The following STIRF projects are funded and in progress or completed:
HPV vaccination for preventing cervical and other HPV-associated cancers: Comparing the knowledge and understanding of factors influencing initiation and completion of the UK and Ugandian school-based vaccination programme – Amanda Mason Jones
Project number: PhD 01.
This 3-year PhD studentship at the University of York was approved on October 2018. The university will advertise for suitable applicant.
Human papilloma virus (HPV) vaccination has been available to girls aged 11-14 since 2008 in the UK and will be made available to boys in the near future. The vaccine, which protects against four strains of HPV that are implicated in genital warts, cervical cancer and some other ano-genital and oral cancers, has also been introduced in Uganda.
The project investigates the attitude of adolescents and parents in both countries to the vaccine. the aim is t identify barriers in the uptake of the vaccine. It will also investigate the prevalence of the various HPV types in the population after vaccination.
Exploring perspectives on provision and accessibility of Pre-exposure prophylaxis (PrEP) in North England and the West Midlands.
Project number: 039
The United Kingdom (UK) has a concentrated HIV epidemic, with an estimated 101,200 people living with HIV in 2015. A decrease in diagnoses among men who have sex with men (MSM), the group most affected by HIV transmission, has recently been observed, and is probably due to increased frequency of 3-monthly testing among those at greatest risk and rapid treatment for those testing positive.
Pre-exposure prophylaxis (PrEP) is an evidence based biomedical HIV prevention strategy which involves HIV negative individuals taking antiretroviral drugs to reduce probability of infection if exposed. The UK PROUD study found PrEP reduced HIV infection risk by 86% among MSM. PrEP is available on the NHS in Wales and Scotland.
In October 2017, the IMPACT trial commenced in England, with PrEP being rolled out to 10,000 eligible people.
This project will explore and describe MSM and health professional perspectives on PrEP using qualitative interviews in three Northern cities (Liverpool, Manchester, Sheffield) and one city in the West Midlands (Birmingham) where PrEP is available through the IMPACT trial.
Interviews with a sample of participants (8-12 MSM and 4-8 health professionals per city) will focus on: PrEP awareness and sources of information including eligibility, compliance, drug interaction and online sourcing; impact of PrEP on HIV testing patterns, hepatitis C, sexual risk and other sexually transmitted infections; and on issues related to accessing PrEP and optimal service provision.
The project began in April 2018 and is in progress
Swinging and Sexual Health in the West Midlands
Project number: 037
Swingers have been identified by sexual health practitioners as an HIV and STI risk group in the West Midlands, but we currently know very little about their sexual health practices. In this project, swingers are defined as broadly heterosexual people who are consensually involved in partner swapping, group sex or visit sex clubs. This research will examine the sexual health practices of the swinging community, including their use of recreational drugs and attitudes to Pre Exposure Prophylaxis (PrEP) – drugs taken to reduce the risk of sexual infection with HIV. The results will be used to identify strategies to engage with this ‘risk’ group; to provide recommendations for developing better sexual health care; and to ascertain potential barriers to swingers accessing PrEP/sexual health advice/drug support services.
Swinging can be organised in different ways. People may swing with a partner; they may use online platforms or private social events to meet potential partners; or attend swinging sex clubs. To capture the experiences of this diverse group the project will include 4 work packages: 1) a scoping review of literature surrounding interventions with swingers; 2) analysis of swinging websites/forums to ascertain how sexual health information is provided/negotiated; 3) interviews with up to 5 swinging club managers/community event organisers, to discuss what sexual health information is provided to the community; 4) interviews with up to 20 people who participate in the swinging community to discuss their sexual health practices, use of recreational drugs, and attitudes to PrEP.
This project received favourable reviews. Because of funding limitations the authors were directed to another source of funds that had expressed interest in pursuing the project.
Measuring patient experience and outcome in health care settings on receiving care after sexual violence: a systematic review
Project number: 035
This project was completed in March 2018.
The aim was to identify key themes regarded by patients as priorities for delivering a high-quality service for individuals who have experienced sexual violence.
The investigators found that while the experience and outcome as reported by the patients are important measures in themselves, there are are no gold standard instruments against which their experience can be measured.
The patients themselves identified the need to feel in control throughout, which is enabled by listening without judgment, carefully conveying information.
The findings present challenges for healthcare professionals who may feel obligated to ensure particular outcomes, such as emergency contraception being offered when the patient simply wants to be offered choices.
Chem-sex, HIV, mental health and other health outcomes amongst gay, bisexual and other men who have sex with men (GBMSM): a longitudinal qualitative interview project.
