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Summary Background The aim of this study was to quantify the change in the number of conceptions and abortions among women younger than 18 years in England in relation to the government's national teenage pregnancy strategy. Methods We undertook geographic analysis of data for 148 top-tier local authority areas. The main outcomes were changes in under-18 conceptions, abortions, and births between the 5-year period before implementation of the strategy (1994–98) and the period immediately after implementation (1999–2003). Findings The number of teenage conceptions peaked in 1998, then declined after the implementation in 1999 of the teenage pregnancy strategy. Under-18 conception rates fell by an average of 2·0% (95% CI 1·8 to 2·2) per year between 1998 and 2003, below the rate needed to achieve the target of 50% reduction by 2010. The net change between 1994–98 and 1999–2003 was a fall in conceptions of 3·2% (2·6 to 3·9) or 1·4 per 1000 women aged 15–17 years, a rise in abortions of 7·5% (6·5 to 8·6) or 1·4 per 1000, and a fall in births of 10·6% (9·9 to 11·3) or 2·8 per 1000. The change in the number of conceptions was greater in deprived and more rural areas, and in those with lower educational attainment. The change was greater in areas where services and access to them were poorer, but greater where more strategy-related resources had been targeted. Interpretation The decline in under-18 conception and birth rates since 1998 and evidence that the declines have been greatest in areas receiving higher amounts of strategy-related funding provides limited evidence of the effect of England's national teenage pregnancy strategy. The full effect of local prevention will be clear only with longer observation, and substantial further progress is needed to remedy England's historically poor international position in teenage conceptions.

High rates of sexually transmitted infections (STIs) and unplanned pregnancy amongst young people in England emphasize the need to explore innovative ways of delivering sexual health information. The National Teenage Pregnancy Strategy and the National Strategy for Sexual Health and HIV advocate better sexual health education. The latter states: "Information on sexual health is often uncoordinated or poorly targeted. It is not consistently accessible and doesnt make enough use of new media and technology". The Internet is a practical accessible tool for increasing sexual health awareness. Sexual health sites can be particularly valuable information sources for young people who have trouble accessing sexual health services and can be used to publicise services by providing information that tackles access barriers (e.g. confidentiality for all ages free emergency contraception how to get there and so on). Access content site quality and level of maintenance are four components we feel should be considered prior to the development of sexual health sites. We present these as a starting point to encourage further debate on the use and evaluation of the Internet in sexual health promotion and to build on Susan Quilliams review of self-help websites in this issue of the journal. (excerpt)

Information on age- and gender-specific prevalence of herpes simplex virus (HSV) types 1 and 2 infections is crucial to guide genital herpes control strategies. Such data are not available from the newly independent Eastern European countries. We present of study of the age- and gender-specific prevalence of HSV-1 and HSV-2 in low risk populations in Estonia. Serum samples from 1016 children, 794 first trimester antenatal women, and 1036 blood donors (462M, 574F) were tested for HSV IgG antibodies by type-specific HSV-1 and HSV-2 assays. High seroprevalence rates of HSV-1 among children, pregnant women and (non-paid) blood donors were found. HSV-2 infection was not detected among boys. Gender differences in HSV-2 seroprevalence rates among people of reproductive age were observed: higher rates were recorded among pregnant women (23%) and female blood donors (21%), compared to 11% among male blood donors. HSV-1 seroprevalence was high in adults. HSV-2 seroprevalence was higher among females than males and increased substantially with age. HSV-2 prevalence in these non-high risk populations was relatively high, and may indicate a risk for an impending sexually- and STI- driven HIV epidemic.

