BMJ Public Health

BackgroundThe 2022 multicountry mpox outbreaks predominantly affected gay, bisexual and other men who have sex with men (GBMSM) in non-endemic countries, including the Netherlands. We conducted a survey-based assessment of the alignment between the risk factors associated with mpox diagnosis among GBMSM in the Netherlands and the eligibility criteria used in 2022 for vaccinating this group, with the aim to refine these criteria. MethodsAn online self-report survey was conducted among adult GBMSM in the Netherlands between 29 July and 30 August 30, 2022, corresponding to the first month of the Dutch mpox vaccination campaign. GBMSM were recruited via advertisements on social media and gay dating apps. Participants reported on their sexual behaviour, mpox diagnosis, and/or (initial) mpox vaccination since the start of the outbreak. Covariables of mpox diagnosis and vaccination were assessed using logistic regression analyses. ResultsOf the 2,460 participants, 73 (3.0%, 95% CI 2.3%-3.6%) were diagnosed with mpox and 485 (19.7%, 95% CI 18.1%-21.3%) had received (initial) mpox vaccination. Using sample weighting, we estimated that, of the GBMSM population aged 18-80 years in the Netherlands, 1.1% (95% CI 0.7%-1.6%) had been diagnosed with mpox and 7.8% (95% CI 6.8%-8.9%) had received (initial) vaccination. HIV-PrEP use, living with HIV, reporting 20 or more sex partners in the past 12 months, and sex in sex venues/parties in the past 2 months were independent risk factors for mpox diagnosis. Except for sex in sex venues/parties, these variables were also independently associated with mpox vaccination. ConclusionThis study provides novel evidence regarding the degree to which eligibility criteria for mpox vaccination align with the risk factors for mpox among GBMSM in the Netherlands. The findings contribute to a refinement of the eligibility criteria for mpox vaccination, to which sex in sex venues/parties should be added.

BackgroundWe assessed whether participants in the EZI-PrEP study, a non-inferiority trial evaluating online and six-monthly monitoring of oral HIV pre-exposure prophylaxis (PrEP), represent the broader population of PrEP users in the Netherlands. MethodsWe conducted a cross-sectional study using routinely collected data from September 2021 to August 2022 at four sexual health centres (SHCs) in the Netherlands. Socio-demographic characteristics, sexual behaviour, and prevalence of bacterial STIs were compared between EZI-PrEP participants at baseline and other PrEP users during their first PrEP monitoring visit in said time period. ResultsThe analysis included 469 EZI-PrEP participants and 5196 other PrEP users; respectively 99% and 96% were men who have sex with men (MSM). EZI-PrEP participants were less often transgender or gender divers persons (TGDP) (1% vs. 4%, p<0.001), older (median age=36 vs. 34 years, p=0.004), more often born in the Netherlands (68% vs. 58%, p<0.001), and more often completed a university/college degree (81% vs. 76%, p=0.01). They reported more group sex (38% vs. 33%, p=0.023) and condomless anal sex (95% vs. 92%, p=0.004), but less often sex work (1% vs. 6%, p<0.001). Prevalence of bacterial STIs was similar between groups (19% vs 18%, p=0.766). ConclusionsThe similar STI prevalence suggests comparable risk for HIV acquisition among EZI-PrEP participants and other PrEP users, making EZI-PrEP study outcomes applicable to a broader population of PrEP users. However, under-representation of TGDPs, sex workers, individuals not born in the Netherlands, and individuals without university or college degree may limit generalizability.

