Janey Sewell

Objectives: This national cross‐sectional observational study aimed to assess mental health, quality of life, supportive network, experiences of HIV‐related stigma in healthcare and unmet service need among trans and gender‐diverse people with HIV, compared to cisgender people with HIV. Methods: Positive Voices 2022 is a questionnaire survey of people accessing HIV care in England, Scotland and Wales carried out in 2022 and 2023 that included measures of depression and anxiety symptoms and suicidal ideation (PHQ‐9 and GAD‐7), health‐related quality of life (EQ‐5D‐5L), supportive network (modified Duke FSSQ), experiences of HIV‐related stigma in healthcare and service needs. Logistic and ordinal logistic regression assessed the association of gender identity with these measures unadjusted and adjusted for age group and ethnicity. Results: Overall, 67 trans or gender‐diverse and 4551 cisgender people with HIV participated. Compared to cisgender participants, trans and gender‐diverse participants were younger, more likely to be Asian and less likely to be black. They were less likely to be in employment, homeowners and financially secure. Trans and gender‐diverse participants had a higher prevalence of depression symptoms (35.5% [22/62] vs. 20.5% [865/4219], adjusted odds ratio [aOR] [95% confidence interval, CI] = 1.96 [1.15, 3.34]; p = 0.014) and suicidal ideation (37.1% [23/62] vs. 14.6% [616/4219]; aOR = 3.09 [1.85, 5.17]; p < 0.001) compared to cisgender participants. They also had poorer health‐related quality of life for three domains (anxiety and depression, usual activities and self‐care) and lower levels of supportive network in unadjusted and adjusted analyses. A higher proportion of trans and gender‐diverse participants than cisgender participants had unmet needs for health services, including mental health services (49.2% [31/63] vs. 30.2% [1310/4343]; aOR = 2.02 [1.22–3.35]; p = 0.007), lifestyle services, and welfare and social services. Conclusions: Trans and gender‐diverse people with HIV have poorer mental health and wellbeing than cisgender people with HIV, and a higher prevalence of unmet service needs, highlighting the need for access to culturally competent mental health and other health and welfare services.

The effectiveness of population-level intervention for HIV elimination is influenced by individual-level variation in sexual behaviour. We assess within-person changes in the frequency of condomless anal sex with two or more partners (CLS2+), estimate the transition probabilities and examine the predictors of transitions among a prospective cohort of HIV-negative gay, bisexual, and other men who have sex with men (GBMSM). Participants were recruited through one of three sexual health clinics in London and Brighton (July 2013 to April 2016) and self-completed a baseline paper questionnaire in the clinic. During follow-up, they were invited to complete four-monthly questionnaires twice a year and subsequent annual online questionnaires once a year (March 2015 to March 2018). We used Markov chain models to estimate transition probabilities from ‘higher-risk’ (CLS2+) to ‘lower-risk’ (no CLS2+) and vice versa, and to assess factors associated with transitions between different sexual risk levels. Among 1,162 men enrolled in the study, 622 (53.5%) completed at least one online questionnaire. Higher-risk behaviour was reported in 376/622 (60.4%) men during online follow-up. Overall, 1,665/3,277 (37.5%) baseline and follow-up questionnaires reported higher-risk behaviour. More than 60% of men (376/622) reported higher-risk behaviour at least one period during the follow-up, while 39.5% of men (246/622) never reported CLS2+ during the follow-up. In the next four months, the estimated probability of continuing higher-risk behaviour among men who reported higher-risk behaviour was 78%. Calendar time, recent HIV tests, PrEP and PEP use were the predictors of staying in higher-risk behaviour, while less stable housing status was associated with switching to lower-risk behaviour. Among men who reported lower-risk behaviour, the probability of engaging in the same behaviour was 88%. Recent HIV tests, PrEP and PEP use, recreational drugs, chemsex-associated drug and injection drugs, and bacterial STIs diagnosis were the predictors of switching to higher-risk behaviour. Our results indicate that at any one point in time, the majority of GBMSM are at low risk for HIV acquisition, although many experience short periods in which they are at higher risk. Markers of transitions can be utilized to identify which GBMSM are likely to increase or decrease their risk, thus helping the timing of HIV prevention interventions.

[This corrects the article DOI: 10.2196/58531.].

