Improving the sexual health of heterosexual people and men who have sex with men by preventing transmission of sexually transmitted infections and reducing undiagnosed HIV: a mixed methods programme of research
Sexual health clinics across the UK are testing whether a faster way to track down and treat the partners of people diagnosed with chlamydia can cut reinfection rates and curb the spread of sexually transmitted infections. Two-thirds of chlamydia cases occur in heterosexuals under 25, while most gonorrhoea and syphilis, and nearly half of new HIV infections, are in men who have sex with men (MSM). Partner notification—contacting recent sexual partners so they can be tested and treated—is a cornerstone of STI control, but it often fails in practice. This programme tackles that gap head-on. In Stream A, 14 clinics will randomise 2,940 heterosexual patients with chlamydia to either standard partner notification or accelerated partner therapy, where a health adviser immediately phones the partner and arranges treatment without requiring a clinic visit. The primary outcome is whether the original patient tests positive again three to four months later. Streams B and C use mathematical modelling and interviews with MSM to design better notification strategies for bacterial STIs and HIV, where co-infection is common. If successful, the research could give clinics a proven, cost-effective tool to reduce repeat infections and undiagnosed HIV—improving sexual health without requiring new drugs or technology.
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Aims: to improve the sexual health of people at highest risk of sexually transmitted infections (STIs) and HIV by: 1) improving partner notification (PN) outcomes for people with bacterial STIs; 2) developing strategies to reduce undiagnosed HIV and prevent onward HIV transmission. Objectives: to determine the effectiveness and cost-effectiveness of accelerated partner therapy (APT) for genital chlamydia in heterosexuals in a cluster randomised cross-over trial; to estimate the impact of improving STI PN effectiveness for men who have sex with men (MSM) in reducing the prevalence of undiagnosed HIV; to explore barriers and facilitators to effective PN for bacterial STIs and HIV in MSM; to develop and cost novel, tailored PN models for bacterial STIs and HIV in MSM. Background and rationale STI diagnoses have increased over the past decade. Two thirds of chlamydia is diagnosed in heterosexuals under 25, while most gonorrhoea and syphilis and almost half of new HIV infections are diagnosed in MSM. Preventing onward transmission is essential to STI and HIV control. PN is a key intervention for identifying undiagnosed STI but is challenging in practice. APT is a promising new PN method; pilot studies show that APT reduces time to partner treatment for heterosexuals, but whether this reduces STI transmission is unknown. STI and HIV co-infection are common in MSM. Better PN for bacterial STIs could enable earlier HIV diagnosis in partners. Current PN outcomes in MSM are poor and optimal approaches are unknown (particularly in light of recent opportunities created by digital media). Monitoring of PN performance is limited by the lack of standardised outcome measures and definitions of sexual partnership types. Research Plan STREAM A: Does APT improve outcomes of PN for heterosexual people with chlamydia? Preliminary work will develop a standard partnership typology with face validity for both patients and service providers underpinned by existing behavioural and empirical data. Following intervention optimisation, we will undertake a cluster randomised cross-over trial of APT for heterosexual people with chlamydia. Across 14 sexual health clinics in urban and rural areas, in 2940 patients with chlamydia, we will compare health adviser-led immediate telephone APT with standard PN. The primary biological outcome is repeated detection of C. trachomatis in index patients 3-4 months after treatment. We will also conduct a process evaluation using mixed methods. A within-trial cost analysis will inform a cost-effectiveness evaluation comparing APT with standard PN, based on outcomes from a transmission dynamic model. STREAM B: Can improved PN for bacterial STIs in MSM reduce undiagnosed HIV? Mathematical modelling. We will use available data from UK studies of MSM sexual behaviour, STI/HIV infection and co-infection and PN outcomes. We will develop first a compartmental mathematical model to explore the complex non-linear dynamics of STI and HIV transmission in MSM. We will then construct an individual-based model to study the potential impact of STI PN interventions to identify MSM with undiagnosed HIV. This will estimate population attributable fractions for undiagnosed HIV in MSM with and without STI and with different sexual partnership types. STREAM C: Development of optimal PN interventions for MSM for bacterial STIs and HIV: mixed methods research We will undertake a systematic review and cost comparison of alternative PN pathways for MSM with STI and HIV. Using in depth interviews with men who have experienced PN we will explore barriers and facilitators to PN approaches. Informed by the results of Stream B, we will use cross-sectional surveys to assess the patterning, acceptability and feasibility of PN approaches to STIs and HIV across clinic and online samples of MSM. We will use the behaviour change wheel approach to develop a candidate PN intervention for MSM with bacterial STIs a
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