In the United Kingdom, services for contraceptive consultation and family planning were first opened in the 1960s. Early and relevant information to adolescents is of importance. The aim of this paper was to examine young people's attitudes towards and experiences of consultations with health care providers about contraception, taking account of the context of their contraceptive use. Young people aged 16-21 years were recruited to the study from health services (young people's contraceptive and sexual health clinics and a termination of pregnancy clinic), secondary schools and community projects (a youth club, a young mothers' support group, a community education project and a young women offenders unit). As part of the needs' assessment, in-depth interviews and focus groups were conducted. Thirty-two young male and females were interviewed. Knowledge about contraception, sexually transmitted infections and the risk of pregnancy was often high. Many respondents noted that in a five to ten minute consultation there was not the time to discuss personal factors that may affect contraceptive decision making and effective use of methods. Many described a feeling of being rushed through the service and did not feel they had the opportunity to ask questions. What young people said they wanted from consultations with health care workers and their experiences of the consultation process often conflicted. They wanted the time and opportunity to discuss their options. Often the young men, who were accessing services, described how initially they had gone in to collect condoms, but once they knew the clinic and staff would consider making an appointment. It is concluded that young people want to be given choices and information regarding contraception that fit their lifestyles. Improving the structures of contraceptive and sexual health services for young people will help to remove some of the barriers that prevent some young people from accessing them. However, it is just as important that barriers in the service delivery are tackled to ensure young people receive effective contraceptive advice.

Objective To assess the relative contraceptive effectiveness, tolerability and acceptability of the levonorgestrel-releasing (20 mu g per day) intrauterine system (LNG-20) compared with reversible contraceptive methods in women of reproductive age.Design A systematic review and meta-analysis of randomised controlled trials.Identification Studies were identified through seven databases, and by contacting investigators and organisations working in the contraceptive field.Main outcome measures Unplanned pregnancy and continuation of contraceptive method.Results Five of the seven randomised controlled trials which met the inclusion criteria were included in the meta-analyses; four were comparisons of the LNG-20 intrauterine system with nonhormonal intrauterine devices. LNG-20 intrauterine systems were compared with intrauterine devices divided into two categories, those > 250 mm(3) (Copper T 380 Ag and Copper T 380A intrauterine devices) and those less than or equal to 250 mm(3) (Nova-T, Copper T 220C and Copper 200 intrauterine devices). Pregnancy rates for the LNG-20 intrauterine system users were significantly less likely to become pregnant compared with users of intrauterine devices less than or equal to 250 mm(3), and significantly less likely to have an ectopic pregnancy. LNG-20 intrauterine system users were more Likely to experience amenorrhoea and device expulsion than women using intrauterine devices > 250 mm(3). LNG-20 intrauterine system users were significantly more likely than all the intrauterine device users to discontinue because of hormonal side effects and amenorrhoea. When the LNG-20 intrauterine system was compared with Norplant-2, the LNG-20 users were significantly more likely to experience oligo-amenorrhoea, but significantly less likely to experience prolonged bleeding and spotting.Conclusions The effectiveness of the LNG-20 intrauterine system was similar to or better than other contraceptive methods with which it was compared. Amenorrhoea was the main reason for the discontinuation of the LNG-20 intrauterine system, usually unnecessarily, since this end-organ suppression of bleeding is benign, associated with normal oestrogen levels. Women choosing this method should be informed of potential amenorrhoea when having pre-contraceptive counselling and that absent bleeding may be viewed as a positive outcome.