Project number: 032
The key aim of this study is to explore how chemsex (the use of drugs such as methamphetamine, GBL, ketamine and mephedrone in sexual contexts) is effecting gay, bisexual and men who have sex with men. The focus of this study is to explore two areas in particular depth for their links with chemsex, namely: HIV seroconversion, and mental health.
The project has to date been a success with only minor delays to recruitment and interviewing of participants. Data analysis is progressing, but as is to be expected is in the early stages, none-the-less important and novel findings are starting to emerge. Dissemination activities are ongoing and are contributing to the broader development of the project.
Project is due for completion in December 2018
Understanding young people’s perceptions of the value of STI testing and exploring preferences for STI testing in different settings
Project number: 031
Emerging findings from the focus groups indicate that there are concerns about privacy and confidentiality in certain settings, with particular issues for young people living with their families. In addition, there is a lack of awareness of when STI screening is needed, and about screening in newer settings such as pharmacies. The importance of convenience, the speed of obtaining results, and the attitude of healthcare staff in all settings has also been highlighted.
We are sharing findings with those involved in providing and planning services, providing information and making decisions at the local, national and international levels. Interim findings were shared at an international conference in July 2016 and at the Priorities conference in Birmingham in September. The Priorities conference involves a range of local and national decision-makers. Further dissemination is planned in the local area from September. The results are enabling service development to reflect the views of young people, which will help to improve screening rates and thereby the health of patients.
Development of a weighting scale to evaluate the relative importance of items in a validated HIV patient satisfaction questionnaire.
Project number: 020
Using a validated patient reported outcome measure for HIV services, this study employed a formal consensus development method to measure the extent of agreement over which elements of care were most important to individuals attending an HIV clinic outpatient appointment.
The aim of this study was to extend the properties of the HIV PROM by determining the relative importance to patients of the specific items within the questionnaire.
Fifty two patients returned the questionnaires. The one to one interaction between doctors and patients has emerged as the most important part of the patients’ experience. Being treated with dignity and respect, having confidence in trust in their doctor as well as feeling able to discuss treatment issues have remained a significant aspect of the consultation over many years.
The overall data suggests that this method of rating importance is not sufficiently discriminating as there is not a great deal of difference between the highest and lowest scores and that a larger sample would provide an opportunity to conduct a factor analysis. There is also a possibility that the participants have placed higher importance on those elements of care that they find most satisfaction with. However the study has improved the face validity of the HIV PROM.
This project was a continuation of STIRF 012.
Increased vascular permeability: a possible mechanism for the increased cardiovascular risk seen in HIV patients treated with abacavir?
Project number: 008 (part two)
Background: An increased incidence of cardiovascular events (heart attacks and strokes) in the first six months of starting antiviral regimens containing abacavir has been reported in some studies but not others.
Aims: This project is the continuation of an investigation into the effect of long-term anti-HIV treatment on various aspects of metabolism (see Project 008 below). In this part of the study the authors examined the effect of antiviral treatment on genes in subcutaneous fat.
Methods: Subcutaneous fat biopsies were taken before, at 6- and 18-24-months after treatment with three commonly used antiretroviral regimens:
Zidovidine (AZT, lamivudine (3TC) and efavirenz
Tenofavir (TDF), emtricitabine (FTC) and efavirenz
Abacavir (ABC), lamivudine (3TC) and efavirenz
and from HIV negative controls.
Groups were matched for age, ethnicity, weight, body-fat distribution, biochemical profile, and pre-treatment CD4 count. Microarray data was generated on the extracted RNA.
Results: The study showed major effects of abacavir-containing treatment regimens on genes controlling vascular permeability. The potential increased vascular ‘leakiness’, particularly marked marked in the first 6 months of starting treatment may provide possible mechanisms for the vascular plaques leading to heart attacks and strokes.
Dissemination: The study has been published in Plos One 2015 and would need confirmation by more detailed studies.
Why don’t the Somali Refugee Community Access Sexual Health Services.
Project number: 027
Background: In the United Kingdom there is an established and growing refugee population from Somalia. Despite this Somalis have remained absent from much of the official statistics largely because ‘Somali’ is rarely recognised as a distinct ethnic category. Consequently, when decisions are being made in relation to addressing the needs of recently arrived refugees the needs of those who originate from Somalia may be neglected. Little is known about the sexual health needs of this particular community but in terms of their broader health issues, Somalis are known to have a high level of need but low uptake of health care services (Carswell et al. 2011).