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Background: Due to advances in treatment, HIV is now a chronic condition with near-normal life expectancy. However, people with HIV continue to have a higher burden of mental and physical health conditions and are impacted by wider socioeconomic issues. Positive Voices is a nationally representative series of surveys of people with HIV in the United Kingdom. It monitors the physical, mental, and social health, well-being, and needs of this population so that they can be addressed. Objective: This paper aimed to describe the methodology, recruitment strategies, and key demographic features of participants recruited for the second national round of Positive Voices (PV2022). Methods: PV2022 was a national, cross-sectional questionnaire study that included people attending HIV care at 101 of the 178 clinics in the United Kingdom between April 2022 and March 2023. Data from the HIV and AIDS reporting system (HARS), a national surveillance database of people with HIV and attending care that is held at the UK Health Security Agency (UKHSA), was used as a sampling frame. The information collected in PV2022 included demographic and socioeconomic factors, HIV diagnoses and treatment, mental and physical health, health service use and satisfaction, social care and support, met and unmet needs, stigma and discrimination, quality of life, lifestyle factors, and additional challenges experienced due to the COVID-19 pandemic. Data linkage to HARS enabled the extraction of clinical information on antiretroviral therapy (ART), HIV viral load, and CD4 lymphocyte counts. Probabilistic sampling was used to provide a randomly selected, representative sample of people attending HIV care who could be invited to complete a paper or online questionnaire. At the start of 2023, due to under-recruitment mainly due to the impact of the monkeypox (Mpox) outbreak, a separate sequential recruitment strategy was initiated in 14 of the largest clinics to increase participant numbers. Results: Of the 4622 participants who completed the questionnaire, 3692 were recruited through probabilistic recruitment and 930 through sequential recruitment. The overall response rate (measured as the number of people who completed a questionnaire of those who either accepted or declined) was 50%. Survey respondents represented approximately 1 in 20 people diagnosed with HIV in England, Wales, and Scotland. The median age of participants was 52 years, 3428 of participants were men, 2991 were White, and 1121 were Black. Conclusions: PV2022 is currently the largest survey of people with HIV in the United Kingdom (as of September 2024). The PV2022 findings will be used to explore the health and well-being of the HIV population and examine associations with demographic, socioeconomic, lifestyle, and other HIV-related factors. International Registered Report Identifier (IRRID): RR1-10.2196/58531