Sex work is diverse and includes a broad range of people and settings. Over the last thirty years, a large proportion of public health emergencies of international concern (PHEIC) have involved infections transmitted through sexual or close contact and in sexual networks (WHO 2024). Sex workers can face increased disadvantage in relation to these public health emergencies. Given the significant health inequalities sex workers can face, they should be eligible to receive targeted and tailored health support to reduce health protection risks (Hester 2019; Jeal and Salisbury 2004a). However, they are often not explicitly eligible for targeted and tailored support due to a lack of information on incidence, prevalence of disease, and even more basic data such as reliable estimates of the number of sex workers in the UK. Accordingly, the aim of this paper is to determine a population size estimate, with uncertainty, that is more robust than those currently available. In this study, we apply Bayesian Evidence Synthesis to bring together historic estimation efforts with recent ONS National Population Estimates and Genito-Urinary Medicine Clinics Attendance Data (GUMCAD) from the UK Health Security Agency (UKHSA). A key feature of our model is the embedding of uncertainty from each input study in model priors, hence propagating it through to our final estimate. The Bayesian evidence synthesis model estimated a total of 84,000 sex workers in the United Kingdom (95% credible interval: 49,000-130,000), representing 0.121% of the current UK population.

ObjectivesDespite being the largest ethnic minority group in England, South Asians have historically had low levels of utilisation of sexual health services and sexually transmitted infection (STI) diagnoses, though recent data suggests this may be changing. This study aimed to investigate factors associated with a bacterial STI diagnosis amongst South Asians attending SHS in England. MethodsUsing data from the GUMCAD STI Surveillance system, a descriptive analysis of South Asians attending sexual health services in England in 2019 was carried out. Factors associated with a bacterial STI diagnosis were examined using univariate and multivariable logistic regression models adjusted for age, Asian ethnic subgroup, HIV status, patient region of residence and Index of Multiple Deprivation quintile. Analyses were stratified by gender and sexual orientation (heterosexual male vs. gay, bisexual, and other men who have sex with men [GBMSM] vs. women of any sexual orientation). Crude and adjusted associations were derived using binary logistic regression. ResultsThere were 121,842 attendances by South Asians to SHS in England in 2019. Compared to heterosexual South Asian men, GBMSM had a higher odds of being diagnosed with a bacterial STI (aOR 2.32, 95% CI 2.19-2.44) and South Asian women had a lower odds (aOR 0.83, 95% CI 0.78-0.87). For women and heterosexual South Asian men, a diagnosis was associated with younger age, being of any other Asian background other than Bangladeshi, Indian or Pakistani and not being HIV positive. For heterosexual South Asian men, there was an association with increasing socioeconomic deprivation. For GBMSM, a bacterial STI diagnosis was associated with known HIV positive status and living in London. ConclusionsPeople of South Asian ethnicity in England are heterogenous with regards to their sexual health needs, which should be explored further through focused research and policy. Key MessagesO_LIWhat is already known on this topic: Historically South Asians in England have had low rates of sexually transmitted infections and sexual health service utilisation. Despite South Asians being the largest ethnic minority group in England, there has been a paucity of research investigating their sexual health needs. C_LIO_LIWhat this study adds: To our knowledge, this is the first national epidemiological study focusing on people of South Asian ethnicity accessing sexual health services in England, finding variation in factors associated with bacterial STI diagnosis, particularly when stratified by gender and sexual orientation. C_LIO_LIHow this study might affect research, practice or policy: Our results reflect the heterogeneity of South Asian communities in England with regards to sexual health need, and we suggest that policy makers and researchers should prioritise this under-served group to improve their sexual health outcomes. C_LI

We assessed if there was a country-level association between intensity of screening MSM for Neisseria gonorrhoeae and Chlamydia trachomatis and self-reported incidence of these infections in 2010 and 2017. Unexpectedly, we found that screening intensity was associated with a higher incidence of these infections. Short summaryWe found a positive association between intensity of screening for chlamydia and gonorrhoea and the self-reported incidence of these infections in MSM in European countries.