Aims: Through the use of focus groups and individual interviews this study sought to explore the sexual health needs of the local Somali community by ascertaining from their perspective, what they know about sexual health services, the challenges that may prevent them taking up these services and how services could be adapted to best meet their needs.
Results: Lack of knowledge of services, lack of knowledge about sexual health, issues pertaining to accessing services, shame, stigma and taboo, the influence of gender, religious and cultural norms, the perceptions of young people, the language barrier lack of cultural awareness and sensitivity demonstrated by healthcare professionals.
- Urgent attention be given to raising awareness, amongst the Somali community, about local sexual health services and how they can be accessed.
- Information about sexual health services be made available in a format that is accessible to the Somali refugee community, for example, via a CD, DVD or USB stick.
- That public health professionals and health care practitioners make clear the concept of preventative screening, making explicit the value of screening and early diagnosis for infectious diseases including TB and HIV/AIDS.
- Health practitioners and public health professionals exercise extreme sensitivity when discussing issues related to sexual health and well-being. Every effort must be made to gain the trust of the individual so that they are able to discuss their fears or concerns.
- Public health professionals and health care practitioners receive appropriate training and education so that they are equipped with the necessary cultural understanding and skills when working with the Somali community.
- That a proactive approach be taken to helping Somali refugees to attend a programme of induction that includes language classes.
- That a register of trained interpreters, who understand medical terminology and who are trained to work with those who may have experienced rape and torture should be available for public health professionals and health practitioners. Telephone interpretation should also be made available during consultations.
Dissemination: The results of the study have been presented in international meetings and published in reputable international journals.
It is hoped that results from this research can be used to inform service provision by identifying barriers to access and any opportunities that may help to overcome them.
Designing a research project for understanding the role of stigma and shame in STI and HIV testing.
Project number: 026
Later diagnosis of STI and HIV bring significant costs. Increasing take-up of regular testing and disclosure of one’s status to future sexual partners will bring benefit to individuals and also reduce overall rate of new infection.
The authors believe that shame is a significant factor in preventing access to sexual health facilities as well as partner notification. The study aims to find and validate the methodology or investigating the role of shame in STI and HIV testing. This is a preliminary feasibility study before undertaking a more in depth study.
Antimicrobial resistance in Chlamydia trachomatis: is it a reality?
Project number: 022
Background: Infections of the genital tract caused by Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in the UK. The burden of infection is seen in young people, with 147,594 infections diagnosed in 15 to 24 year olds in England in 2011. Chlamydia frequently does not cause any symptoms. Untreated infection can spread to cause pelvic inflammatory clisease (PID) in women with serious complications such as infertility and ectopic pregnancy.
The need to identify infected indivicluals has been recognised by the government who have funded the National Chlamydia Screening Programme (NCSP). This has resulted in large numbers of individuals receiving treatment in addition to those already attending specialised sexual health clinics. Resistance to antibiotics is currently rarely reported but there is concern that extensive use may select for resistant strains. Published and anecdotal evidence exists of patients who have persistent infection that is resistant to therapy.
Aims: This project aims to determine if there is evidence that Chlamydia resistance to antibiotics exists.
Methods: Specimens are collected and isolates from individuals that have failed antibiotic treatment are tested for resistance. A control group of individuals will be asked to provide an additional sample for Chlamydia culture prior to treatment to see prevalence of Chlamydia resistance in community
Publication: Rachel Pitt, Sarah Alexander, Catherine Ison, Patrick Horner, Emma Hathorn, Penny Goold, Neil Woodford, Michelle J Cole; Phenotypic antimicrobial susceptibility testing of Chlamydia trachomatis isolates from patients with persistent or successfully treated infections, Journal of Antimicrobial Chemotherapy, Volume 73, Issue 3, 1 March 2018, Pages 680–686, https://doi.org/10.1093/jac/dkx454
Pitt, R. A., Alexander, S., Horner, P. J., & Ison, C. A. (2013). Presentation of clinically suspected persistent chlamydial infection: a case series. International Journal of STD & AIDS, 24(6), 469–475. https://doi.org/10.1177/0956462412472815
Testing for chlamydia and gonorrhoea: persistence of a positive test result after successful treatment.
Project number: 015
Aims: Chlamydia and gonorrhoea are the most common treatable bacterial sexually transmitted infections diagnosed within the United Kingdom. Most sexual health clinics now use Nucleic Acid Amplification based Tests (NAATs), which test for DNA sequences particular to the organism in question, to diagnose these infections.
