Regular STI Testing amongst Men Who Have Sex with Men & Use Social Media Is Suboptimal - A Cross-Sectional Study

Sexually transmitted infections (STIs) disproportionately affect men who have sex with men, with marked increases in most STIs in recent years. These are likely underpinned by coterminous increases in behavioural risks which have coincided with the development of Internet and geospatial sociosexual networking. 

Current guidelines advocate regular, annual sexually transmitted infection testing amongst sexually active men who have sex with men (MSM), as opposed to symptom-driven testing. This paper explores sexually transmitted infection testing regularity amongst MSM who use social and sociosexual media. 

Data were collected from 2668 men in Scotland, Wales, Northern Ireland and the Republic of Ireland, recruited via social and gay sociosexual media. Only one-third of participants report regular (yearly or more frequent) STI testing, despite relatively high levels of male sex partners, condomless anal intercourse and high-risk unprotected anal intercourse. The following variables were associated with regular STI testing; being more 'out' (adjusted odds ratio = 1.79; confidence interval = 1.20-2.68), HIV-positive (adjusted odds ratio = 14.11; confidence interval = 7.03-28.32); reporting ≥10 male sex partners (adjusted odds ratio = 2.15; confidence interval = 1.47-3.14) or regular HIV testing (adjusted odds ratio = 48.44; confidence interval = 28.27-83.01). Men reporting long-term sickness absence from work/carers (adjusted odds ratio = 0.03; confidence interval = 0.00-0.48) and men aged ≤25 years (adjusted odds ratio = 0.36; 95% confidence interval = 0.19--0.69) were less likely to test regularly for STIs. 

As such, we identify a complex interplay of social, health and behavioural factors that each contribute to men's STI testing behaviours. In concert, these data suggest that the syndemics placing men at elevated risk may also mitigate against access to testing and prevention services. Moreover, successful reduction of STI transmission amongst MSM will necessitate a comprehensive range of approaches which address these multiple interrelated factors that underpin MSM's STI testing.

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By:  Frankis J1, Goodall L2, Clutterbuck D3, Abubakari R4, Flowers P5.

• 1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow j.frankis@gcu.ac.uk.
• 2Cobridge Sexual Health Centre, Church Terrace, Cobridge, Stoke on Trent.
• 3Chalmers Sexual Health Centre, NHS Lothian, Edinburgh.
• 4School of Health and Life Sciences, GCU London, Glasgow Caledonian University, Glasgow.
• 5School of Health and Life Sciences, Glasgow Caledonian University, Glasgow. 
• Int J STD AIDS. 2016 Mar 4. pii: 0956462416636780.

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Economic & Health Implications from Earlier Detection of HIV Infection in the United Kingdom

Purpose: 

To model the budget and survival impact of implementing interventions to increase the proportion of HIV infections detected early in a given UK population.

Patients and methods: 

A Microsoft Excel decision model was designed to generate a set of outcomes for a defined population. Survival was modeled on the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex, and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions, and surviving cases. Three locations in the UK were chosen to model outcomes across a range of HIV prevalence areas: Lambeth, Southwark, and Lewisham (LSL), Greater Manchester Cluster (GMC), and Kent and Medway (K&M).

Results: 

In LSL, the projected cumulative cost savings over 5 years were £3,210,206 or £5,290,206 when including the value of the 104 life-years saved. Savings were insensitive to transmission rates, but sensitive in direct proportion to the percentage shift from late to early detection. In GMC, savings were in a similar proportion to LSL, but the magnitude was smaller, as a consequence of the lower base-case HIV prevalence. In K&M, with a smaller population and lower HIV prevalence than GMC, savings were commensurately smaller (£733,202 cumulatively over 5 years).

Conclusion: 

The results strengthen the rationale for implementing increased testing in high prevalence areas. However, in areas of low prevalence, it is unlikely that costs will be returned over a 5-year period.

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By:  Vladimir Zah,^1,2 Mondher Toumi¹

¹Ecole Doctoral Interdisciplinaire Sciences-Santé (EDISS), University of Lyon, Lyon, France; ²ZRx Outcomes Research Inc., Mississauga, Canada

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The Epidemiology of Self-Harm in a UK-Wide Primary Care Patient Cohort, 2001–2013

BACKGROUND:

Most of the research conducted on people who harm themselves has been undertaken in secondary healthcare settings. Little is known about the frequency of self-harm in primary care patient populations. This is the first study to describe the epidemiology of self-harm presentations to primary care using broadly representative national data from across the United Kingdom (UK).

