Objective: The aim of this study was to evaluate Scotland's national HIV preexposure prophylaxis (PrEP) programme in relation to PrEP uptake and associated population-level impact on HIV incidence among MSM. Design: A retrospective cohort study within real-world implementation. Methods: Comparison of HIV diagnoses from national surveillance data and HIV incidence within a retrospective cohort of HIV-negative MSM attending sexual health clinics from the National Sexual Health information system between the 2-year periods pre(July 2015–June 2017) and post(July 2017–June 2019) introduction of PrEP. Results: Of 16 723 MSM attending sexual health services in the PrEP period, 3256 (19.5%) were prescribed PrEP. Between pre-PrEP and PrEP periods, new HIV diagnoses among MSM declined from 229 to 184, respectively [relative risk reduction (RRR): 19.7%, 95% confidence interval (95% CI) 2.5–33.8]; diagnosed recently acquired infections declined from an estimated 73 to 47, respectively (35.6%, 95% CI 7.1–55.4). Among MSM attending sexual health clinics, HIV incidence per 1000 person-years declined from 5.13 (95% CI 3.90–6.64) pre-PrEP to 3.25 (95% CI 2.30–4.47) in the PrEP period (adjusted IRR 0.57, 95% CI 0.37–0.87). Compared with the pre-PrEP period, incidence of HIV was lower in the PrEP period for those prescribed PrEP (aIRR 0.25, 95% CI 0.09–0.70) and for those not prescribed PrEP (aIRR 0.68, 95% CI 0.43–1.05). Conclusion: We demonstrate national population-level impact of PrEP for the first time in a real-world setting. HIV incidence reduced in MSM who had been prescribed PrEP and, to a lesser extent, in those who had not. Promotion of the benefits of PrEP needs to extend to MSM who do not access sexual health clinics.

Rectal infection with Chlamydia trachomatis affects approximately 7% of men having sex with men (MSM), attending departments of Genito-Urinary (GU) Medicine [Manavi et al. Int J STD AIDS 2004;15:162-4], and the British Association for Sexual Health and HIV (BASHH) guidelines for the treatment of uncomplicated genital C. trachomatis infection include 1 g of single-dose oral azithromycin as a recommended regimen [BASHH 2006]. A retrospective analysis was performed on case-notes from all patients diagnosed with rectal C. trachomatis infection in the department of GU Medicine, Edinburgh for the one-year period from 1 June 2005. Of 101 new episodes of rectal chlamydial infection, only 9% were associated with anorectal symptoms. Excluding these, 85% of asymptomatic patients were treated with a single dose of azithromycin 1 g orally, with a calculated treatment failure rate of 13% (nine of 68). This suggests that single-dose azithromycin may be a less than effective treatment in asymptomatic rectal C. trachomatis infection. The potential treatment failure rate with this regimen emphasizes the need for a test of cure at the appropriate interval following treatment to ensure clearance of infection.

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. In July 2017, a national HPV vaccine programme for men who have sex with men (MSM) was initiated across Scotland with vaccine being offered in the sexual health clinic setting. During the first year of this targeted vaccination programme, there were 5,905 individuals who received at least one dose of HPV vaccine, representing 63.7% of eligible MSM attendees in this period. Vaccine uptake was relatively stable across all age groups (range 49.8-55.5%). The vaccination programme appears to have dovetailed well with pre-existing sexual health services and appears to be popular with MSM attending the service. The MSM HPV vaccine programme is a robust adjunct to the national girls programme but gender-neutral immunisation will reduce stigma and inequality in HPVdriven disease.

Objectives: HIV Pre-Exposure Prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention and is key to HIV transmission elimination. However, implementation is challenging. We identified barriers and facilitators to PrEP awareness and access during the roll out of Scotland′s national PrEP programme to develop recommendations for future provision. Design: Multi-perspectival qualitative approach incorporating implementation science tools. Setting: Sexual health services and sexual health/HIV community-based organisations (CBOs) in Scotland. Participants: Semi-structured telephone interviews and focus groups with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n=39), sexual healthcare professionals (n= 54), CBO users (n=9) and staff (n=15). Analysis: Using deductive thematic analysis we mapped barriers and facilitators to PrEP awareness and access. We then applied the Theoretical Domains Framework, Behaviour Change Wheel, and Behaviour Change Technique Taxonomy to analyse barriers and facilitators to generate targeted solutions. Finally, we applied APEASE criteria, expert opinion, and the socio-ecological model to synthesise and present multi-levelled and interdependent recommendations to enhance implementation. Results: Barriers and facilitators were multifaceted, relating to the macrosocial (e.g., government, service ecology), the mesosocial (e.g., values and practices of organisations and dynamics and norms of communities) and the microsocial (peer influence). We derived 28 overarching recommendations including: incentivising organisations to share expertise, addressing future generations of PrEP users, expanding the reach of PrEP services, cascading effective service innovations, changing organisational cultures, instigating and managing novel outreach, establishing monitoring systems, supporting diverse PrEP users, providing training addressing awareness and access to professionals, and development of PrEP champions within a range of organisations. Conclusion: Improving awareness and access to PrEP sustainably will require intervention across the whole system, changing policy and practice, organisations and their cultures, communities and their social practices, and individuals themselves. These evidence-based recommendations will prove useful in extending the reach of PrEP to all who could benefit.

The British HIV Association currently recommends vaccination against hepatitis B virus (HBV) for all susceptible HIV-infected individuals, therefore a retrospective analysis was performed on case notes from all patients diagnosed with HIV infection in our department for a one-year period from 1st August 2005; in each case HBV serological testing and vaccination status were recorded. Fifty-one patients were diagnosed with HIV infection during the study period, however, serological testing for HBV infection had been undertaken in only 76% of susceptible patients by 12 months following their HIV diagnosis. At the time of analysis only 31% of patients were adequately vaccinated against HBV, with recorded HBV surface antibody titres of >100 IU/L. HBV remains a considerable cause of morbidity and mortality in HIV-infected individuals and this study suggests that prevention or detection of HBV infection requires increased vigilance on the part of physicians managing HIV-positive patients.