These tests are highly sensitive and specific but can remain positive for a while after the infection is successfully treated with antibiotics. This is because NAAT tests, unlike bacterial culture, do not distinguish between live and dead organisms. If individuals are retested too soon after completing treatment, their test result will still be positive from the initial treated infection. We do not know for how long this will be the case, making interpretation of repeat tests difficult. This is important in clinical practice, since there are a number of clinical scenarios (e.g. pregnancy, gonorrhoea infection) where a test of cure is essential.
Methods: The proposed project involves following up a cohort of individuals known to have chlamydia or gonorrhoea at a particular site for a period of six weeks. These individuals will be treated as per national guidelines and then retested every week (using NAAT tests) for the initial infection until this is no longer detected. Non-compliance and possible re-infection will be ruled out through structured questionnaires during the follow up period.
Publication: , et al Feasibility study to determine the time taken for NAATs tests to become negative following treatment for Chlamydia trachomatis and Neisseria gonorrhoeae in men and women.
Development of a patient derived measure of satisfaction with HIV services
Project number: 012
Aims: The aim of this study is to develop, validate and test a local questionnaire to objectively measure patient satisfaction with HIV services. We had previously performed a systematic review of the instruments measuring patient satisfaction with HIV services and did not find a ‘gold standard’ measure by which services could be evaluated. The study has been divided into two work streams.
Work stream 1: Development of a local Survey Tool using focus groups and in depth interviews.
Work stream 2: Qualitative assessment of patient barriers to the completion of satisfaction questionnaires.
Results: The focus groups identified key questions that need to be covered in the more in-depth questionnaire. In the next phase an assessment will be been made of the patients’ barrier to completion of the questionnaire.
Future use: The results will allow the construction of a questionnaire that will address the concerns of patients attending settings delivering HIV care. The questionnaire will then be used and evaluated in a field study.
Publication: The results have been published in International Journal of STD AIDS July 2011 22:366—367; doi:10.1258/ijsa.2011.010319
Collaboration between the University of Yale (USA) and Kazan (Russian Republic of Tataristan) and Birmingham to conduct courses in the antiviral treatment of HIV
Project number: 010
Aims: The epidemic of HIV in Russia and Eastern Europe has been explosive and threatens the health of the European continent as a whole. The collaboration was set up to organise regular courses to teach those directly involved with the care of patients infected with HIV how to use anti-HIV drugs correctly and effectively. The effective use of these drugs not only improves the immediate health and survival of the patient, but also dramatically reduces their ability to infect others. Treatment has both a clinical and an epidemiological role in reducing the spread of HIV.
Results: Seven annual two-week intensive courses were organised to train and update health care workers. The project covered the cities of Kazan and Chelney in Tataristan and Ufa in neighbouring Bashkurdistan province (once only). STIRF part funded the travel costs of one participant from the University of Birmingham (MS) on two occasions.
Future prospects: The conferences are now an annual event covering the training of hundreds of healthcare workers in all aspects of HIV care. The result has been a dramatic increase in the number of patients taking treatment in Tataristan which is now one of the leading centres of HIV management in the Russian Federation. The long term effects of this programme on the spread of HIV within Russia and beyond needs further study.
The effect of different antiviral treatments of HIV on genes controlling fat and energy metabolism in subcutaneous fat
Project number: 008 (part one)
Aims: With the discovery of treatment of HIV, the infection is no longer a death sentence and patients could look forward to a normal life span. However many of the treatments that control the virus were found to affect the metabolism of fat and sugars in the body so that there was an increased incidence of heart disease, diabetes and cancer – diseases associated with aging – at a much younger age.
Results: The study found that there was a profound difference between antiviral regimens that are currently in use in the way they affect key genes controlling fat and energy metabolism. However, all the regimens appeared to impair efficient use of oxygen as fuel and create conditions that are associated with leakage of the highly toxic reactive oxygen species (ROS). Since ROS is known to speed up the aging process and also the appearance of cancer, these results are very important and will stimulate further research on finding treatment regimens that are less likely to produce ROS.
Dissemination: The results of the study have been presented in international meetings and published in reputable international journals.
Future use: Since ROS is known to speed up the aging process and also the appearance of cancer these results are very important and will stimulate further research to find treatment regimens that are less likely to produce ROS.
Is filter paper suitable for transporting samples of Chlamydia trachomatis?
Project number: 006
Aim: The best way to obtain intimate samples is for patients to take them in the privacy of their homes and send them through the post. Since posting liquids, such as urine, is fraught with technical difficulties, using samples soaked into filter paper and allowed to dry would be ideal.
Results: The study showed that it is technically possible to extract the samples from the dried filter paper without much loss of accuracy.
Future use: The work now needs to be tested in the field.