HIV prevention and testing programmes primarily reach people who self-refer or attend routine health services. Higher-risk individuals are missed if they are healthy, under-estimate their risk of infection or under-report sexual risk-behaviours. We assess a new approach to address limitations in existing programmes by targeting HIV services on ''Circumstantial Determinants'' (CDs) of HIV risk - the social circumstances, settings, and norms associated with behaviours that increase risk of HIV acquisition. Data on potential CDs and sexual behaviour were collected in a population survey in Zimbabwe in 2018/19 (N=9141). HIV-negative individuals reporting [&ge;] 1 sexual risk-behaviours were defined as the 'priority population' for HIV prevention. For each sex, six circumstantial determinants were associated with being in the priority population (aOR [&ge;] 1.30; p [&le;] 0.01). Reach and efficiency of CDs (and combinations) were calculated; ROC curve algorithms evaluated their ability to identify priority population membership; and HIV prevention condom cascades were compared between CD-defined priority population subgroups. Example findings include that targeting men at bars and beerhalls could reach 48.5% of the priority population and 25.1% of lower-risk men. These percentages increase to 77.1% and 53.7% if men with poor mental health, no religious affiliation, negative social capital, or living on agricultural estates are also targeted. Targeting women with poor mental health could reach 32.0% of the priority population and 21.3% of lower-risk women. Targeting additional circumstantial determinants increases these percentages to 54.1% and 37.5%, respectively. Cascade barriers to condom use differed between CD-defined subgroups. The Circumstantial Determinants approach demonstrates proof-of-concept potential to strengthen HIV prevention services.

BackgroundHIV prevention through pre-exposure prophylaxis (PrEP) may encourage riskier sexual behaviours that undermine the protection afforded by PrEP and generates negative spillovers on sexually transmitted diseases. Tests for such risk compensatory behaviour in high-risk populations, such as the female sex workers (FSW) in Senegal we studied, are lacking. MethodsWe stratified the sample by self-reported sexual risk-taking and prior PrEP experience and randomly assigned them to PrEP referral in October 2021-January 2022 (treatment, n=300) or to deferred PrEP referral after the endline survey in April-May 2022 (control, n=200). We randomised 500 FSWs to start PrEP and included 308 FSWs in the final analysis (T=182, C=126). We compared outcomes in the period preceding PrEP referral of the control group. The primary outcome was self-reported condom use with clients. Secondary outcomes were self-reported sexual risk taking, number of clients, proportion of regular clients, perceived HIV risk of clients, and type of sex act. We estimated intention-to-treat effects of PrEP referral and both average treatment effects on the treated and local average treatment effects of PrEP utilisation. The trial is registered with ISRCTN (ISRCTN16445862). FindingsPrEP referral increased the probability of using PrEP by 34.5 percentage points (pp) [95% CI: 25.4, 43.6; p<0.0001, control group mean: 11.1%]. Estimated effects of PrEP referral and PrEP use on condom use with the last client were 3.3 pp [95% CI: -4.0, 10.6; p=0.376] and 7.9 pp [95% CI: -10.4, 26.3; p=0.397 respectively (control group mean: 84.9%). When looking at condom use with all last three clients, these effects were 11.0 pp [95% CI: 0.8, 21.1; p=0.034] and 25.8 [95% CI: 5.2, 46.4] respectively (control group mean: 67.5%) There were no notable effects on other risky behaviours. InterpretationThis randomised experiment did not give strong grounds for concerns that PrEP encouraged sexual risk-taking by FSWs, at least in the short-term. Robustness of this finding should be tested in larger, longer-term studies and in other contexts. Whether PrEP users are more likely to overreport condom use than non-PrEP users should also be further investigated. FundingMRC Public Health Intervention Development Scheme from UKRI and D.P. Hoijer Fonds, Erasmus Trustfonds, Erasmus University Rotterdam, The Netherlands. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSPre-exposure prophylaxis (PrEP) is becoming an essential part of HIV prevention among high-risk populations in low-and middle-income countries. However, compensatory risky behaviour may partially offset the protection PrEP gives against HIV and may increase the prevalence of other sexually transmitted diseases. Risk compensation may exhibit more strongly among female sex workers (FSWs) as condomless sex is better renumerated. We searched PubMed in January 2024 using the terms (prep) AND (female sex workers) AND (randomised controlled trial) (28 search results) and (PrEP) AND (risk compensation) (140 search results). We did not find any randomised controlled trial testing whether PrEP uptake impacts the prevalence of unprotected sex amongst FSWs. For men who have sex with men, the evidence was mixed, with risk compensation evident in more recent studies. Added value of this studyTo our knowledge, this study provides the first evidence from a randomised experiment on whether PrEP causes compensatory risky sexual behaviour by FSWs. We found no strong evidence that either PrEP referral or PrEP use reduces condom use or increases measures of sexual risk-taking. Conversely, we found that PrEP users believe that PrEP is more effective when used with condoms. Implications of all the available evidenceIt is generally believed that prescribing PrEP to populations at high risk of HIV infection improves HIV prevention, despite some offsetting risk compensation, but may have a negative impact on the control of other sexually transmitted infections. Our study, which should be replicated with larger samples and in other contexts, suggests that concerns about a negative spillover effect of PrEP on risky sexual behaviour of FSWs may not be well founded. However, this could change if beliefs about dependence of PrEP effectiveness on complementary condom use were to change.