METHODS:

Using the Clinical Practice Research Datalink (CPRD), we calculated directly standardised rates of incidence and annual presentation during 2001-2013. Rates were compared by gender and age and across the nations of the UK, and also by degree of socioeconomic deprivation measured ecologically at general practice level.

RESULTS:

We found significantly elevated rates in females vs. males for incidence (rate ratio - RR, 1.45, 95 % confidence interval - CI, 1.42-1.47) and for annual presentation (RR 1.56, CI 1.54-1.58). An increasing trend over time in incidence was apparent for males (P < 0.001) but not females (P = 0.08), and both genders exhibited rising temporal trends in presentation rates (P < 0.001). We observed a decreasing gradient of risk with increasing age and markedly elevated risk for females in the youngest age group (aged 15-24 years vs. all other females: RR 3.75, CI 3.67-3.83). Increasing presentation rates over time were observed for males across all age bands (P < 0.001). We found higher rates when comparing Northern Ireland, Scotland, and Wales with England, and increasing rates of presentation over time for all four nations. We also observed higher rates with increasing levels of deprivation - most vs. least deprived male patients: RR 2.17, CI 2.10-2.25.

CONCLUSIONS:

Incorporating data from primary care yields a more comprehensive quantification of the health burden of self-harm. These novel findings may be useful in informing public health programmes and the targeting of high-risk groups toward the ultimate goal of lowering risk of self-harm repetition and premature death in this population.

Below: Overall incidence and annual presentation rates. a Incidence. b Annual presentation rates

Full article at:  http://goo.gl/xfGSjq

By:  Carr MJ1, Ashcroft DM2,3, Kontopantelis E4,5, Awenat Y6, Cooper J7, Chew-Graham C8,9, Kapur N7, Webb RT7.

• 1Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK. matthew.carr@manchester.ac.uk.
• 2Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK.
• 3NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester, UK.
• 4Centre for Health Informatics, Institute of Population Health, University of Manchester, UK, Manchester, UK.
• 5NIHR School for Primary Care Research, University of Manchester, Manchester, UK.
• 6School of Psychological Sciences, University of Manchester, Manchester, UK.
• 7Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK.
• 8Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
• 9Manchester Mental Health and Social Care Trust, Manchester, UK. 
• BMC Psychiatry. 2016 Feb 29;16(1):53. doi: 10.1186/s12888-016-0753-5.

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Prisoners with Intellectual Disabilities & Detention Status. Findings from a UK Cross Sectional Study of Prisons

The purpose of this study was to compare social and environmental historical and contextual risk factors between prisoners with intellectual disabilities and those without intellectual disabilities, and to investigate whether prisoners with intellectual disabilities were more likely to be placed on remand in prison (awaiting trial or sentencing) compared to those without intellectual disabilities, after controlling for socio-demographic factors such as age, gender, ethnicity, accommodation status and nature of offences. 

In this study, we carried out a secondary analysis of data from the 1997 Prison survey, which included 131 prisons in England and Wales. A fixed sampling fraction was used to obtain a representative sample of prisoners. 

A total of 3563 prisoners were approached and 3142 (88%) prisoners gave informed consent to be interviewed. Of these, 170 were identified as having intellectual disabilities using the Quick Test. Prisoners with intellectual disabilities were more likely to have lived in institutions or taken into local authority care and more likely to live in temporary accommodation. They were less likely to have had a paid job or any educational qualifications and more likely to perceive a lack of social support. Prisoners with intellectual disabilities were more likely to be placed on remand and were less likely to be sentenced, even after controlling for socio-demographic factors and nature of offence. 

This study suggests that prisons should be more pro-active at identifying people with intellectual disabilities and ensuring that their needs are met, including appropriate access to bail and court diversion schemes.

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By:  Ali A1, Ghosh S2, Strydom A3, Hassiotis A4.

• 1Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: afia.ali@ucl.ac.uk.
• 2Violence Prevention Research Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, William Harvey House, 61 Bartholomew Close, London EC1A 7BE, UK. Electronic address: s.ghosh@qmul.ac.uk.
• 3Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: a.strydom@ucl.ac.uk.
• 4Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: a.hassiotis@ucl.ac.uk. 
• Res Dev Disabil. 2016 Feb 24;53-54:189-197. doi: 10.1016/j.ridd.2016.02.004.

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Towards Preparedness for PrEP: PrEP Awareness & Acceptability among MSM at High Risk of HIV Transmission Who Use Sociosexual Media in Four Celtic Nations: Scotland, Wales, Northern Ireland & the Republic of Ireland: An Online Survey

OBJECTIVE:

To assess the awareness and acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and use sociosexual media at high risk of HIV infection in four Celtic nations.

