood-borne viruses (BBVs) amongst MSM attending GUM clinics Methods We collected demographic data and numbers tested for BBVs in all MSM attending 2 GUM clinics between 01/07/14 and 30/06/15 from electronic records. We compared proportion tested and prevalence in high-risk vs low-risk MSM and in HIV+ vs HIV- MSM. High-risk was defined as ≥1 sexually transmitted Infection (STI) i.e. Gonorrhoea, chlamydia and syphilis. Results 4,415 patients were included. 3,289 (88.0%) were tested for HIV, 2,162 (49.1%) for HBV, 794 (18.1%) for HCV. Positives: 48 (1.5%) HIV, 11 (0.5%) HBV and 18 (2.3%) HCV [9/16 (56.3%) viraemic]. 1,003 (22.7%) were diagnosed with an STI: Syphilis 159 (3.6%), Gonorrhoea 640 (14.5%), Chlamydia 398 (9.0%). BBV prevalence was higher in high-risk vs low-risk MSM: HIV 23 (3.4%) vs 25 (1.0%); HBV 4 (0.7%) vs 7 (0.4%); HCV 10 (3.5%) vs 8 (1.6%).More HIV+ MSM were tested for HCV; 198 (27.8%) vs 587 (16.9%) HIV- (crude OR 1.9 (95% CI 1.6–2.3). HCV prevalence in those tested was 12 (6.1%) in HIV+ and 6 (1.0%) in HIV–. Discussion/conclusion MSM were less likely to be tested for HCV than for HIV. Amongst those tested, HCV prevalence was 5x the national prevalence (0.4%). Prevalence of viral hepatitis was highest in HIV+ and in high-risk MSM suggesting that testing efforts should be increased.

Background/introduction With an ever decreasing financial envelope, sexual health services are being tasked with developing more cost effective ways of managing patients without impacting on quality of care. Centralised patient management systems have reduced the need for face to face contact, using virtual systems, based upon Health and Social Care information Centre (HSCI) definitions, to manage ongoing care for patients including partner notification. Aim(s)/objectives Analyse virtual management undertaken with patients following new attendance for episodes of STI care. To ascertain and categorise the number of virtual contacts that prevented a face to face follow up attendance. Methods Thematic analysis was performed on a randomised sample of telephone consultations definitions between 04/15 and 01/16 Results 82,994 calls were made to automated results systems. 13,373 calls were transferred from the automated system. Discussion/Conclusion The automated system manages 82% of calls without patients opting to speak with clinicians. Significant numbers of patients opted for telephone consultation upon notification of an infection, giving opportunity for initiation of PN alongside management of further testing and treatment. Approaching ¼ of consultations analysed, showed no additional testing or treatment was indicated, but advice and reassurance was the primary reason for speaking with staff. Virtual consultations can provide a high quality alternative to face to face follow-up visits.

Background Correct management of Pelvic Inflammatory Disease (PID) is important to reduce complications but often varies widely. An audit of PID management in our trust’s GUM clinics was undertaken in 2014 which led to trust guidelines being updated in early 2015. The main finding was antibiotic regimes were varied; only 12% received a BASHH recommended regime. We re-audited the management of PID in 2015. Aim To compare PID management across our trust’s GUM clinics in 2014 and 2015. Methods Electronic patient records of 141 female patients with C5A codes in 2014 and 100 in 2015 were reviewed and compared. Results In both audits 98% of patients had Chlamydia/Gonorrhoea NAATs sent; 93% had vaginal microscopy in 2014 and 92% in 2015, but cervical microscopy improved from 13% in 2014 to 45% in 2015. Pregnancy tests were inconsistently done, 83% in 2014 and 75% in 2015. Those with chlamydia, gonorrhoea or trichomonas vaginalis increased from 8% to 13% but bacterial vaginosis was the most common finding, 28% in 2014 and 46% in 2015. Antibiotic regimes were BASHH recommended in 12% (2014) and 88% (2015), due to updated 2015 trust guidelines being in line with BASHH. Discussion Improvements have occurred since 2014 but cervical microscopy and pregnancy tests are still not consistently being done. Low levels of STIs detected may represent incorrect diagnosis in some. Antibiotic prescription has improved significantly, however we are still below the BASHH target of 95% (currently 88% compliance). We will re-present findings of this re-audit to clinics to improve standardisation of PID management.

