T. Charles Witzel

Background: HIV self‐testing (HIVST) is feasible, highly acceptable and can increase HIV testing uptake/frequency without harm while also reducing costs. Despite HIVST's benefits, UK service provision has been sporadic partially due to policymakers and commissioners' reluctance over concerns about linkage to care/surveillance, which ultimately reduces user choice. Methods: We synthesized current evidence and in a multidisciplinary collaboration developed an Implementation Action Framework to facilitate and promote person‐centred HIVST provision, focusing on reducing health inequalities among gay, bisexual and other men who have sex with men (GBMSM), trans and gender‐diverse people. We do this by exploring implementation context, establishing a standard level of support for HIVST interventions and outlining intervention adaptations to support priority subgroups in the United Kingdom . Results and Discussion: A large body of published evidence demonstrates that HIVST is feasible to deliver, highly acceptable, easy to perform and can make a meaningful difference to HIV testing behaviours among GBMSM, trans and gender‐diverse people without leading to substantial harm or decreases in linkage to care. Synthesizing 29 publications from the United Kingdom or other high‐income settings , we demonstrate that the UK implementation context can be harnessed by emphasizing the need to expand testing to meet the 2030 HIV elimination goals. Concerns around linkage to care/surveillance can be addressed by highlighting successful linkage approaches and the importance of respecting patient autonomy. We establish a minimum standard level of support for HIVST interventions, including a results reporting system with a user opt‐out option, clear information on linkage to care, inclusion of a helpline and guidance to link to clinical follow‐up for those who report reactive HIVST results. To address health inequalities, person‐centred intervention adaptations include innovative approaches to HIVST delivery to reach underserved groups, provision of additional tests for other sexually transmitted infections (STIs), targeted demand generation and tailored support for the most marginalized. Conclusion: Person‐centred HIVST is critical to improving HIV testing uptake by responding to, and ultimately reducing, entrenched health inequalities in the United Kingdom . Our Framework provides a person‐centred roadmap for implementing HIVST across a range of high‐income settings.

Background: Gay, bisexual and other men who have sex with men’s (GBMSM) sexualised drug use, defined as taking psychoactive drugs before or during sex, is the focus of public health concern globally. ‘ Hi-fun’ in Thailand (similar to the practice of ‘chemsex’ in Western settings) is a subset of sexualised drug use. Much harm reduction programming relies on Western chemsex definitions, obscuring critical variation related to local cultures, drug markets and legislative contexts. We aimed to develop, informed by transnational queer sociology, a locally grounded definition of hi-fun compared to other sexualised drug use types practiced among GBMSM in Thailand. Methods: To delineate sexualised drug use types and explore structural and social influences on how hi-fun is practiced and organised, focus groups and in-depth interviews (May-Sept 2024) were conducted with GBMSM (with sexualised drug use experience within prior 12-months) recruited from community organisations in Bangkok, Khon Kaen and Pattaya. Data were transcribed, translated where necessary and analysed with a thematic framework. Results: Participants ( n = 30) were aged 25–47 years, 25 gay, ten living with HIV, seven born outside Thailand. Most ( n = 23) used crystal methamphetamine ( ice ) before/during sex in preceding 12-months, with fewer taking other drugs (ecstasy/MDMA= 14, ketamine = 12, cocaine = 10, GHB/GBL = 5). Participants’ accounts coalesced around three main sexualised drug use types: hi-fun , sex at homepas (medium to large parties where men socialise, usually while wearing only underwear) and incidental sex with drugs (spontaneous and situational combining sex with drugs, often after a night out). Hi-fun was delineated from other sexualised drug use types based on participant motivations to increase wellbeing through pleasure and intimacy, in contrast to homepas and incidental sex with drugs which were linked more to socialising. Crystal methamphetamine ( ice ) was considered foundational to hi-fun , whereas other drugs (e.g. cocaine, ecstasy/MDMA, ketamine and GHB/GBL) were more common in homepas and incidental sex with drugs. Technology, especially geolocation social/sexual networking apps, were central to hi-fun organisation, but potentially less important for other sexualised drug use types. Both hi-fun and homepas primarily took place in private settings, whereas incidental sex with drugs happened in a wider range of venues. Conclusions: Hi-fun in Thailand can be defined as the intentional combination of sex and crystal methamphetamine ( ice ) to enhance intimacy and pleasure with one or more other man/men, facilitated by technology and usually in a private setting. This definition will be useful for those supporting GBMSM in Thailand through policy, research and service provision.