Background: Rates of human immunodeficiency virus diagnoses in UnitedKingdom men who have sex with men were at a 10-year high in 2014; many recent infections indicated ongoing transmission. There was a need to increase testing rates, reduce late diagnosis and understand how to best allocate human immunodeficiency virus prevention resources. Objective: We aimed to assess (1) the feasibility of human immunodeficiency virus self-testing among men who have sex with men, (2) whether the offer of free human immunodeficiency virus self-testing resulted in earlier diagnosis of human immunodeficiency virus in an online randomised controlled trial, (3) the cost-effectiveness of strategies for preventing human immunodeficiency virus in men who have sex with men, including free human immunodeficiency virus self-testing. Design: We produced a systematic evidence map and conducted focus groups and interviews with men who have sex with men and relevant stakeholders to identify barriers and facilitators to human immunodeficiency virus self-testing. We conducted an internet-based randomised controlled trial (a human immunodeficiency virus Self-testing Public Health Intervention to assess whether free human immunodeficiency virus self-testingwith reminders results in earlier diagnosis of human immunodeficiency virus compared with standard of care. We evaluated the cost-effectiveness of human immunodeficiency virus prevention strategies in men who have sex with men in the UnitedKingdom using a simulation model. Data sources: Databases included MEDLINE, EMBASE, Global Health, Social Policy and Practice, PsycInfo, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. Review methods: Searches combined key terms relating to human immunodeficiency virus with terms related to self-testing. Data were manually extracted through a standard form and then entered into an open-access relational map (HIVST.org). Setting: Internet-based study conducted in England and Wales. Participants: Participants were men (including trans men) and trans women aged ≥ 16 years old, resident in England or Wales, and not known to be human immunodeficiency virus-positive, who had ever had anal sex with a man. The qualitative work also included human immunodeficiency virus service providers and commissioners. Intervention: At baseline participants were randomised (randomisation A) to the offer of a single, free baseline human immunodeficiency virus self-test versus no free human immunodeficiency virus self-test (no baseline test). At 3 months, eligible participants from the baseline test group were randomised (randomisation B) to regular offers of free human immunodeficiency virus self-testingevery 3 months for up to 24 months (regular test) versus no offer of free self-tests (no regular test). Main outcome measure: The primary outcome for randomisation A was a confirmed new human immunodeficiency virus diagnosis within 3 months of randomisation (detection of prevalent infections, binary outcome). The primary outcome for randomisation B was the time from randomisation to a confirmed new human immunodeficiency virus diagnosis (detection of incident infections, time-to-event outcome). Results: Focus groups (n = 47 men who have sex with men) and interviews (n = 18 key informants) showed that human immunodeficiency virus self-testing was a highly acceptable intervention for men who have sex with men, with potential to reduce barriers related to convenience, stigma and privacy. The Self-testing Public Health Intervention randomised controlled trial randomised 10,135 men whohave sex with menand trans women 3 : 2 to baseline test or no baseline test. There was no significant difference at 3 months in confirmed new human immunodeficiency virusdiagnoses [p = 0.64, 19/6049 (0.3%) in baseline test vs. 15/4062 (0.4%) in no beseline test], but human immunodeficiency virus testing rates were higher in baseline test. Following the second randomisation (n = 2308) to regular test versus no regular test there was no significant difference between groups in confirmed human immunodeficiency virus diagnoses although there was a substantial increase in testing rate in regular test versus no regular testwith no reduction in sexually transmitted infectiontesting. Modelling suggested that provision of oral tenofovir/emtricitabine pre-exposure prophylaxis increased human immunodeficiency virus testing, with anti-retroviral therapy initiation at diagnosis, and reductions in the level of condom-less sex, that each played an important role in decreasing human immunodeficiency virus incidence among men who have sex with men, and that the current human immunodeficiency virus incidence would have been double what it is if any one of them had not occurred. A combined substantial increase in human immunodeficiency virus testing and pre-exposure prophylaxis could avert 34% of infections. However, at the current cost-effectiveness threshold, a 16% reduction in the cost of delivery of testing and pre-exposure prophylaxis would be required for this scenario to offer value for money. Limitations: The decline in human immunodeficiency virus incidence over the study period resulted in under-powering of the trial. However, we recruited a large number of men at risk of human immunodeficiency virus. A further limitation of the study is the low (but typical) completion rates of surveys, which may have introduced bias into the analysis of the secondary end points, although not the primary end point. Finally, the majority of the participants were white gay men, which may make our results less generalisable. Conclusions: Human immunodeficiency virus self-testing is highly acceptable to men who have sex with men with potential to increase first and repeat human immunodeficiency virus testing and broaden testing options, particularly in among key sub-populations at risk of human immunodeficiency virus. The trial did not demonstrate that self-testing increased human immunodeficiency virus diagnoses linked to care, but was underpowered to do so. Future work: Future research includes investigating the role of marginalisation based on ethnicity, migration status, sexual orientation and education in making testing decisions, and how social exclusion and health inequalities shape engagement with human immunodeficiency virus self-testing. Study registration: This study is registered as ISRCTN20312003. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-1212-20006) and is published in full in Programme Grants for Applied Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

BACKGROUND Due to advances in treatment, HIV is now a chronic condition with near-normal life expectancy. However, people with HIV continue to have a higher burden of mental and physical health conditions and are impacted by wider socioeconomic issues. Positive Voices is a nationally representative series of surveys of people with HIV in the United Kingdom. It monitors the physical, mental, and social health, well-being, and needs of this population so that they can be addressed. OBJECTIVE This paper aimed to describe the methodology, recruitment strategies, and key sociodemographic features of participants recruited for the second national round of Positive Voices (PV2022). METHODS PV2022 was a national, cross-sectional questionnaire study that included people attending HIV care at 101 of the 178 clinics in the United Kingdom between April 2022 and March 2023. Data from the HIV and AIDS reporting system (HARS), a national surveillance database of people with HIV and attending care that is held at the UK Health Security Agency (UKHSA), was used as a sampling frame. The information collected in PV2022 included demographic and socioeconomic factors, HIV diagnoses and treatment, mental and physical health, health service use and satisfaction, social care and support, met and unmet needs, stigma and discrimination, quality of life, lifestyle factors, and additional challenges experienced due to the COVID-19 pandemic. Data linkage to HARS enabled the extraction of clinical information on antiretroviral therapy (ART), HIV viral load, and CD4 lymphocyte counts. Probabilistic sampling was used to provide a randomly selected, representative sample of people attending HIV care who could be invited to complete a paper or online questionnaire 'on the web' to online. At the start of 2023, the study was underrecruiting, mainly due to the mpox outbreak, and a separate sequential recruitment strategy was initiated in 14 of the largest and most demographically diverse clinics to increase participant numbers. RESULTS Of the 4622 participants who completed the questionnaire, 3692 were recruited through probabilistic recruitment and 930 through sequential recruitment. The overall response rate (measured as the number of people who completed a questionnaire of those who either accepted or declined) was 50%. Survey respondents represented approximately 1 in 20 people diagnosed with HIV in England, Wales, and Scotland. The median age of participants was 52 years, 3428 of participants were male, 2991 were of White ethnicity, and 1121 were of Black ethnicity. CONCLUSIONS PV2022 is currently the largest survey of people with HIV in the United Kingdom (as of September 2024). The PV2022 findings will be used to explore the health and well-being of the HIV population and examine associations with demographic, socioeconomic, lifestyle, and other HIV-related factors. INTERNATIONAL REGISTERED REPORT RR1-10.2196/58531