DESIGN:

Cross-sectional study.

METHODS:

Online self-complete survey of 386 HIV-negative/status unknown MSM who reported condomless anal intercourse (CAI) with ≥2 men in the last year, recruited from gay sociosexual media.

RESULTS:

One-third (34.5%, 132/386) of the participants were aware of PrEP but over half (58.5%, 226/356) reported that they would be willing to use PrEP if it were available to them. Only men who regularly tested for HIV every 6 months were more likely to be aware of PrEP. PrEP acceptability was only associated with reporting ≥5 CAI partners in the last year.

CONCLUSIONS:

Low levels of PrEP awareness were reported across these Celtic nations. Only one-third of high-risk MSM had heard of PrEP but over one-half would be willing to take a daily pill to prevent HIV infection. Sociodemographic factors, commercial gay scene proximity and social network use were unrelated to considering PrEP use. However, those reporting most CAI partners were more likely to consider PrEP use.

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By:  Frankis JS1, Young I2, Lorimer K1, Davis M3, Flowers P1.

• 1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
• 2MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK.
• 3School of Social Sciences, Monash University, Melbourne, Victoria, Australia. 
• Sex Transm Infect. 2016 Jan 22. pii: sextrans-2015-052101. doi: 10.1136/sextrans-2015-052101.

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United Kingdom PornHub 2015 Use Review

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Transmission of Non-B HIV Subtypes in the UK Is Increasingly Driven by Large Non-Heterosexual Clusters

BACKGROUND:

In the UK HIV epidemic, historically dominated by subtype B transmission among men who have sex with men (MSM), 50% of diagnoses and prevalent infections are now heterosexual, mainly non-B subtypes. Between 2002 and 2010 non-B diagnoses among MSM increased from 5.4% to 17% and this study has focused on the drivers of this change.

METHODS:

Growth between 2007 and 2009 in transmission clusters among 14,000 subtype A1, C, D and G sequences from the UK HIV Drug Resistance Database was analysed by risk group.

RESULTS:

Of 1148 clusters containing at least two sequences in 2007, >75% were pairs and >90% were heterosexual. Most clusters (71.4%) did not grow during the study period. Growth was significantly lower for small clusters, and higher for clusters ≥7, being highest for clusters comprising sequences from MSM and people who inject drugs (PWID). Risk group (p<0.0001), cluster size (p<0.0001) and subtype (p<0.01) were predictive of growth in a generalized linear model.

DISCUSSION:

Despite the increase in non-B subtypes associated with heterosexual transmission, MSM and PWID are at risk for non-B infections. Crossover of subtype C from heterosexuals to MSM has led to the expansion of this subtype within the UK.

Below:  Figure 1: Risk group classification of clusters (2009). 2327 clusters (304 A1, 1785 C, 113

D, 125 G) contained at least two sequences: 1630 clusters were pairs and 681 comprised

more than two sequences. MSM men who have sex with men, HET heterosexual, PWID

people who inject drugs, NA not available

Full article at [PDF]:   http://goo.gl/ytqckM

By:   Ragonnet-Cronin M1, Lycett S2, Hodcroft E1, Hué S3, Fearnhill E4, Brown AE5, Delpech V5, Dunn D4, Leigh Brown AJ6; UK HIV Drug Resistance Database.

• 1Institute for Evolutionary Biology, University of Edinburgh, Edinburgh, UK.
• 2The Roslin Institute, University of Edinburgh, Edinburgh, UK.
• 3London School of Hygiene and Tropical Medicine, London, UK.
• 4MRC Clinical Trials Unit at UCL, London, UK.
• 5Public Health England, London, UK.
• 6Institute for Evolutionary Biology, University of Edinburgh, Edinburgh, UK A.Leigh-Brown@ed.ac.uk. 

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Trends in Violence in England and Wales 2010-2014

BACKGROUND:

The National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age-specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied.

METHODS:

Data on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

RESULTS:

In total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/1000 population; males 6.5/1000 and females 2.4/1000. On average, overall attendances decreased by 13.8% per year over the 5 years. Attendances decreased significantly for both genders and all age groups; declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July.

CONCLUSIONS:

From an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May-July.

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By:   Sivarajasingam V1, Page N1, Wells J1, Morgan P2, Matthews K2, Moore S1, Shepherd J1.

• 1Violence Research Group, School of Dentistry, Cardiff University, Cardiff, UK.
• 2Cardiff Business School, Cardiff University, Cardiff, UK. 

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Keeping Confidence: HIV & the Criminal Law from HIV Service Providers’ Perspectives

We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. 

Participants’ understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. 

