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The Adapted Microplanning to Eliminate Transmission of HIV in Sex Transactions (AMETHIST) randomised controlled trial tested a combination of microplanning (peer-led risk-differentiated support) and self-help groups (SHGs) to reduce the proportion of female sex workers (FSW) at risk of acquiring or transmitting HIV infection in Zimbabwe. The trial found overall high levels of FSW engagement with treatment which further improved in intervention sites. HIV prevention uptake, however, was low and not affected by AMETHIST. We conducted a mixed methods process evaluation to assess implementation, explore FSW perceptions, and understand the trial’s outcomes. We integrated routine programme statistics, qualitative data, and an endline respondent driven sampling survey among 4444 FSW to consider fidelity of implementation, feasibility of delivery, and acceptability. We also examined whether the intervention triggered changes hypothesised in its programme theory. Microplanning was successfully introduced, with peers effectively providing risk-differentiated support. Early difficulties related to mapping sex work “hotspots,”, maintaining contact with mobile FSW, and some resistance to regular risk assessments, but double the number of new FSW registered at intervention clinics compared to comparison sites (8443 v 3824), and significantly more HIV tests were performed (11882 vs. 6808). SARS-COV2 disrupted the intervention, particularly SHG. Fewer groups were established than planned, and lockdowns prevented group members meeting in person and participating in collective activities. Nonetheless, 30 of 65 established SHG remained active after two years, and more SHG members registered with clinics than those reached by microplanning alone (82 cv 76% p,0.001). Increased service use did not increase effective prevention. Over 80% FSW reported condomless sex and PrEP adherence was insufficient to achieve protection. Qualitative data show FSW prefer to “wait” until HIV seroconversion before taking daily medication. They feared conflation of ART with PrEP and resulting stigma. Concerns about side effects and immediate financial priorities undermined perceived future benefits of PrEP and condoms. Strengthening HIV prevention should consider how to improve FSW’s hope and agency alongside reducing stigma and supporting collective rights and action. The Pan African Clinical Trials Registry registered the trial 2nd July 2020 (PACTR202007818077777) which was after randomisation but before any research data were collected.

ABSTRACT Chemicals are added to treated drinking water to protect water quality during long residence times within ageing drinking water distribution systems (DWDSs). The impacts and benefits of this, phosphate dosing to mitigate lead exposure risks in particular, in operational systems, are not fully understood, and hence dosing practices may not be optimal. Regulatory sampling data from the water treatment works (WTWs) outlet and at customers' taps from six contrasting systems for 6 years were analysed (2014–2020). Results showed the expected variation in chlorine decay throughout the DWDS as a function of the source water, network infrastructure and residence time. Phosphate concentrations had no measurable change detected from the WTW to the customer tap, irrespective of the seasonal dose. As phosphate concentrations at the WTW increased seasonally, at times doubling, the phosphate concentrations at the tap followed suit, questioning the effectiveness of this increased seasonal dosing. This is significant given the increasing costs, decreasing availability and wider environmental concerns around phosphate.

SummaryBackgroundChlamydia is the most commonly reported sexually transmitted infection (STI) in Europe and untreated chlamydia is associated with poor health outcomes. Online postal self-sampling enables people to test for STIs including chlamydia without having to visit a health-care provider, but the extent to which the addition of this mode of testing in England has impacted access to testing in different populations is unclear. In England, there is national-level surveillance data enabling identification of the factors associated with use of online postal self-sampling (OPSS) for chlamydia testing. The aim of this analysis was to determine the change in chlamydia testing, chlamydia positivity, and test location as a result of the introduction of OPSS, and to determine socio-demographic factors associated with uptake of OPSS services compared to testing in-person.MethodsWe conducted a retrospective cohort study analysing data on all publicly funded chlamydia tests between 01/01/2015 and 31/12/2022 in England using two pseudonymised national surveillance systems (GUMCAD STI Surveillance System and CTAD Chlamydia Surveillance System) for STIs. We conducted a descriptive analysis of 25,171,919 chlamydia tests to establish the uptake and positivity of chlamydia tests by testing mode and gender over time. We used bivariate and multivariable logistic regression to examine associations of uptake of testing and positivity of tests with sociodemographic characteristics and testing by OPSS or a different mode.FindingsThe overall number of chlamydia tests/quarter (OPSS and in-person) gradually increased over time until 2019 (884,843 tests/quarter in quarter 1) and then declined in early 2020 (376,118 in quarter 2) and had not returned to 2019 levels by the end of 2022 (715,166 in quarter 4). During this time, the proportion of OPSS testing completed through OPSS increased from 2.6% (88,144/3,433,987) in 2015 to 38.4% (1,168,828/2,972,226) in 2022. Women were less likely than men to use OPSS compared to all available in-person testing (aOR = 0.75, 95% CI 0.75–0.75)). Those aged 20–24 were more likely to use OPSS than 15–19-year-olds (aOR = 1.55, 95% CI 1.55–1.56) and use of OPSS then decreased with increasing age. People in the most deprived areas were the least likely to use OPSS (aORs 1.18–1.28 for index of multiple deprivation quintile groups 2–5 vs 1). People were less likely to test positive using OPSS compared to in-person testing (aOR = 0.87, 95% CI 0.87–0.88). Between 2015 and 2022 OPSS chlamydia test-positivity decreased from 9.3% (2551/27,557) to 7.5% (34,050/454,596) in men and 7.4% (4458/60,367) to 6.1% (43,088/702,867) in women. During the same period, chlamydia test-positivity in sexual health services increased from 8.2% (57,139/692,873) to 10.6% (43,061/406,161) in men and 6.4% (51,080/797,143) to 7.9% (33,292/420,760) in women.InterpretationWe have found changes in access to care, with a shift towards testing via OPSS, and variations in who tests where and differences in positivity by testing mode and gender. Further research is needed to ensure available testing pathways meet the needs of all populations.Funding10.13039/501100000272National Institute for Health and Care Research.