Background Chemsex (the use of psychoactive drugs in sexual contexts) has been associated with HIV acquisition and other STIs, so there is benefit in identifying those most likely to start chemsex to offer risk reduction interventions such as pre-exposure prophylaxis (PrEP). To date, there have been no data from a longitudinal study analysing factors most associated with starting and stopping chemsex. Methods The prospective cohort study, Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2), collected 4 monthly and annual online questionnaire data from men who have sex with men (MSM) from 2015 to 2018. We investigate the association of sociodemographic factors, sexual behaviours and drug use with starting and stopping chemsex among 622 men who completed at least one follow-up questionnaire. Poisson models with generalised estimating equations were used to produce risk ratios (RRs) accounting for multiple starting or stopping episodes from the same individual. Multivariable analysis was adjusted for age group, ethnicity, sexual identity and university education. Findings In the multivariable analysis, the under 40 age group was significantly more likely to start chemsex by the next assessment (RR 1.79, 95% CI 1.12 to 2.86). Other factors which showed significant association with starting chemsex were unemployment (RR 2.10, 95% CI 1.02 to 4.35), smoking (RR 2.49, 95% CI 1.63 to 3.79), recent condomless sex (CLS), recent STI and postexposure prophylaxis (PEP) use in the past year (RR 2.10, 95% CI 1.33 to 3.30). Age over 40 (RR 0.71, 95% CI 0.51 to 0.99), CLS, and use of PEP (RR 0.64, 95% CI 0.47 to 0.86) and PrEP (RR 0.47, 95% CI 0.29 to 0.78) were associated with lower likelihood of stopping chemsex by the next assessment. Interpretation Knowledge of these results allows us to identify men most likely to start chemsex, thus providing an opportunity for sexual health services to intervene with a package of risk mitigation measures, especially PrEP use.

Introduction: HIV transmission continues among gay and bisexual men who have sex with men (GBMSM), with those who are younger, or recent migrants, or of minority ethnicity or who are gender diverse remaining at increased risk. We aimed to identify and describe recent studies evaluating the effectiveness of HIV prevention interventions for GBMSM in high income countries. Methods: We searched ten electronic databases for randomized controlled trials (RCTs), conducted in high income settings, and published since 2013 to update a previous systematic review (Stromdahl et al, 2015). We predefined four outcome measures of interest: 1) HIV incidence 2) STI incidence 3) condomless anal intercourse (CLAI) (or measure of CLAI) and 4) number of sexual partners. We used the National Institute for Health and Care Excellence (UK) Quality Appraisal of Intervention Studies tool to assess the quality of papers included in the review. As the trials contained a range of effect measures (e.g. odds ratio, risk difference) comparing the arms in the RCTs, we converted them into standardized effect sizes (SES) with 95% confidence intervals (CI). Results: We identified 39 original papers reporting 37 studies. Five intervention types were identified: one-to-one counselling (15 papers), group interventions (7 papers), online interventions (9 papers), Contingency Management for substance use (2 papers) and Pre-exposure Prophylaxis (PrEP) (6 papers). The quality of the studies was mixed with over a third of studies rated as high quality and 11% rated as poor quality. There was some evidence that one-to-one counselling, group interventions (4–10 participants per group) and online (individual) interventions could be effective for reducing HIV transmission risk behaviours such as condomless anal intercourse. PrEP was the only intervention that was consistently effective at reducing HIV incidence. Conclusions: Our systematic review of the recent evidence that we were able to analyse indicates that PrEP is the most effective intervention for reducing HIV acquisition among GBMSM. Targeted and culturally tailored behavioural interventions for sub-populations of GBMSM vulnerable to HIV infection and other STIs should also be considered, particularly for GBMSM who cannot access or decline to use PrEP.