OBJECTIVES: To assess the contraceptive efficacy, tolerability and acceptability of hormonally impregnated intrauterine systems (IUSs) in comparison to other reversible contraceptive methods. SEARCH STRATEGY: Literature was identified through database searches, reference lists and individuals/organisations working in the field. SELECTION CRITERIA: All randomised controlled trials comparing IUSs with other forms of reversible contraceptives and reporting on pre-determined outcomes in women of reproductive years. The primary outcomes were pregnancy due to method/user failure and continuation rate. DATA COLLECTION AND ANALYSIS: The quality assessment of studies and data extraction were completed independently by two blinded reviewers. A quality checklist was designed to identify general methodological and contraceptive specific factors which could bias results. Events per women months and single decrement life table rates were extracted where possible for pregnancy, continuation, adverse events and reasons for discontinuation. Events per total number of women at follow up were collected for hormonal side effects and menstrual disturbance. When appropriate, data were pooled at the same points of follow up to calculate rate ratios in order to determine the relative effectiveness of one method compared to another. For the single decrement life table rates, the rate differences were pooled to determine the absolute difference in effectiveness of one method compared to another. Interventions were only combined if the contraceptive methods were similar. Non-hormonal IUDs were divided into three categories for the purpose of comparison with IUSs: IUDs >250mm2 (i.e. CuT 380A IUD and CuT 380 Ag IUD), IUDs 250mm2 users. However, women using the LNG-20 IUS were significantly less likely to become pregnant than those using the IUD 250mm2. LNG-20 users were significantly more likely than all the IUD users to discontinue because of hormonal side effects and menstrual disturbance, which on further breakdown of the data was due to amenorrhoea. When the LNG-20 IUS was compared to Norplant-2, the LNG-20 users were significantly more likely to experience amenorrhoea and oligomenorrhoea, but significantly less likely to experience prolonged bleeding and spotting. No other significant differences were observed. Progestasert users were significantly less likely to become pregnant and less likely to continue on the method than non-medicated IUD users after one year, but no significant differences was noted for these two outcomes when Progestasert users were compared to IUD 250mm2 and Norplant-2 users. The LNG-20 IUS was more effective in preventing either intrauterine or extrauterine pregnancies than IUDs

Contemporary health promotion emphasises the concepts of lifestyle, risk, and preventive health behaviour alongside the broader societal concerns of the environment, public policy, and culture.1 The recent green paper Our Healthier Nation stresses a more coordinated approach to health promotion for people who are socially excluded, emphasising behavioural change through targeted interventions at the level of the community.2 There have been extensive reviews of homelessness and health, 3 4 along with calls for urgent action,5–7 but little attention has been paid to the health promotion needs of homeless people, and there is no firm evidence base for practice. One challenge for health promotion is to develop and deliver appropriate initiatives to a heterogeneous population that is not always easy to categorise but has a wide range of needs. The healthcare priorities of a young man sleeping on the streets differ from those of a single mother in temporary accommodation. To be homeless means more than just the absence of secure accommodation. Homelessness has as much to do with social exclusion as with bricks and mortar, and demands a range of health promotion strategies. #### Summary points At one level, the health condition of homeless people is a product of housing policy.3 Over the past two decades in …

To investigate the effect of pregnancy on disease progression and survival in women infected with HIV by a systematic review of the literature and meta-analysis.Appropriate publications were identified using electronic and hand searching of relevant journals from 1983 to 1996. Studies were included in the review if they were cohort studies, either prospective or retrospective, or case-control studies which investigated disease progression of pregnant women infected with HIV and included a control group of non-pregnant women infected with HIV for comparison. Methodological quality was assessed for each study. Data were extracted for predetermined outcome measures. Sensitivity analyses were performed to explore the association between pregnancy and disease progression for the following study characteristics: clinical setting (developed or developing countries), methodological quality (high or poor) and whether studies had controlled for potential confounding.Seven studies, all prospective cohorts, were eligible to be included in the review. The summary odds ratio for the risk of an adverse maternal outcome related to HIV infection and pregnancy were as follows: death 1.8 (85% CI 0.99-3.3); HIV disease progression 1.41 (95% CI 0.85-2.33); progression to an AIDS-defining illness 1.63 (95% CI 1.00-2.67) and fall of CD4 cell count to below 200 x 10(6)/L 0.73 (95% CI 0.17-3.06). Sensitivity analyses showed that HIV progression in pregnancy was significantly more common in a developing country setting (odds ratio 3.71, 95% CI 1.82-7.75) than in developed countries (odds ratio 0.55, 95% 0.27-1.11) and also significantly more common in high quality studies when compared to low quality ones, odds ratios 3.71 (95% CI 1.82-7.57) and 0.55 (95% CI 0.27-1.11), respectively. However, there appears to be less progression of HIV disease and progression to AIDS when studies attempted to control for confounding by matching or restriction techniques, although this was not statistically significant in either case.The findings of this review have implications for women infected with HIV who are pregnant or are considering a pregnancy. There does appear to be an association between adverse maternal outcomes and pregnancy in women infected with HIV, although this association is not strong. The relation may be due to the result of bias including residual confounding. Further large scale observational studies with long term follow up are required before this issue can be fully resolved.The effect of pregnancy on disease progression and survival in HIV-infected women was investigated through a systematic literature review and meta-analysis of the results of eligible studies. The literature search identified seven studies--all prospective cohort analyses--on this topic published in 1983-96. The summary odds ratios (ORs) for adverse maternal outcomes related to HIV infection were as follows: maternal death, 1.8 (95% confidence interval (CI), 0.99-3.3); HIV disease progression, 1.41 (95% CI, 0.85-2.33); progression to an AIDS-defining illness, 1.63 (95% CI, 1.00-2.67); and fall of CD4 cell count to below 200, 0.73 (95% CI, 0.17-3.06). Sensitivity analyses indicated HIV progression during pregnancy was significantly more common in developing countries (OR, 3.71; 95% CI, 1.82-7.75) than developed countries (OR, 0.55; 95% CI, 0.27-1.11) as well as in studies of high methodological quality (OR, 3.71; 95% CI, 1.82-7.57) compared with low-quality studies (OR, 0.55; 95% CI, 0.27-1.11). When studies attempted to control for confounding factors by matching or restriction techniques, there was less progression of HIV disease, but this was not statistically significant. Although this meta-analysis suggests that pregnancy in HIV-positive women may be associated with at least small increases in risk of adverse maternal outcomes, further large-scale observational studies of pregnant and nonpregnant HIV-infected women with long-term follow-up are required. Data on immune function should be available before pregnancy to facilitate determination of the effect of pregnancy on immune status.