BackgroundThe COVID-19 pandemic disproportionately affected people of Black ethnicities, however, there are limited data on the post-acute sequelae of COVID-19 infection in these populations, and none in those with HIV.MethodsWe conducted a cross-sectional study in people of Black ethnicities with HIV in the UK. Participants were assessed for functional impairment, frailty, respiratory symptoms, anxiety and depression; they were also asked to rate aspects of their physical and mental health on a scale from 1 (poor) to 10 (excellent), both at enrolment and prior to the pandemic. We report associations with COVID-19 history and recovery status.ResultsWe enrolled 183 participants between June 2021 and October 2022, 131 (72%) of whom reported COVID-19. A history of COVID-19 was associated with a reduced ability to carry out usual activities (OR 2.54 [1.03-6.21], p = 0.04), an increase in pain, tiredness and breathlessness, and overall decline in physical health. Of those with a history of COVID-19, 111 (85%) reported to have fully recovered. Those who had not fully recovered reported poorer functional status (p < 0.001) and had higher generalised anxiety scores (p = 0.02). Objective measures of physical function were similar in those who reported no COVID-19, COVID-19 with full recovery, and COVID-19 with incomplete recovery.ConclusionsIn this cohort of Black people with HIV, participants with a history of COVID-19 reported a reduced ability to carry out activities of daily living and various other health issues. Although most people reported full recovery from COVID-19, self-reported limitations in functional status and anxiety were common sequelae.

The utility of whole genome sequencing (WGS) to inform sexually transmitted infection (STI) patient management is unclear. Timely WGS data might support clinical management of STIs by characterising epidemiological links and antimicrobial resistance profiles. We conducted a systematic review of clinical application of WGS to any human pathogen that may be transposable to gonorrhoea. We searched six databases for articles published between 01/01/2010-06/02/2023 that reported on real/near real-time human pathogen WGS to inform clinical intervention. All article types from all settings were included. Findings were analysed using narrative synthesis. We identified 12,179 articles, of which eight reported applications to inform tuberculosis (n=7) and gonorrhoea (n=1) clinical patient management. WGS data were successfully used as an adjunct to clinical and epidemiological data to enhance contact-tracing (n=2), inform antimicrobial therapy (n=5) and identify cross-contamination (n=1). WGS identified gonorrhoea transmission chains that were not established via partner notification. Future applications could include insights into pathogen exposure detected within sexual networks for targeted patient management. While there was some evidence of WGS use to provide individualised tuberculosis and gonorrhoea treatment, the eight identified studies contained few participants. Future research should focus on testing WGS intervention effectiveness and examining ethical considerations of STI WGS use.

Objective:Bone loss in people with HIV (PWH) is poorly understood. Switching tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) has yielded bone mineral density (BMD) increases. PETRAM (NCT#:03405012) investigated whether BMD and bone turnover changes correlate.Design:Open-label, randomized controlled trial.Setting:Single-site, outpatient, secondary care.Participants:Nonosteoporotic, virologically suppressed, cis-male PWH taking TDF/emtricitabine (FTC)/rilpivirine (RPV) for more than 24 weeks.Intervention:Continuing TDF/FTC/RPV versus switching to TAF/FTC/RPV (1 : 1 randomization).Main outcome measures::[18F]NaF-PET/CT for bone turnover (standardized uptake values, SUVmean) and dual-energy x-ray absorptiometry for lumbar spine and total hip BMD.Results:Thirty-two men, median age 51 years, 76% white, median duration TDF/FTC/RPV 49 months, were randomized between 31 August 2018 and 09 March 2020. Sixteen TAF:11 TDF were analyzed. Baseline-final scan range was 23–103 (median 55) weeks. LS-SUVmean decreased for both groups (TAF -7.9% [95% confidence interval -14.4, -1.5], TDF -5.3% [-12.1,1.5], P = 0.57). TH-SUVmean showed minimal changes (TAF +0.3% [-12.2,12.8], TDF +2.9% [-11.1,16.9], P = 0.77). LS-BMD changes were slightly more favorable with TAF but failed to reach significance (TAF +1.7% [0.3,3.1], TDF -0.3 [-1.8,1.2], P = 0.06). Bone turnover markers decreased more with TAF ([CTX -35.3% [-45.7, -24.9], P1NP -17.6% [-26.2, -8.5]) than TDF (-11.6% [-28.8, +5.6] and -6.9% [-19.2, +5.4] respectively); statistical significance was only observed for CTX (P = 0.02, P1NP, P = 0.17).Conclusion:Contrary to our hypothesis, lumbar spine and total hip regional bone formation (SUVmean) and BMD did not differ postswitch to TAF. However, improved LS-BMD and CTX echo other TAF-switch studies. The lack of difference in SUVmean may be due to inadequate power.