Background: Prospective cohort studies of incident HIV and associated factors among gay, bisexual, and other men who have sex with men (GBMSM) in the United Kingdom are lacking. We report time trends in and factors associated with HIV incidence between 2013 and 2019 among a cohort of GBMSM: the AURAH2 prospective study. Methods and findings: Participants were recruited through 1 of 3 sexual health clinics in London and Brighton (July 2013 to April 2016) and self-completed a baseline paper questionnaire and subsequent 4-monthly and annual online questionnaires (March 2015 to March 2018), including information on sociodemographics, lifestyle, health and well-being, HIV status, sexual/HIV-related behaviours, and preexposure prophylaxis and postexposure prophylaxis (PrEP/PEP). Incident HIV was ascertained by linkage with national HIV surveillance data from Public Health England (PHE). We investigated the associations of HIV incidence with (1) baseline factors using mixed-effects Weibull proportional hazard models, unadjusted and adjusted for age, country of birth and ethnicity, sexuality, and education level; and (2) time-updated factors, using mixed-effects Poisson regression models. In total, 1,162 men (mean age 34 years, 82% white, 94% gay, 74% university-educated) were enrolled in the study. Thirty-three HIV seroconversions occurred over 4,618.9 person-years (PY) of follow-up: an overall HIV incidence rate (IR) of 0.71 (95% confidence interval (CI) 0.51 to 1.00) per 100 PY. Incidence declined from 1.47 (95% CI 0.48 to 4.57) per 100 PY in 2013/2014 to 0.25 (95% CI 0.08 to 0.78) per 100 PY in 2018/2019; average annual decline was 0.85-fold (p < 0.001). Baseline factors associated with HIV acquisition included the following: injection drug use (6/38 men who reported injection drug-acquired HIV; unadjusted conditional hazard ratio (HR) 27.96, 95% CI 6.99 to 111.85, p < 0.001), noninjection chemsex-related drug use (13/321; HR 6.45, 95% CI 1.84 to 22.64, p < 0.001), condomless anal sex (CLS) (26/741; HR 3.75, 95% CI 1.31 to 10·74, p = 0.014); higher number of CLS partners (HRs >10 partners [7/57]; 5 to 10 partners [5/60]; and 2 to 4 partners [11/293]: 14.04, 95% CI 4.11 to 47.98; 9.60, 95% CI 2.58 to 35.76; and 4.05, 95% CI 1.29 to 12.72, respectively, p < 0.001); CLS with HIV–positive partners (14/147; HR 6.45, 95% CI 3.15 to 13.22, p < 0.001), versatile CLS role (21/362; HR 6.35, 95% CI 2.18 to 18.51, p < 0.001), group sex (64/500; HR 8.81, 95% CI 3.07 to 25.24, p < 0.001), sex for drugs/money (4/55, HR 3.27, 95% CI 1.14 to 9.38, p = 0.027) (all in previous 3 months); previous 12-month report of a bacterial sexually transmitted infection (STI) diagnoses (21/440; HR 3.95, 95% CI 1.81 to 8.63, p < 0.001), and more than 10 new sexual partners (21/471, HRs 11 to 49, 50 to 99, and >100 new partners: 3.17, 95% CI 1.39 to 7.26; 4.40, 95% CI 1.35 to 14.29; and 4.84, 95% CI 1.05 to 22.4, respectively, p < 0.001). Results were broadly consistent for time-updated analysis (n = 622 men). The study’s main limitation is that men may not be representative of the broader GBMSM population in England. Conclusions: We observed a substantial decline in HIV incidence from 2013 to 2019 among GBMSM attending sexual health clinics. Injection drug use, chemsex use, and measures of high-risk sexual behaviour were strongly associated with incident HIV. Progress towards zero new infections could be achieved if combination HIV prevention including Test and Treat strategies and routine commissioning of a PrEP programme continues across the UK and reaches all at-risk populations.