British HIV Association guidelines recommend that all HIV-positive pregnant women should be encouraged to disclose their HIV infection to their partner and that this should be viewed as a process rather than an event. The aim of this study was to describe local practice of partner notification (PN) and patterns of disclosure in a group of HIV-positive women in an antenatal setting. A retrospective case note and local pregnancy database review was undertaken. Women who had accessed specialist HIV antenatal care at one of three east London hospitals with an expected delivery date between 1 March 2004 and 30 June 2006 were identified. In total, 145 women were identified. HIV status had not been disclosed to a partner in 19% (n=27) of case notes reviewed. There was no documented discussion about PN in 18% (n=26) of case notes. Forty-three per cent (n=62) of case notes documented that the male partner had accessed HIV testing after PN was discussed. All HIV-positive pregnant women should have a documented discussion about PN. Concurrent HIV testing offered to both partners may improve HIV testing uptake in male partners and should be explored further. Care plans should include screening for intimate partner violence and housing problems; referral pathways should be established clearly when involving other agencies.

Introduction In comparison to other specialities, generating feedback from sexual health patients on clinic experience is challenging. Web-based technology can address many challenges associated with paper-based surveys, and is increasingly used to generate feedback in healthcare. A survey conducted in our service showed that four-fifths of our patients use smartphones; we therefore wanted to use technology to capture patient experience of our service. Aim To measure real-time patient experience of our sexual health service using an online questionnaire. Methods Since May 2014, new patients attending one of our five services are sent a link to an online survey via free text message. The short survey captures demographic data and feedback, with facility to request call back to discuss any concerns. Results Since May 2014, 2457 new patients (18%) have completed the survey (2457/13753). Discussion We have demonstrated high levels of satisfaction with our service as a result of this online survey. Implementation challenges include varying response rates, administration time and cessation of free messaging. However, the generation of real-time feedback is valued by staff, commissioners and patients, and has resulted in several service improvements e.g. improved signage and new processes for triaging patients.

Background/introduction Diagnosis and management of pelvic inflammatory disease (PID) in the genitourinary medicine clinic can be challenging. Optimising management is essential in preventing potential sequelae. The national BASHH PID audit (2012) indicated that adherence to guidelines was inconsistent. Aim(s)/objectives To audit PID management to help inform introduction of new trust guidelines. Methods Retrospective case note review of all patients with a PID clinic code over six months at three clinics across the trust. Results Of 184 cases identified, 99.5% of patients had either one or more of PID symptoms: lower abdominal pain, dyspareunia, abnormal bleeding, vaginal discharge. 92% and 97.8% of patients underwent microscopy and STI screening respectively. 16 tested positive for chlamydia, 4 for gonorrhoea, 5 for herpes simplex virus, 2 for trichomonas vaginalis, 47 for bacterial vaginosis (BV), 8 for urinary tract infection (UTI) and 10 for candida. 61% received a recommended treatment regimen, with up to 20 different treatment regimens prescribed. 44% of patients attended for follow-up after two weeks. Discussion/conclusion In this cohort, there were relatively few STI diagnoses, with BV being the most likely microbiological diagnosis. There was wide variation in prescribing practice and adherence to local and national guidelines. Diagnostic criteria for PID were simplified and disseminated at a trust-wide meeting. New trust guidelines were introduced taking local resistance patterns and national guidance into account.

Background/introduction Clinical coding in England provides monitoring data for Public Health England via the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) and Sexual and Reproductive Health Activity (SRHAD) returns. In London, this data is also used to reflect activity for the Integrated Sexual Health Tariff (ISHT) which may form the basis for payment in future. Integration of contraception and GUM services presents a challenge in maintaining accuracy of clinical coding. Aim(s)/objectives To audit the accuracy of SHAPPT, SRHAD and SRH coding in a multi-site integrated sexual health service, comparing sites traditionally providing GUM services vs contraception. Methods Local standards were agreed; 95% of patients should have accurate SHAPPT, SRHAD and SRH codes. 229 records from 2 GUM sites and 53 from 1 contraception site were audited from attendances between May and July 2014. Results Discussion/conclusion As expected, the accuracy of coding reflected the traditional nature of the sites. The locally set standard of 95% was only reached on one occasion. Missing SRH codes alone would equate to lost income of £1259 from 77 visits if the ISHT was in place. Staff training and weekly capture and correction of missing HIV codes through targeted email reminders has resulted in an improvement in coding.