BackgroundInitial reports suggest that ethnic minorities may be experiencing more severe coronavirus disease 2019 (COVID19) outcomes. We therefore assessed the association between ethnic composition, income deprivation and COVID19 mortality rates in England. MethodsWe performed a cross-sectional ecological analysis across Englands upper-tier local authorities. We assessed the association between the proportion of the population from Black, Asian and Minority Ethnic (BAME) backgrounds, income deprivation and COVID19 mortality rates using multivariable negative binomial regression, adjusting for population density, proportion of the population aged 50-79 and 80+ years, and the duration of the epidemic in each area. FindingsLocal authorities with a greater proportion of residents from ethnic minority backgrounds had statistically significantly higher COVID19 mortality rates, as did local authorities with a greater proportion of residents experiencing deprivation relating to low income. After adjusting for income deprivation and other covariates, each percentage point increase in the proportion of the population from BAME backgrounds was associated with a 1% increase in the COVID19 mortality rate [IRR=1.01, 95%CI 1.01-1.02]. Each percentage point increase in the proportion of the population experiencing income deprivation was associated with a 2% increase in the COVID19 mortality rate [IRR=1.02, 95%CI 1.01-1.04]. InterpretationThis study provides evidence that both income deprivation and ethnicity are associated with greater COVID19 mortality. To reduce these inequalities, Government needs to target effective control and recovery measures at these disadvantaged communities, proportionate to their greater needs and vulnerabilities, during and following the pandemic. FundingNational Institute of Health Research; Medical Research Council

IntroductionSexual behaviour data are essential for monitoring behavioural trends and designing effective sexual health interventions. However, in Singapore and Southeast Asia more broadly, most research has focused on key populations, leaving a decades-long research gap in the general adult population. To address this, characterised sexual behaviour patterns and examined associations with socio-demographic characteristics, engagement with sex workers, and STI positivity. MethodsWe conducted a nationwide cross-sectional online survey (September 2023 to July 2024). Of 2,876 respondents, 2,297 were eligible (aged 21 years and above with complete key demographic data). Participants reported socio-demographic characteristics and sexual behaviours within the past year, 6 months, and 3 months. Outcomes included fitted distributions of partner numbers across partnered activities (mutual masturbation, oral, vaginal, anal sex) and associations with socio-demographic factors, sex worker engagement, and self-reported STI positivity. ResultsOf participants, 51.5% were male, 84.4% were Singapore citizens, 69.6% were aged between 21-60. Individuals reporting sexual partners of the same sex had a higher probability of having 5 or more same-sex partners respectively in the past year (WSW: 28.4% mutual masturbation, 27.8% oral sex; MSM: 36.2% mutual masturbation, 34.5% oral sex). Engagement with sex workers was reported by 4.7% (95% CI, 3.7-6.2%) of females and 18.1% (16.1-20.4%) of males, with higher odds among individuals with at least 5 partners in the past year (e.g., vaginal sex AOR = 7.40, 95% CI, 4.03-13.58). Self-reported STI positivity was 13.1%, associated with having at least 5 partners in the past year (e.g., vaginal sex AOR = 5.03, 95% CI, 1.44-17.61) and ever engaging with sex workers (e.g., vaginal sex AOR = 3.16, 95% CI, 1.67-5.99), but not with barrier protection frequency. ConclusionsPatterns varied by sex, sexual orientation, and risk behaviours, underscoring the need for context-specific behavioural data to inform STI modelling and public health interventions.

