Dolutegravir (DTG) is the third HIV integrase inhibitor (INI) available for prescription in Belfast since July 2014. It has shown high virological efficacy in both treatment-naïve and -experienced patients. We carried out a retrospective case chart analysis of HIV-1-positive adults commenced on DTG between July 2014 and September 2015. Patients were identified from records as either treatment-naïve or antiretroviral therapy (ART) experienced. Outcomes included: (1) virological response (HIV-1 RNA viral load at 0, 4, 8 and 12 weeks), (2) immunological response (CD4+ cell count at 0, 4, 8 and 12 weeks) and (3) tolerability (side effects and discontinuation). The main exclusion criteria were patients transferring care already established on DTG from other treatment centres or inadequate follow-up information (defined as attendance at <50% of clinical and serological follow-up visits). One hundred and fifty-seven commenced DTG out of 823 patients on ART; 106 (68%) were switched to DTG from another regimen, and 51 (32%) were ART-naïve. One naïve and 14 treatment-experienced patients were excluded from the analysis due to failure to attend clinical follow-up. Analysis of HIV-1 RNA viral load (HIV-1 VL) was divided into three groups: 50 new starters, 68 suppressed at switch and 24 not suppressed at switch. New starters: Baseline median HIV-1 RNA VL 71,259 copies/mL (19,536-196,413); 73% were virally undetectable (HIV-1 RNA VL <70 copies/mL) by week 4. Switching patients: Of those with an HIV-1 RNA undetectable viral load prior to switching, two were detectable with a mean viral load of 443,730 copies/mL after four weeks. Of the 24 patients detectable at switch (median HIV-1 VL 2212 [311-43,467]), 10 were detectable after four weeks. For those with a recordable viraemia, the median HIV-1 VL reduced to 376 (220-1181). At week 12, four patients were detectable with a median VL of 12,390 (567-52,285). Overall, 56 (35%) reported side effects; 40 (25%) reported either difficulty with low mood, anxiety or sleep disturbance. Sixteen (10%) discontinued DTG, with 13 (8%) due to intolerable side effects. DTG is a useful drug in naïve or switch patients. It has the potential to effectively suppress the viral load within the first four weeks of treatment and thus reduces infectiousness. Within the cohort, DTG was generally well tolerated but side effects such as low mood, anxiety and sleep disturbance were high, with 8% of patients discontinuing treatment.

An audit of 72 patients presenting for post-exposure prophylaxis following sexual exposure (PEPSE) to HIV (68 genitourinary medicine and 4 accident & emergency) was conducted from 2003 to 2009. The principal indications for PEPSE included 27 (38%) unprotected intercourse (15/27 vaginal and 12/27 anal) with a known HIV-positive partner, 20 (28%) unprotected receptive anal sex with male partner of unknown status, 17 (24%) following sexual assault and three (4%) unprotected sex with a partner from an endemic country. Of those who commenced PEPSE, 92% did so within the recommended 72 hours. Concurrent sexually transmitted infection (STI) was diagnosed in 8.3% patients (6.9% non-gonococcal urethritis and 1.4% rectal chlamydia). Fifty (69%) patients attended for follow-up and only 8% of these did not complete treatment. Twenty-five (35%) patients attended for repeat serology at three months and 18 (25%) at six months. All of the patients followed up remained HIV-negative.