Objective: To evaluate the feasibility and effectiveness of a standardized HIV partner notification programme within genitourinary medicine clinics in England. Design: A prospective survey of HIV partner notification activity over a 12-month period. Setting: Nineteen genitourinary medicine clinics in England. Patients and participants: A total of 501 eligible HIV-positive patients (either newly diagnosed or with whom partner notification had not been undertaken previously) seen during the study period. Main outcome measures: The numbers of partners named by patients, and the number of contacts notified, counselled and HIV-tested. Results: Information on overall partner notification activity was obtained by reviewing available medical records of 471 patients; 353 (75%) had discussed partner notification with a health-care worker during the study period and 197 (42%) had undertaken partner notification. Detailed information on outcomes was obtained for only 70 patients who named 158 contacts as being at risk of acquiring HIV. Although 71 (45%) contacts were eventually notified, only 28 were subsequently seen in participating clinics. Almost all contacts (n = 27) requested HIV counselling and testing, and five were diagnosed HIV-positive. Patient referral was the most popular notification method chosen. Conclusions: This study illustrates some of the practical difficulties that limit HIV partner notification within genitourinary medicine clinics. These include health-care workers' misgivings about undertaking partner notification, insufficient locating information to identify contacts, and migration of newly diagnosed patients, which prevents continuity and completion of notification. Nevertheless, HIV partner notification uncovered previously undiagnosed HIV infections. Further work needs to be undertaken in staff training and policy implementation if higher rates of partner notification and outcome measurements are to be achieved.

Background Since May 2004, ten Central and Eastern European (CEE) countries have joined the European Union, leading to a large influx of CEE migrants to the United Kingdom (UK). The SALLEE project (sexual attitudes and lifestyles of London's Eastern Europeans) set out to establish an understanding of the sexual lifestyles and reproductive health risks of CEE migrants. CEE nationals make up a small minority of the population resident in the UK with no sampling frame from which to select a probability sample. There is also difficulty estimating the socio-demographic and geographical distribution of the population. In addition, measuring self-reported sexual behaviour which is generally found to be problematic, may be compounded among people from a range of different cultural and linguistic backgrounds. This paper will describe the methods adopted by the SALLEE project to address these challenges. Methods The research was undertaken using quantitative and qualitative methods: a cross-sectional survey of CEE migrants based on three convenience samples (recruited from community venues, sexual health clinics and from the Internet) and semi-structured in-depth interviews with a purposively selected sample of CEE migrants. A detailed social mapping exercise of the CEE community was conducted prior to commencement of the survey to identify places where CEE migrants could be recruited. A total of 3,005 respondents took part in the cross-sectional survey, including 2,276 respondents in the community sample, 357 in the clinic sample and 372 in the Internet sample. 40 in-depth qualitative interviews were undertaken with a range of individuals, as determined by the interview quota matrix. Discussion The SALLEE project has benefited from using quantitative research to provide generalisable data on a range of variables and qualitative research to add in-depth understanding and interpretation. The social mapping exercise successfully located a large number of CEE migrants for the community sample and is recommended for other migrant populations, especially when little or no official data are available for this purpose. The project has collected timely data that will help us to understand the sexual lifestyles, reproductive health risks and health service needs of CEE communities in the UK.