Background: Rising rates of young people Not in Education, Employment, or Training (NEET) in the UK have recently coincided with declining youth physical and mental health but no study has asked whether this reflects a growing proportion of young people with health problems (prevalence) or those with health problems becoming more likely to be NEET (penalty). Methods: Using 15 years of Understanding Society data (2009-23), we analysed 15,242 respondents aged 16-24 (66,160 observations). We employed three complementary approaches: descriptive trends, Blinder-Oaxaca-Kitagawa (BO) probit decomposition comparing 2009-2013 and 2019-2023 against a 2014-2018 reference period, and fixed-effects (FE) Poisson models with lagged health status. Exposures included self-reported health conditions or disability (SRHD), psychological distress , diagnosed conditions and socio-demographic factors. Findings: NEET rates were lowest in 2014-18 (10.5-11.5%) and higher in 2009-13 (12-15%) and 2019-23 (15-16%). Higher prevalence of SRHD, psychological distress, diagnosed depression and multimorbidity explained changes in NEET prevalence across both the 2009-13 to 2014-2018 and 2014-18 to 2019-23 periods. No change in penalty was observed for any health variable across periods, except for an increase in the penalty for SRHD between the 2009-13 to 2014-18 periods. Interpretation: Rising NEET rates among UK youth are driven largely by more young people having physical and psychological ill health. Whilst labour market and education accommodations remain important, reducing NEET rates will require reversing the decline in youth health, not just accommodating it.

BackgroundYoung (ages 18-35 years) men are inadequately engaged in HIV prevention and treatment globally, including in South Africa, increasing the likelihood of them having sexually transmissible HIV (i.e. living with HIV but with high viral loads). We sought to understand how mens experiences of poverty and violence, impacted on transmissible HIV, directly or indirectly via mental health and substance misuse. SettingRural communities in northern KwaZulu-Natal, South Africa. MethodsCross-sectional population-based random selection (September 2018-June 2019), assessing transmissible HIV (living with HIV and viral load [&ge;]400 copies/mL) via dried blood spots, and socio-demographic data. Structural equation models (SEM), assessed direct and indirect pathways from food insecurity and violence experience to transmissible-HIV, with mediators common mental disorders, alcohol use, gender inequitable attitudes and perceptions of life chances. Results2,086 young (ages 18-36 years) men and 8.6%(n=178) men had transmissible HIV. In SEM no direct pathways between food insecurity, or violence experience, and transmissible HIV. Poor mental health and alcohol use mediated the relationship between violence experience and food insecurity and transmissible HIV. Life chances also mediated the food insecurity to transmissible HIV pathway. ConclusionsThere was a high level of transmissible HIV in a representative sample of young men. The analysis highlights the need to address both the proximate drivers poor mental health and substance misuse, as well as the social contexts shaping these among young men, namely poverty and violence experience. Building holistic interventions that adequately engage these multiple challenges is critical for improving HIV among young men.

BackgroundEthnic inequalities in health and care are well-established. However, the lack of fine-grained data and small group sizes mean that the health and care needs of some ethnic groups are not well-quantified. MethodsThe North West London (NWL) Whole Systems Integrated Care (WSIC) database contains linked, deidentified records from General Practices (GPs), hospitals, and social care in NWL. Using this data, we examined health outcomes and healthcare utilisation of the Romanian and Somali communities in Brent. ResultsAfter age- and sex-standardisation, Somalis had higher prevalence of long-term conditions (LTCs), while Romanians had lower prevalence. Even after adjusting for prevalence of LTCs, the odds of having had an emergency department attendance, or hospital admission was higher for Somali adults, while Romanian adults had higher odds of having hospital admissions or avoidable emergency department attendances. ConclusionThis work is the first to quantify health outcomes and utilisation of these communities in the UK, and demonstrate that routine healthcare data can be used to understand and quantify ethnic inequalities in health and care.