Background: Recent mpox outbreaks have underscored significant gaps in global preparedness for emerging and re-emerging infections. These outbreaks have disproportionately affected vulnerable and marginalized populations, exposing the weaknesses of health systems, particularly in resource-limited settings. The global spread of mpox beyond endemic African countries in 2022 and the emergence of a new Clade Ib in 2024 emphasize the pressing need for comprehensive and context-specific public health responses. We outline the protocol for an innovative multimethod qualitative study (VERDIQual [SARS-CoV-2 (and Mpox) Variants Evaluation in Pregnancy and Paediatrics Cohorts Qualitative Study]). This study is being conducted across 4 different countries and settings—Italy, Nigeria, Thailand, and the United Kingdom. Objective: VERDIQual uses multiple qualitative methods to explore the lived experiences of different populations with mpox and frontline health care workers in endemic and nonendemic settings. With this approach, we aim to identify missed and new opportunities for effective public health messaging on prevention and treatment in this and future pandemics. Methods: VERDIQual’s flexible, multimethod approach integrates content analysis of news and social media, focus group discussions, semistructured interviews, and participatory photography. We apply intersectionality theory to capture perspectives from a diverse range of participants, including gay, bisexual, and other men who have sex with men, pregnant women, adolescents with mpox, and frontline health care workers providing mpox services. Data will be collected and analyzed using the rapid assessment procedure approach, enabling real-time data synthesis to provide timely and contextually relevant insights. We use a standardized approach to data integration at the interpretation stage, summarizing findings in a multimethod integration matrix to visualize and synthesize data by objective, method, and site. Results: Data collection tools, including focus group discussions and semistructured interview topic guides, have been developed in collaboration with local community advisory boards. Data collection was completed by October 31, 2025, and analysis is ongoing. Teams across the 4 countries have identified media houses and social media platforms for inclusion in the news and social media analysis. Study results will be disseminated through peer-reviewed journals, scientific conferences, policy briefs, and stakeholder workshops and community events, with a focus on informing equitable and inclusive future public health responses to re-emerging infections. Conclusions: We expect our principal findings to be applicable to a range of settings. Our use of intersectionality theory will also facilitate considerations for intersecting identities and characteristics in equity-centered pandemic responses. Ultimately, we expect VERDIQual to inform pandemic preparedness, inclusive of people with stigmatized and vulnerable characteristics or identities. International Registered Report Identifier (IRRID): DERR1-10.2196/77321

Gay, bisexual and other men-who-have-sex-with-men’s (GBMSM) sexualised drug use (SDU), defined as taking psychoactive drugs before or during sex, is the focus of public health concern globally. ‘Hi-fun’in Thailand (similar to the practice of ‘chemsex’ in Western settings) is a subset of SDU. Much harm reduction programming relies on Western chemsex definitions, obscuring critical variation related to local cultures, drug markets and legislative contexts. We aimed to develop, informed by transnational queer sociology, a locally grounded definition of hi-fun compared to other SDU types among GBMSM in Thailand. To delineate SDU types and explore structural and social influences on how hi-funis practiced and organised, focus groups and in-depth interviews (April-Sept 2024) were conducted with GBMSM (with SDU experience within 12-months) recruited from community organisations in Bangkok, Khon Kaen and Pattaya. Data were transcribed, translated and analysed with a thematic framework. Participants (n=30) were aged 25–47 years, 25 gay, ten with HIV, seven born outside Thailand. Most (n=23) used crystal methamphetamine (ice) before/during sex in preceding 12-months, with fewer taking other drugs (ecstasy/MDMA=14, ketamine=12, cocaine=10, GHB/GBL=5). Participants’ accounts coalesced around three main SDU types: hi-fun, sex at homepas, and incidental sex with drugs. Hi-fun was delineated from other SDU types based on participant motivations to increase wellbeing through pleasure and intimacy, in contrast to homepas and incidental sex with drugs which were linked more to socialising. Crystal methamphetamine (ice) was considered foundational to hi-fun, whereas other drugs (e.g. cocaine, ecstasy/MDMA, ketamine and GHB/GBL) were more common in homepas and incidental sex with drugs. Technology, especially geolocation social/sexual networking apps, were central to hi-funorganisation, but potentially less important for other SDU types. Both hi-fun and homepas primarily took place in private settings, whereas incidental sex with drugs happened in a wider range of venues. Hi-fun in Thailand can be defined as the intentional combination of sex and crystal methamphetamine (ice) to enhance intimacy and pleasure with one or more other man/men, facilitated by technology and usually in a private setting. This definition will be useful for those supporting GBMSM in Thailand through policy, research and service provision.