General practitioner Kidsgrove, Staffordshire (b Newcastle upon Tyne 1936; q Guy's Hospital, London, 1962; DObst RCOG), d 1 February 2003.​2003. Figure 1 He was a principal in general practice in Westbury, Wiltshire, from 1965 to 1970 and in Regina, Saskatchewan, Canada, from 1970 to 1979. In Canada he trained as a pilot. He returned to England in 1979 and joined his father's practice in Kidsgrove. David was a man of many interests—a great lover of books, photography, music, the theatre, and astronomy. He had a humorous sense of the absurd that never diminished despite severe arthritis. He leaves a wife, Josephine; four children; and two grandchildren.

Loss to follow-up in randomised controlled trials reduces statistical power and increases the potential for bias. Almost half of all trials fail to achieve their follow-up target. Statistical methods have been described for handling losses to follow-up and systematic reviews have identified interventions that increase follow-up. However, there is little guidance on how to develop practical follow-up procedures. This paper describes the development of follow-up procedures in a pilot randomised controlled trial of a sexual health intervention that required participants to provide and return questionnaires and chlamydia test samples in the post. We identified effective methods to increase follow-up from systematic reviews. We developed and tested prototype procedures to identify barriers to follow-up completion. We asked trial participants about their views on our follow-up procedures and revised the methods accordingly.We identified 17 strategies to increase follow-up and employed all but five. We found that some postal test kits do not fit through letterboxes and that that the test instructions were complicated. After identifying the appropriate sized test kit and simplifying the instructions, we obtained user opinions. Users wanted kits to be sent in coloured envelopes (so that they could identify them easily), with simple instructions and questionnaires and wanted to be notified before we sent the kits. We achieved 92 % (183/200) overall follow-up for the postal questionnaire at 1 month and 82 % (163/200) at 12 months. We achieved 86 % (171/200) overall follow-up for the postal chlamydia test at 3 months and 80 % (160/200) at 12 months.By using established methods to increase follow-up, testing prototype procedures and seeking user opinions, we achieved higher follow-up than previous sexual health trials. However, it is not possible to determine if the increase in response was due to our follow-up procedures.Current Controlled Trials ISRCTN02304709 Date of registration: 27 March 2013.

Background Loss to follow-up in randomised controlled trials reduces statistical power and increases the potential for bias. Almost half of all trials fail to achieve their follow-up target. Statistical methods have been described for handling losses to follow-up and systematic reviews have identified interventions that increase follow-up. However, there is little guidance on how to develop practical follow-up procedures. This paper describes the development of follow-up procedures in a pilot randomised controlled trial of a sexual health intervention that required participants to provide and return questionnaires and chlamydia test samples in the post. We identified effective methods to increase follow-up from systematic reviews. We developed and tested prototype procedures to identify barriers to follow-up completion. We asked trial participants about their views on our follow-up procedures and revised the methods accordingly. Results We identified 17 strategies to increase follow-up and employed all but five. We found that some postal test kits do not fit through letterboxes and that that the test instructions were complicated. After identifying the appropriate sized test kit and simplifying the instructions, we obtained user opinions. Users wanted kits to be sent in coloured envelopes (so that they could identify them easily), with simple instructions and questionnaires and wanted to be notified before we sent the kits. We achieved 92 % (183/200) overall follow-up for the postal questionnaire at 1 month and 82 % (163/200) at 12 months. We achieved 86 % (171/200) overall follow-up for the postal chlamydia test at 3 months and 80 % (160/200) at 12 months. Conclusions By using established methods to increase follow-up, testing prototype procedures and seeking user opinions, we achieved higher follow-up than previous sexual health trials. However, it is not possible to determine if the increase in response was due to our follow-up procedures. Trial registration Current Controlled Trials ISRCTN02304709 Date of registration: 27 March 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1155-1) contains supplementary material, which is available to authorized users.