Mumps epididymo-orchitis has not been recorded as a cause of testicular symptoms without systemic features (including parotitis). The aim of the present study was to assess if we were missing cases in the genitourinary clinic during a previous outbreak of mumps in the community. During a prospective pilot study from November 2005 to February 2006, all patients presenting with symptoms or signs of epididymo-orchitis were studied. These patients were assessed for previous exposure to mumps virus or vaccine, and any current evidence of systemic illness. All patients included had a full sexual health screen (loop test, chlamydia polymerase chain reaction [PCR], gonorrhoea culture, HIV and Venereal Disease Research Laboratory [test]/Treponema pallidum particle agglutination assay), urinary tract infection excluded by urinalysis and mid-stream specimen of urine (MSSU) and mumps serology (Immunoglobulin M [IgM] and Immunoglobulin G [IgG]) performed. Twenty-three patients met inclusion criteria. Their ages ranged from 16 to 50 years, average 30.8 years. All had symptoms of these, 18 had testicular pain, eight swelling, (four had both pain and swelling) and three also had dysuria. On examination, 12 had tenderness, seven swelling, (two both tenderness and swelling) and six had no signs. Seventeen denied history of mumps, one patient had a record of vaccination and five described fever. None had parotid swelling. Three patients were chlamydia PCR positive, two had candida cultured, three had non-specific urethritis (>10 polymorphonuclear leucocyte/high powered field) and 13 had negative sexually transmitted infection screen (one known HIV-positive). Three had positive IgM mumps serology and two were IgG-positive. It is important to include mumps in the differential of epididymo-orchitis and to be aware of outbreaks in the community that may present with genital symptoms, as the management and partner notification will be different.

The concern about the specificity of nucleic acid amplification tests (NAATs) in low prevalence GC populations is associated with its false positivity (cross-reactions with different Neisseria species) impacting on positive predictive value. Not all NAATs are the same and this type of false positivity has not been observed with AC2 to date. 2,3 In Cheshire and Merseyside, UK, we have since 2004 incorporated dual testing for chlamydia (CT) and GC into our chlamydia screening programmes using the Gen-Probe Aptima Combo 2 assay (AC2).Lavelle et al. in the Liverpool and South Sefton Chlamydia Screening Programme showed that, in those under age 25, a total of 55 cases of GC would have been missed if tested only for CT (47/4680(1%) of women and 8/473(1.7%) of men. Of the 47 women positive for GC, more than half, 26 (55%) were negative for CT. The CT prevalence in their population was 12% and 15.7% for women and men, respectively. 4 Our recent article in this journal showed that dual testing in the community contributed substantially to the overall number of GC cases found -40 community cases versus 35 at Macclesfield Genitourinary (GU) Medicine clinic. The overall prevalence of GC in the GU medicine clinic was 1.3% (true prevalence 0.9% on primary test) and that in the community was 0.4%. In the asymptomatic chlamydia screening population aged 15 -24 years, community tests made a total contribution of 32 cases (9/1330 [0.67%] men and 23/5070 [0.45%] women). 3 These 32 cases would have gone undiagnosed and untreated for GC within the community if the NAAT performed had been for CT alone. In our study too, the majority of the GC cases (.60%) were found in those with a negative result for CT. 5 Both of the above studies 4,5 thus show that dual testing at the outset would find more GC infections than reflex testing of CT positives.The Cheshire and Merseyside Sexual Health network already recommends concomitant screening for CT and GC using AC2 in asymptomatic low-risk individuals. 6 Publications from this region 5,7,8 have already shown that AC2 picks up extra cases of GC over and beyond culture in GU medicine clinics. The pick up of extra cases of GC at extragenital sites by AC2 has been reported by us and others. 5,9,10 Even in low prevalence populations we have demonstrated the opportunity to pick up substantial additional numbers of GC cases beyond those detected by current services. 11 The accumulating evidence shows that consideration of incorporating dual testing for CT and GC by the NCSP is long overdue and a wider consideration of application of GC NAATs should be considered.

We report a case of HIV-1 infection transmission caused by a fist fight between brothers. A 30-year-old Caucasian UK resident man developed 'flu-like illness with symptoms of lethargy and weakness. Persistent lymphadenopathy six months later lead to HIV antibody testing, which was positive. Of note, his 37-year-old brother, who was HIV antibody-positive since August 2000, was taking HAART (combivir and nevaripine) with CD4 350 x 106/L (16%) with viral load 4800 copies/mL (log 2.58). A bloody fight had occurred between them four weeks prior to onset of symptoms. Phylogenetic analysis was undertaken. Analysis of the pol gene region indicated that samples from both brothers belonged to the subtype C clade of HIV-1, and that the sequences were closely related to one another. Exposure risk data are extremely useful in helping counsel patients prior to HIV-testing but, as this case illustrates, does not cover all situations.