In the UK, gay, bisexual, and other men who have sex with men (GBMSM) at risk of sexually transmitted infections (STIs) are recommended quarterly testing, but it is not known how many are following this recommendation. We described the prevalence and correlates of frequent STI testing amongst GBMSM. We analysed data on participants of the community-based Reducing Inequalities in Sexual Health (RiiSH) online survey of GBMSM, recruited in November-December 2024 via social media and dating apps. Participants were UK residents aged [&ge;]16 years who reported sex with a man in the previous year. We described the frequency of STI testing amongst individuals recommended quarterly testing, using proxies for national guidelines for quarterly testing eligibility (over the past three months: new male sexual partner, condomless anal sex, [&ge;]10 male partners, or chemsex). We explored factors associated with frequent testing ([&ge;]4 tests/past year) using univariate and multivariable logistic regression, adjusting for country of birth and residence, ethnicity, employment, and education. Among 2758 participants (median age 45 years, 88% white), we estimated that 2366 (86%) would be recommended quarterly STI testing. Over the past year, 562 individuals (24%) met or exceeded this recommendation (testing [&ge;]4 times), 1107 (47%) had 1-3 tests, and 673 (28%) no tests. Factors associated with frequent testing were: reporting using PrEP in the past year (adjusted odds ratio 7.66 (95% confidence intervals 5.77-10.30)), STI diagnosis in the past three months (1.96 (1.45-2.64)), and younger age (1.50 (1.04-2.16), aged 16-29 years vs [&ge;]45 years). Straight/bisexual orientation was associated with less frequent testing than gay/homosexual (0.71 (0.52-0.96)). Overall, data from a large UK community survey suggest that only 1 in 4 GBMSM who are recommended frequent STI testing meet this recommendation, and testing levels vary by PrEP use, STI history, age, and sexual orientation. Interventions are needed to address these inequalities.

BackgroundLate HIV diagnosis (LD) remains a major challenge in controlling the HIV epidemic, contributing to higher morbidity, mortality, and ongoing transmission. We aimed to estimate its prevalence and to identify associated socio-territorial inequalities in Greater Paris. MethodsThis observational study included PLWH diagnosed during 2014-2021 and treated in all HIV hospital centers across Greater Paris. Seven transmission groups were defined according to birth region, gender, and transmission mode. Neighborhood deprivation was assessed using the French Deprivation Index (FDEP) based on residence place. Factors associated with LD were identified using multilevel modeling. FindingsAmong 8,346 PLHW, 58% were born abroad, 43% were MSM, and 16% lived in precarious housing (3% among French-born MSM (FMSM) vs. 26% and 30% among foreign-born heterosexual men (fHM) and women (fW)) Overall, 47% lived in the most deprived neighborhoods, reaching 64% among fHM and 62% among fW. Nearly half had LD (47%), ranging from 30% among FMSM, to 65%/57% among fHM/fW. In multivariate analysis, LD was associated with living in deprived neighborhoods (aOR=1.39, 95%CI [1.17-1.65]). After adjustment for transmission group, all groups showed higher LD risk than FMSM, and previous associations disappeared. ConclusionLiving in deprived areas was associated with higher LD risk, driven by the concentration of high-risk populations (fHM and fW) and reflecting the socio-spatial segregation of PLWH. These findings highlight the need for innovative, geography-based, screening strategies that go beyond traditional risk-group approaches. Moreover, the seven-category "transmission group" classification represents a valuable social indicator for studying health inequalities among PLWH.