BACKGROUND: Men who have sex with men (MSM) are at increased risk of HIV infection in both high- and low-income settings. Mass media campaigns have been used as a means of communicating HIV health promotion messages to large audiences of MSM. There is no consensus on which designs are most appropriate to evaluate the process and outcomes of such interventions. METHODS: An exploratory review was conducted to assess research examining awareness, acceptability, effects on HIV testing, disclosure and sexual risk, and cost-effectiveness of HIV mass media campaigns targeting MSM. We searched for quantitative and qualitative studies published between 1990 and May 2011 via the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Psych Info, ISI Web of Science, OpenGrey and COPAC, and contacting experts. No exclusions were made on the basis of study design or methods because our primary aim was to map evidence. We appraised study quality and present a narrative synthesis of findings. RESULTS: Sixteen reports from 12 studies were included. All were from high-income countries and most examined multi-media interventions. Half of the studies were single cross-sectional surveys. Three repeat cross-sectional studies collected data pre and post the campaign launch. The remaining three studies monitored routine data. Three studies included a nested qualitative component. Campaign coverage was the most commonly reported outcome (9 studies). Imagery, tone of language, content and relevance were identified in the qualitative research as factors influencing campaign acceptability. HIV testing rates (or intention to test) were reported by five studies. Two studies reported that testing rates were higher among men who had seen the campaigns compared to men who had not, but this may reflect confounding. Findings were less consistent regarding reductions in sexual risk behaviours (4 studies). None of the studies examined cost-effectiveness. CONCLUSIONS: Campaigns aim to provide MSM with information to help prevent transmission of HIV and to address increasing motivation and changing norms towards precautionary behaviours. However, the limitations of mass media in imparting skills in effecting behaviour change should be recognised, and campaigns supplemented by additional components may be better-suited to achieving these goals.

OBJECTIVES: To evaluate the extent to which larger genitourinary medicine (GUM) clinics in England have established local clinic policies for HIV Partner Notification (PN) and to describe the process of HIV PN within this setting. DESIGN: A cross-sectional survey of HIV PN policies and practices within GUM clinics. SUBJECTS AND SETTING: Senior consultants in 59 GUM clinics in England. MAIN OUTCOME MEASURES: The presence of clinic policies for HIV PN, indicators of HIV PN activity (that is, its initiation, documentation, performance and evaluation) and factors hindering the acceptance of HIV PN into clinical practice. RESULTS: Only 18% (10/57) of respondents stated that their clinics had developed their own local policies for HIV PN. Fifteen percent (9/58) of clinics had audited HIV PN activity, 15% had provided specific HIV PN training for doctors and 47% (27/58) for health advisers. Within GUM clinics, health advisers play a key role in the HIV PN process, being responsible for initiating the discussion of partners, patient follow-up and documenting HIV PN activity in patients9 notes. Notifying partners was primarily seen as the responsibility of the newly diagnosed HIV positive patient. Although 77% (43/56) of responding consultants believed that HIV PN had become an accepted part of their clinics9 practice, the perceived unacceptability of HIV PN to patients and health care workers were seen as important limiting factors. CONCLUSION: In many GUM clinics, local policies on HIV PN have yet to be established and appropriate training for the health personnel provided. Nevertheless, there appears to be wide-spread acceptance of HIV PN in clinical practice with an acknowledgement of its limiting factors. Further research into the acceptability of HIV PN to health care workers and patients in this setting should be undertaken.