These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.

...Understanding the law

Accurate understanding of and ability to communicate about the law are two important and distinct skills for those who inform service users about the criminal law or are expected to field questions on the topic. Many participants had a basic understanding of the conditions that could lead to a prosecution.

I think the important thing is that transmission actually has to take place. So it is not just about unsafe sex - it is about transmission essentially happening. Somebody has to become positive. (Clinical service provider)

However, many participants expressed confusion about the technical legal meaning of recklessness, and what a sufficient defence might be against such a charge. Arriving at a mutually agreed legal definition of reckless grievous bodily harm was far from straightforward, with many participants struggling to find accurate and concise means of distinguishing between common-sense uses of recklessness and this particular form of criminal liability.

So the way I understood it was, that the law is defined into an act and a mental state. And the original law applied to intention, which is to intentionally and to wilfully desire to do it. And it’s kind of flowed out into recklessness, which is sort of omission, or by not caring, or not caring if you transmit. But not taking reasonable precaution, or by not telling people it’s kind of involved wider of what my understanding about what the original law was meant to be? (Community service provider)...

Full article at:   http://goo.gl/HLuD0y

By:   Catherine Dodds, a , * Matthew Weait, b Adam Bourne, a and Siri Egede c

aSigma Research, London School of Hygiene and Tropical Medicine, London, UK

bSchool of Law, Birkbeck College, London, UK

cDepartment of Sociology, University of Copenhagen, Copenhagen, Denmark

^* Corresponding author. Email: ku.ca.mthsl@sddod.enirehtac

 

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Needle Fixation Profile: An Exploratory Assessment of Applicability in the Australian Context

Needle fixation has the potential to undermine harm-reduction efforts and may affect up to one-quarter of all injecting drug users (IDUs). Being largely ignored in the extant literature, the majority of research on this phenomenon has been carried out exclusively in Cardiff, Wales.

The current exploratory study examined the applicability of needle fixation in a population of Australian IDUs to determine whether Australian IDUs were familiar with the behaviors and secondary gains that have been found to be associated with needle fixation and are assessed by the needle fixation profile (NEFPRO).

A mixed-method design utilizing semi-structured interviews and questionnaire data was employed.

Australian IDUs were aware of or had experience with the behaviors and secondary gains that have been found to be associated with needle fixation. A number of other behaviors and secondary gains associated with injecting were discussed by participants during the semi-structured interviews. 

This study offers preliminary support for the use of NEFPRO as a clinical and research tool within Australia. To ensure that all avenues toward harm reduction are being explored, it would be fruitful to engage in further research concerning the cross-cultural representations of needle fixation specifically as well as the general influence of needle fixation in perpetuating injecting drug use.

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By:  Hinton S1, Signal T2, Ghea V3.

• 1 Central Queensland Mental Health , Alcohol and Other Drugs Division, Queensland Government , Rockhampton , Queensland , Australia.
• 2 School of Human Health and Social Sciences , CQUniversity , North Rockhampton , Queensland , Australia.
• 3 Rockhampton Psychology Services , Rockhampton , Queensland , Australia.

 

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Examining the Profile of High-Potency Marijuana & Its Association with Severity of Marijuana Dependence

Cannabis use is decreasing in England and Wales, while demand for cannabis treatment in addiction services continues to rise. This could be partly due to an increased availability of high-potency cannabis.

Adults residing in the UK were questioned about their drug use, including three types of cannabis (high potency: skunk; low potency: other grass, resin). Cannabis types were profiled and examined for possible associations between frequency of use and (i) cannabis dependence, (ii) cannabis-related concerns.

Frequent use of high-potency cannabis predicted a greater severity of dependence [days of skunk use per month] and this effect became stronger as age decreased. By contrast, use of low-potency cannabis was not associated with dependence. Frequency of cannabis use (all types) did not predict severity of cannabis-related concerns. High-potency cannabis was clearly distinct from low-potency varieties by its marked effects on memory and paranoia. It also produced the best high, was preferred, and most available.

High-potency cannabis use is associated with an increased severity of dependence, especially in young people. Its profile is strongly defined by negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency.

Below:  Current age and first use of cannabis. Young people in the sample (currently under 23) were exposed to all three types of cannabis at similar ages. Older people were exposed to resin earlier than other types of cannabis, and skunk use was markedly delayed in the over 27's. These results support a shift in the relative availability of resin and skunk over time.

Below:  Characteristics of three cannabis types. Skunk was the predominant choice for all attributes apart from value for money.