Comprehensive sexual education (CSE) is an important approach for health promotion dissemination in schools, particularly when delivered in participatory ways that are sport based, peer or near-peer led, and include concepts of gender and power dynamics. Sufficient attendance at CSE sessions is critical to ensure content exposure and build potential for impact. This article details implementation lessons from the delivery of an after-school, near-peer-led CSE program called SKILLZ during a cluster randomized controlled trial among 40 secondary schools in Cape Town, South Africa. SKILLZ is an evidence-based program previously implemented in similar contexts. Attendance in this study was suboptimal (less than 50%) despite qualitative indications of high acceptability and extensive efforts to adapt implementation and boost attendance. Qualitative and quantitative data gathered during anonymous surveys, in-depth interviews, and focus group discussions with participants with high and low attendance records, near-peer coaches, and school staff from both cohorts indicated that poor attendance could be attributed to several factors. Program adaptations, such as delivering difficult-to-access health services before participants attended the SKILLZ program rather than after, may have reduced the incentive for young people to attend the program. Practical barriers to attendance were identified, including security concerns, competing priorities, and unfamiliarity with after-school programming culture in this setting. Community engagement and acceptability of sexual education programs for adolescents alone may be insufficient to ensure program uptake and engagement.

Transgender (trans) and non-binary people may be at increased risk of alcohol harms, but little is known about motives for drinking in this community. This study explored the relationship between risk of alcohol dependence, experience of alcohol harms, drinking motives, dysphoria, and discrimination within a United Kingdom sample of trans and non-binary people with a lifetime history of alcohol use. A cross-sectional survey was co-produced with community stakeholders and administered to a purposive sample of trans and non-binary people from 1 February until 31 March 2022. A total of 462 respondents were included-159 identified as non-binary and/or genderqueer (identities outside the man/woman binary), 135 solely as women, 63 solely as men, 15 as another gender identity, 90 selected multiple identities. Higher levels of reported discrimination were associated with higher risk of dependence and more reported harms from drinking. Coping motives, enhancement motives, and drinking to manage dysphoria were associated with higher Alcohol Use Disorders Identification Test scores. Social, coping, and enhancement motives alongside discrimination and drinking to have sex were associated with harms. The relationship between discrimination and risk of dependence was mediated by coping motives and drinking to manage dysphoria. Further to these associations, we suggest that reducing discrimination against trans and non-binary communities might reduce alcohol harms in this population. Interventions should target enhancement motives, coping motives and gender dysphoria. Social and enhancement functions of alcohol could be replaced by alcohol free supportive social spaces.

IntroductionIn response to the national shortage of procaine penicillin for first-line neurosyphilis treatment we designed a treatment pathway using intravenous (IV) Ceftriaxone 2 grams for 14 days delivered via our local outpatient parenteral antibiotic treatment (OPAT) services from November 2021.We present clinical outcomes from our cohort.MethodsA retrospective case notes analysis of patients treated with Ceftriaxone IV for neurosyphilis, ocular and otosyphilis between November 2021 – March 2023 was performed.Anonymised clinical and epidemiological data was collected from electronic patient records and analysed using Excel spreadsheets.Results16 patients were identified. All cisgender and 14 (87.5%) were male, median age 49 years (IQR 23–68). Ethnicity was documented in 9/16– majority of whom were white British (77.7%). 11 were MSM, 1 bisexual, 3 heterosexual. 1 declined to disclose their sexuality.2 (12.5%) were HIV positive (CD4 390, 480 cells/mm3). 2 (12.5%) were on HIV PrEP. 3 (18.7%) patients had a concurrent STI.11 (68.7%) reported visual symptoms; 10 with ocular changes consistent with ocular syphilis. 7 (43.7%) reported hearing loss, tinnitus or vertigo: 4 had confirmed sensorineural high frequency hearing loss. 3 (18.7%) had concurrent ocular and otosyphilis.Median RPR at diagnosis was 1:32.100% completed treatment.Serological outcome data is currently available for 6 patients (37.5%) at 3 months and 6 months respectively post-treatment.5/6 (83.3%) patients achieved a serological response of >2 titre RPR reduction in 3 months.12 (75%) reported complete or partial symptom resolution so far.DiscussionOur work adds to emerging data demonstrating Ceftriaxone as a successful treatment option for neurosyphilis. Using an IV line for the whole treatment course simplified the pathway and achieved excellent completion rates. Future work is planned to assess patient satisfaction and service impact.