BACKGROUND Recent mpox outbreaks have underscored significant gaps in global preparedness for emerging and re-emerging infections. These outbreaks have disproportionately affected vulnerable and marginalized populations, exposing the weaknesses of health systems, particularly in resource-limited settings. The global spread of mpox beyond endemic African countries in 2022 and the emergence of a new Clade Ib in 2024 emphasize the pressing need for comprehensive and context-specific public health responses. We outline the protocol for an innovative multimethod qualitative study (VERDIQual [SARS-CoV-2 (and Mpox) Variants Evaluation in Pregnancy and Paediatrics Cohorts Qualitative Study]). This study is being conducted across 4 different countries and settings—Italy, Nigeria, Thailand, and the United Kingdom. OBJECTIVE VERDIQual uses multiple qualitative methods to explore the lived experiences of different populations with mpox and frontline health care workers in endemic and nonendemic settings. With this approach, we aim to identify missed and new opportunities for effective public health messaging on prevention and treatment in this and future pandemics. METHODS VERDIQual’s flexible, multimethod approach integrates content analysis of news and social media, focus group discussions, semistructured interviews, and participatory photography. We apply intersectionality theory to capture perspectives from a diverse range of participants, including gay, bisexual, and other men who have sex with men, pregnant women, adolescents with mpox, and frontline health care workers providing mpox services. Data will be collected and analyzed using the rapid assessment procedure approach, enabling real-time data synthesis to provide timely and contextually relevant insights. We use a standardized approach to data integration at the interpretation stage, summarizing findings in a multimethod integration matrix to visualize and synthesize data by objective, method, and site. RESULTS Data collection tools, including focus group discussions and semistructured interview topic guides, have been developed in collaboration with local community advisory boards. Data collection was completed by October 31, 2025, and analysis is ongoing. Teams across the 4 countries have identified media houses and social media platforms for inclusion in the news and social media analysis. Study results will be disseminated through peer-reviewed journals, scientific conferences, policy briefs, and stakeholder workshops and community events, with a focus on informing equitable and inclusive future public health responses to re-emerging infections. CONCLUSIONS We expect our principal findings to be applicable to a range of settings. Our use of intersectionality theory will also facilitate considerations for intersecting identities and characteristics in equity-centered pandemic responses. Ultimately, we expect VERDIQual to inform pandemic preparedness, inclusive of people with stigmatized and vulnerable characteristics or identities. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/77321

Ethnic and sexual minority groups are underserved by mental health services globally despite having potentially greater need. This study aimed to explore how the intersections between sexual orientation and ethnicity shape mental health experiences and service access for Asian, Black and Latin American men who have sex with men (MSM) in the UK. This research was drawn from a qualitative sub-study of a larger HIV self-testing randomised controlled trial (SELPHI). Cis-gender Black, Asian and Latin American MSM who participated in SELPHI were recruited purposively to ensure sample diversity. Semi-structured interviews including a focused section on mental health were conducted between April and July 2020. A thematic framework approach was used to analyse the transcribed interview data. Twenty-nine participants were interviewed, comprising thirteen Black, eleven Asian and five Latin American MSM. The data were organised into three meta-themes exploring 1) Background, culture and upbringing, 2) Sexuality and manifestation of mental health issues, and 3) Barriers and facilitators to accessing mental health services. Childhood experiences of hypermasculine norms shaped the development of self-reliant coping strategies for mental distress. Peer support was protective of mental health, but alcohol, party drugs and chemsex could exacerbate feelings of isolation. Intersectional stigma restricted mental health service access, highlighting the need for culturally competent services. Previous use of mental health services and openness about mental health among social groups were facilitators to access. Private mental health services were often favoured due to perceptions of a superior quality of care and the speed of access, although participants recognised this as a financial barrier which further deepened structural inequities in access to mental healthcare. This study highlights the importance of multi-system and interdisciplinary interventions to facilitate discussions surrounding mental health within Asian, Black and Latin American MSM communities. In particular, services must be mindful of the barriers and facilitators faced by these groups when accessing mental health services, including norms linking self-reliance and masculinity.

