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Chronic hepatitis C virus (HCV) infection is associated with significant morbidity, mortality and health economic burden. Over 90% of HCV cases in England occur in people who inject drugs (PWID). Current treatments for HCV are effective but do not protect against reinfection. This research characterised HCV infection and reinfection risk in PWID in England using 2011-2021 data from the annual, cross-sectional, bio-behavioural survey of PWID, Unlinked Anonymous Monitoring. Risk factors for HCV infection were explored using multivariable logistic regression. Shared frailty models for the force of infection (FOI) were used to estimate the risk of HCV infection throughout injecting career with unmeasured risk variation modelled using gamma-shaped frailty distributions. HCV reinfection rates were derived using the frailty distributions of FOI models fitted to UAM data. Infection rates were highest in the first year of injecting (24 per 100 person-years) but fell to between 5 and 8 infections per 100 person-years subsequently. The estimated average annual risks of HCV primary infection and reinfection were 10.0% and 14.2%, indicating a 42% higher risk of reinfection compared to primary infection. Even those with no a priori risk factors were predicted to have high rates of reinfection if previously infected. These findings support the recognition of primary HCV infection as an independent risk factor for reinfection in PWID and emphasise the importance of reducing high-risk behaviours to prevent HCV reinfection following treatment of primary infection. Public health policies must recognise the importance of preventing reinfection in efforts to reduce HCV infection prevalence., (© 2025 The Author(s). Journal of Viral Hepatitis published by John Wiley & Sons Ltd.)

Objectives: HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP., Methods: Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England., Results: PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning., Conclusions: Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030., Competing Interests: Competing interests: Flavien Coukan has received funding from the BHIVA/ViiV Implementation Science Scholarship to investigate the barriers and facilitators to PrEP access faced by Black women., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: HTLV-1 is predominantly a sexually-transmitted infection but testing is not mentioned in HIV-PrEP guidelines. We ascertained HTLV-1/HTLV-2 seroprevalence amongst HIV-PrEP users in England., Methods: An unlinked anonymous seroprevalence study., Results: Amongst 2015 HIV-PrEP users, 95% were men, 76% of white ethnicity and 83% had been born in Europe. There were no HTLV-1/HTLV-2 seropositive cases (95% confidence interval 0% - 0.18%)., Conclusions: There were no HTLV positive cases, likely reflecting the demographic of mostly white and European-born individuals. Similar studies are needed worldwide to inform public health recommendations for HIV-PrEP using populations, particularly in HTLV-endemic settings., Competing Interests: Declaration of Competing Interest None, (Copyright © 2023. Published by Elsevier Ltd.)

Objectives: In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing., Methods: Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported., Results: Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17)., Conclusions: The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM., (© 2017 Crown copyright. HIV Medicine © 2017 British HIV Association.)

Surveillance data from sexual health clinics indicate recent increases in sexually transmitted infections, particularly among men who have sex with men. The largest annual increase in syphilis diagnoses in a decade was reported in 2014. Less condom use may be the primary reason for these increases.

Background: The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians' use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population., Methods/design: This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage., Discussion: This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care.