Full article at: http://goo.gl/gdo88w

By: T. P. Freeman1,* and A. R. Winstock2

¹Clinical Psychopharmacology Unit, University College London, London, UK

²Institute of Psychiatry, King's College London, Camberwell, UK

   

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Toward Identification of the Sexual Killer: A Comparison of Sexual Killers Engaging in Post-Mortem Sexual Interference & Non-Homicide Sexual Aggressors

Establishing a model of sexual assault reflecting psychosocial and behavioral characteristics of perpetrators of sexual killing and rape is necessary for development in risk assessment and intervention. Methodological variations in defining sexual killing have amalgamated serial and non-serial offenders and perpetrators with direct and indirect associations between killing and sexual arousal. 

This study defined sexual killing specifying that killing should be directly linked to sexual arousal, and sampled 48 sexual killers, operationalized to include only those engaging in post-mortem sexual interference, with one or two known female victims (non-serial), from prison service national (England and Wales) databases. These sexual killers were compared with 48 non-homicide, life or indeterminately sentenced sexual aggressors on psychological and crime scene characteristics. 

Contrary to previous research, fatal outcomes were associated with neither stranger victims nor weapon presence; sexual killing was characterized by severity of violence less so than non-fatal assault. Sexual killers more often reported problems with emotional loneliness, empathic concern, and sexual entitlement than the sexual aggressors. 

Theoretical and applied implications are discussed.

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By: Higgs T1, Carter AJ2, Stefanska EB3, Glorney E4.

• 1University of Nottingham, UK tamsin.higgs@noms.gsi.gov.uk.
• 2National Offender Management Service, London, UK.
• 3University of Birmingham, UK.
• 4Royal Holloway, University of London, UK.  

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Does Antiretroviral Therapy Reduce HIV-Associated Tuberculosis Incidence to Background Rates? A National Observational Cohort Study From England, Wales & Northern Ireland

Whether the incidence of tuberculosis in HIV-positive people receiving long-term antiretroviral therapy (ART) remains above background population rates is unclear. We compared tuberculosis incidence in people receiving ART with background rates in England, Wales, and Northern Ireland.

We analysed a national cohort of HIV-positive individuals linked to the national tuberculosis register. Tuberculosis incidence in the HIV-positive cohort (2007-11) was stratified by ethnic origin and time on ART and compared with background rates (2009). Ethnic groups were defined as follows: the black African group included all individuals of black African origin, including those born in the UK and overseas; the white ethnic group included all white individuals born in the UK and overseas; the south Asian group included those of Indian, Pakistani, and Bangladeshi origin, born in the UK and overseas; and the other ethnic group included all other ethnic origins, including black Afro-Caribbeans.

The HIV-positive cohort comprised 79 919 individuals, in whom there were 1550 incident cases in 231 664 person-years of observation (incidence 6·7 cases per 1000 person-years). Incidence of tuberculosis in the HIV-positive cohort was 13·6 per 1000 person-years in black Africans and 1·7 per 1000 person-years in white individuals. Incidence of tuberculosis during long-term ART (≥5 years) in black Africans with HIV was 2·4 per 1000 person-years, similar to background rates of 1·9 per 1000 person-years in this group (rate ratio 1·2, 95% CI 0·96-1·6; p=0·083); but in white individuals with HIV on long-term ART the incidence of 0·5 per 1000 person-years was higher than the background rate of 0·04 per 1000 person-years (rate ratio 14·5, 9·4-21·3; p<0·0001). The increased incidence relative to background in white HIV-positive individuals persisted when analysis was restricted to person-time accrued on ART with CD4 counts of at least 500 cells per μL and when white HIV-positive individuals born abroad were excluded.

Tuberculosis incidence is unacceptably high irrespective of HIV status in black Africans. In white individuals with HIV, tuberculosis incidence is significantly higher than background rates in white people despite long-term ART. Expanded testing and treatment for latent tuberculosis infection to all HIV-infected adults, irrespective of ART status and CD4 cell count, might be warranted.

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By: Gupta RK1, Rice B2, Brown AE2, Thomas HL3, Zenner D4, Anderson L3, Pedrazzoli D5, Pozniak A6, Abubakar I7, Delpech V2, Lipman M8.

• 1Division of Medicine, University College London, London, UK; HIV/STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
• 2HIV/STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
• 3TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
• 4TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; Centre for Infectious Disease Epidemiology, University College London, London, UK.
• 5TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
• 6Chelsea & Westminster Hospitals NHS Foundation Trust, London, UK.
• 7TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; MRC Clinical Trials Unit and Centre for Infectious Disease Epidemiology, University College London, London, UK.
• 8Division of Medicine, University College London, London, UK. 

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