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Syphilis rates have been increasing in men who have sex with men (MSM) in London. To describe risk behaviour and refine public health interventions, we conducted prospective enhanced surveillance of new syphilis cases in MSM attending selected London sexual health clinics (SHCs) between October 2016 and January 2017. Sexual health advisors (SHAs) completed 107 questionnaires. Eighteen per cent of respondents reported always using condoms, with lower use in HIV-positive (8%, 4/53) than HIV-negative men (33%, 14/52). Almost half of respondents reported condomless sero-discordant sex (46%, 33/72). The most frequent means of meeting new partners reported were venues (80%, 76/95), particularly bars or clubs (34%, 32/95), and apps or websites (79%, 75/95). Nearly a third of respondents reported engaging in group sex (32%, 30/95). Almost half reported drug use during sex (47%, 46/98), with HIV-positive men more likely to report use of the three main ‘chemsex’ drugs. The majority of respondents preferred health promotion information from SHAs (63%, 58/92) compared to other sources such as Google/Wikipedia and apps. Prevention activity should continue to focus on condomless sex, serosorting, multiple and overlapping partners, and chemsex. SHCs, particularly those serving HIV-positive men, are important sources for sexual health promotion advice.

Existing since the 1980s, human immunodeficiency virus (HIV) prevention strategies have developed in parallel with our understanding of HIV transmission and treatment for HIV disease. The past few years have seen exciting advancements in HIV prevention methods, with the development of new, highly effective strategies such as pre-exposure prophylaxis. This sits alongside more traditional approaches such as post-exposure prophylaxis, consistent condom use and increased access to HIV testing. Data now show that an HIV-positive person with a viral load that is undetectable for at least 6 months is not infectious to their sexual partner. Therefore, early HIV diagnosis and initiation of antiretroviral therapy also prevents transmission, referred to as ‘treatment as prevention'. Additionally, in the UK and Ireland, mother-to-child transmission of HIV has been virtually eliminated. These strategies in combination are starting to impact upon the incidence of HIV, both in the UK and worldwide.

We aim to provide evidence-based guidance on best clinical practice in the provision, monitoring and support of pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition. The guidelines include: (i) Guidance on risk assessment prior to PrEP; (ii) Baseline assessment; (iii) Dosing schedules; (iv) Monitoring; (v) Supporting adherence; (vi) Buying generic PrEP; and (vii) Cost-effectiveness. The guidelines are aimed at clinical professionals directly involved in, and responsible for, HIV prevention, and at community advocates and organisations responsible for supporting HIV prevention strategies in those at risk of HIV acquisition. A detailed review of the evidence base is included in Section 4. Sections 5 to 7 are intended to offer practical guidance in risk assessment, starting PrEP, ongoing management while on PrEP and stopping PrEP.

Baseline Sexual Behaviour Questionnaire. (DOC 155 kb)

Adherence and Sexual Behaviour Questionnaire. (DOC 95 kb)

August 2016 was a truly momentous month for HIV prevention in the UK. We saw the National AIDS Trust successfully challenge NHS England with regards to the withdrawal of pre-exposure prophylaxis “PrEP” from the NHS specialised commissioning process.1 There was huge media representation of the case, with PrEP making the main headline on BBC News on August 2nd. NHSE was quick to appeal this outcome, but November 2016 saw the result upheld.2,3 The optimal outcome of “PrEP for all who need it”, provided via the NHS has not been reached yet, but NHSE agreed funding to provide for PrEP for 10,000 people in an implementation trial.4 The trial will be funded by NHSE and implemented by PHE; there are concerns that it could results in another “Prevention Postcode Lottery”, as per the current HPV vaccination pilot. We need reassurance that a full PrEP roll out will follow. The legal challenge by NAT was …

Background A national programme to provide Truvada HIV pre-exposure prophylaxis (PrEP) is currently being considered in England. Some men already access PrEP and some sexual health clinics already offer PrEP monitoring. Aim(s)/objectives We created a Theory of Change (ToC) to define the key components of a clinic-based PrEP programme to reduce HIV incidence. We identified indicators, outputs and outcomes to aid programme evaluation for a large London sexual health clinic. Methods We used a ToC approach to define necessary pre-conditions, indicators, outputs and outcomes for our PrEP delivery programme. Results The aim of our PrEP programme is to prevent HIV seroconversion in those at greatest risk. There are three broad areas: 1) identifying those eligible; 2) engaging eligibles to initiate PrEP and other HIV prevention activities; 3) maintaining effective adherence in those at continuing risk while advising therapy cessation for those no longer at risk. We estimate that approximately 1,200 men attending our service annually could be eligible for PrEP. Assuming a high level of uptake, these men would require 1,000 follow-up appointments annually in order to fulfil quality measures of three monthly HIV and STI testing in those on PrEP. Discussion Using a ToC approach we have defined what a clinic-based PrEP programme might look like against our current service specification to enable us to collect meaningful evaluation data. This ToC might be used by other clinics to evaluate PrEP programmes, and allow comparison across programmes to build understanding of PrEP delivery and enhance new national PrEP surveillance systems.

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 Pre-exposure prophylaxis (PrEP) has proven biological efficacy to reduce the sexual acquisition of the human immunodeficiency virus (HIV). The PROUD study found that PrEP conferred higher protection than in placebo-controlled trials, reducing HIV incidence by 86 % in a population with seven-fold higher HIV incidence than expected. We present the baseline characteristics of the PROUD study population and place the findings in the context of national sexual health clinic data. Methods The PROUD study was designed to explore the real-world effectiveness of PrEP (tenofovir-emtricitabine) by randomising HIV-negative gay and other men who have sex with men (GMSM) to receive open-label PrEP immediately or after a deferral period of 12 months. At enrolment, participants self-completed two baseline questionnaires collecting information on demographics, sexual behaviour and lifestyle in the last 30 and 90 days. These data were compared to data from HIV-negative GMSM attending sexual health clinics in 2013, collated by Public Health England using the genitourinary medicine clinic activity database (GUMCAD). Results The median age of participants was 35 (IQR: 29–43). Typically participants were white (81 %), educated at a university level (61 %) and in full-time employment (72 %). Of all participants, 217 (40 %) were born outside the UK. A sexually transmitted infection (STI) was reported to have been diagnosed in the previous 12 months in 330/515 (64 %) and 473/544 (87 %) participants reported ever having being diagnosed with an STI. At enrolment, 47/280 (17 %) participants were diagnosed with an STI. Participants reported a median (IQR) of 10 (5–20) partners in the last 90 days, a median (IQR) of 2 (1–5) were condomless sex acts where the participant was receptive and 2 (1–6) were condomless where the participant was insertive. Post-exposure prophylaxis had been prescribed to 184 (34 %) participants in the past 12 months. The number of STI diagnoses was high compared to those reported in GUMCAD attendees. Conclusions The PROUD study population are at substantially higher risk of acquiring HIV infection sexually than the overall population of GMSM attending sexual health clinics in England. These findings contribute to explaining the extraordinary HIV incidence rate during follow-up and demonstrate that, despite broad eligibility criteria, the population interested in PrEP was highly selective. Trial registration Current Controlled TrialsISRCTN94465371. Date of registration: 28 February 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1286-4) contains supplementary material, which is available to authorized users.