Background: The risk of onward HIV transmission is strongly influenced by the interval between HIV infection and its diagnosis. The SELPHI trial examined whether this interval could be reduced by offering free HIV self-testing kits to men who have sex with men (MSM). Setting: Internet-based RCT of MSM aged ≥16 years, resident in England/Wales, recruited through sexual and social networking sites. Methods: The second-stage randomization of SELPHI was open to participants who used an initial free HIV self-test kit, were HIV seronegative, and reported recent condomless anal sex. They were randomized to receive a free HIV self-test kit every 3 months (repeat testing [RT] group) versus no such offer (nRT group). The primary outcome was time from randomization to a confirmed HIV diagnosis, determined from linkage to national HIV surveillance databases. The key secondary outcome was the frequency of HIV testing regardless of test modality. Results: In total, 2308 eligible participants (1161 RT, 1147 nRT) were randomized between April 2017 and June 2018, and followed for 15–27 months. The proportion of participants reporting an HIV test in the previous 3 months was much higher in the RT group (86%) than in the nRT group (39%). Overall, 16 (9 RT, 7 nRT) confirmed HIV diagnoses were observed (0.35/100 person-years), with no difference between the groups (hazard ratio = 1.27 [95% CI: 0.47 to 3.41], P = 0.63). Conclusions: Providing regular free self-testing kits to sexually active MSM was highly acceptable and markedly increased HIV testing. However, in this low incidence cohort, it did not result in a demonstrably more rapid diagnosis of incident infections.

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: In the Republic of Ireland, the COVID-19 crisis led to sexual health service closures while clinical staff were redeployed to the pandemic response. Gay, bisexual and other men who have sex with men (gbMSM) face pre-existing sexual health inequalities which may have been exacerbated. The aim of this study is to understand sexual health service accessibility for gbMSM in Ireland during the COVID-19 crisis. Methods: EMERGE recruited 980 gbMSM in Ireland (June-July 2021) to an anonymous online survey investigating well-being and service access through geo-location sexual networking apps (Grindr/Growlr), social media (Facebook/Instagram/Twitter) and collaborators. We fit multiple regression models reporting odds ratios (ORs) to understand how demographic and behavioural characteristics (age, sexual orientation, HIV testing history/status, region of residence, region of birth and education) were associated with ability to access services. Results: Of the respondents, 410 gbMSM accessed sexual health services with some or no difficulty and 176 attempted but were unable to access services during the COVID-19 crisis. A further 382 gbMSM did not attempt to access services and were excluded from this sample and analysis. Baseline: mean age 35.4 years, 88% gay, 83% previously tested for HIV, 69% Dublin-based, 71% born in Ireland and 74% with high level of education. In multiple regression, gbMSM aged 56+ years (aOR = 0.38, 95%CI:0.16, 0.88), not previously tested for HIV (aOR = 0.46, 95%CI:0.23, 0.93) and with medium and low education (aOR = 0.55 95%CI:0.35, 0.85) had lowest odds of successfully accessing services. GbMSM with HIV were most likely to be able to access services successfully (aOR = 2.68 95%CI:1.83, 6.08). Most disrupted services were: STI testing, HIV testing and PrEP. Conclusions: Service access difficulties were found to largely map onto pre-existing sexual health inequalities for gbMSM. Future service development efforts should prioritise (re)engaging older gbMSM, those who have not previously tested for HIV and those without high levels of education.