ObjectivesChemsex is the use of select psychoactive drugs to enhance sexual experiences and has been described among gay, bisexual, and other men who have sex with men (GBMSM). We aimed to characterise sexual risk, wellbeing and health-seeking behaviours among GBMSM and gender-diverse people reporting chemsex-associated drug use. MethodsWe analysed data from Reducing inequalities in Sexual Health (RiiSH), an online community survey of 2,758 UK-resident men and gender-diverse people having sex with men undertaken in November-December 2024. We compared those reporting chemsex-associated drug use with those who did not, assessing sociodemographic characteristics, well-being, sexual risk behaviours and sexual health service (SHS) engagement. ResultsOverall, 8% (218/2,758) reported chemsex-associated drug use in the last year. A higher proportion of participants reporting chemsex-associated drug use in the last year also reported a composite measure of sexual risk based on self-reported behaviours in the previous 3-4 months (e.g. prior bacterial STI diagnosis, [&ge;]5 male condomless anal sex partners) compared to those who did not (85% vs 61%, p<0.001). They also more frequently reported attending a SHS in the last year (81% vs 57%, p<0.001). Those reporting chemsex-associated drug use also more frequently reported a long-term limiting mental health condition (36% vs 24%, p<0.001) and poorer personal wellbeing (e.g. reporting low life satisfaction 36% vs 20%, p<0.001). ConclusionWhile a minority of participants in this national, community-based sample reported chemsex-associated drug use, this group had higher sexual risk and poorer indicators of wellbeing. Many participants also attended SHS, reinforcing the key supporting role of SHS for referral pathways to harm reduction support for those experiencing problematic drug use.

BackgroundFemale sex workers (FSW) are a key population for HIV prevention and care. Increasing evidence suggests that social and structural barriers are key drivers of HIV transmission. This global systematic review assesses whether experiencing violence is associated with worse HIV outcomes among FSW. Methods and FindingsWe searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to February 10th, 2025 assessing the impact of violence on HIV outcomes among FSW, without restriction to language and study design. Some studies had multiple estimates due to reporting on multiple outcomes or exposures of interest. We pooled data from eligible studies using multi-level random-effects meta-analyses to quantify associations between recent (past year) or lifetime exposure to violence (physical, sexual, emotional/psychological and/or financial) and HIV outcomes (prevalent and incident HIV infection, HIV testing, ART use, ART adherence, and viral suppression) among FSW. We preferentially used adjusted estimates over unadjusted estimates if both were available. We included 91 studies with 221 estimates, comprising 179,727 FSWs in 37 countries. We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.33; 95%CI:1.17-1.51; I2:64%; n=73 estimates) and lifetime (pOR:1.36; 95%CI:1.24-1.49; I2:38%; n=67) experiences of violence. Recently experiencing violence was associated with reduced odds of ART use (pOR:0.78; 95%CI:0.64-0.94; I2:8%; n=17). Lifetime exposure to violence was associated with reduced odds of viral suppression (pOR:0.88; 95%CI:0.79-0.98; I2:20%; n=6). There was no evidence of associations between violence and HIV incidence, HIV testing and ART adherence. ConclusionsExperiencing violence may increase HIV transmission risk and worsen HIV treatment outcomes among FSW. HIV interventions for FSWs must address violence as a structural determinant of HIV.

BackgroundThe introduction of mandatory calorie labelling among large food businesses (chains) in England in 2022 has been found to have little impact on consumer behaviour, but overall calories on restaurant menus have decreased slightly. This study examined menu changes post policy implementation, and the population groups likely to have been affected most. MethodsMenu data from 169 chains in Great Britain were extracted from two online food delivery platforms in June 2022 and June 2023. We selected 10 categories (specific foods or chains) jointly with public and policy advisors. Menu changes over time were assessed with multilevel models accounting for whether an item was continuously on the menu and for the type of chain. Where changes were found, we assessed differences in purchasing frequency by consumer characteristics using 2022 OOH purchase data (Worldpanel by Numerator, GB OOH Panel). ResultsChanges were observed in two (out of 10) categories examined and were driven by changing items on the menu rather than reformulating continuous dishes. Chains that used a healthy tag on the delivery website increased the share of mains under 600 kcal by 3.7 percentage points (95% CI 0.2 to 7.2), while average calories did not change (-17.6 kcal/item, 95% CI -38.7 to 3.4). Men, people aged 35-44 years and with high SES were found to purchase more frequently from these chains. Across all chains, the share of lower-calorie coffees decreased by 10 pp (95% CI -18.0 to - 0.02), with purchasing more frequent among men and increasing with age. ConclusionsAlthough data were available for one year only post-policy implementation, menu changes among the investigated foods and chains were limited. While menu change may equitably improve population dietary health, dietary inequalities may exacerbate if only healthy chains already offering lower-calorie food change their menus.

ObjectivesTo investigate rates of mpox beliefs, knowledge, and intended behaviours in the general population and in gay, bisexual or other men who have sex with men (GBMSM), and factors associated with intended behaviours. To test the impact of motivational messages (vs a factual control) on intended behaviours. DesignCross-sectional online survey including a nested randomised controlled trial. SettingData collected 5 September to 6 October 2022. ParticipantsParticipants were aged 18 years and over and lived in the UK (general population). In addition, GBMSM were male, and gay, bisexual or had sex with men. The general population sample was recruited through a market research company. GBMSM were recruited through a market research company, the dating app Grindr, and targeted adverts on Meta (Facebook and Instagram). Main outcome measuresIntention to self-isolate, seek medical help, stop all sexual contact, share details of recent sexual contacts, and accept vaccination. ResultsSocio-demographic characteristics differed by sample. There was no effect of very brief motivational messaging on behavioural intentions. Respondents from Grindr and Meta were more likely to intend to seek help immediately, completely stop sexual behaviour and be vaccinated or intend to be vaccinated, but being less likely to intend to self-isolate (ps<0.001). In the general population sample, intending to carry out protective behaviours was generally associated with being female, older, having less financial hardship, greater worry, higher perceived risk to others, and higher perceived susceptibility to and severity of mpox (ps<0.001). There were fewer associations with behaviours in the Grindr sample, possibly due to reduced power. ConclusionsGBMSM were more likely to intend to enact protective behaviours, except for self-isolation. This may reflect targeted public health efforts and engagement with this group. Associations with socio-economic factors suggests that providing financial support may encourage people to engage with protective behaviours. STRENGTHS AND LIMITATIONSO_LIAnonymous cross-sectional survey in large samples of the general population and men who are gay, bisexual, or have sex with men (recruited from a market research company, the dating app Grindr, and targeted adverts on Meta [Facebook and Instagram]). C_LIO_LIData collection occurred over a short period (5 September to 6 October 2022) during the mpox outbreak. C_LIO_LIResponses may have been affected by social desirability or recall bias, although the anonymous nature of the survey should mitigate this somewhat. C_LIO_LISocio-demographic characteristics differed by sample. Participants recruited from Grindr and Meta were more likely to be working, highly educated, of higher socio-economic grade, and have less financial hardship. C_LIO_LIWe measured behavioural intentions. Rates of engagement with behaviours may be lower. Factors associated with intentions should still be valid. C_LI

Background and AimsThe onset of the COVID-19 pandemic led to significant changes in individual-level alcohol consumption and a sharp increase in heavy drinking in the UK. More recently, high rates of inflation, the resulting cost-of-living crisis and reforms to alcohol taxation have affected the affordability of alcohol, but little is understood about how these changes have impacted on alcohol sales and consumption. We aimed gain insights into recent trends in alcohol sales by assessing changes in alcohol duty revenue collected by the UK government since 2020. Design and SettingWe used published data on UK alcohol duty revenue to model trends from 2010-2019. We forecasted these trends through to October 2024 using a novel statistical approach and compared these forecasts to observed receipts. MeasurementsMonthly inflation-adjusted alcohol duty receipts received by the UK Treasury in pounds sterling for beer, cider, spirits and wine. FindingsDuring the pandemic, alcohol duty receipts fell during lockdowns and rose as restrictions were subsequently lifted. Since 2022 alcohol duty receipts have been consistently below the historical trend, with a gradually increasing deficit in wine receipts and comparable deficit in spirits receipts that began sharply in late 2022. The reforms to the alcohol duty system in August 2023 do not appear to have significantly affected these trends. ConclusionsOur findings suggest that the cost of living crisis in 2022/23 has led to a fall in alcohol sales relative to the pre-pandemic trend. The magnitude of this fall differs by beverage type, indicating that wine and spirits drinkers may have changed their behaviour more than beer and cider drinkers.

Objective To measure the accuracy of clinical coding, clinician review, and a locally deployed large language model (LLM) in identifying alcohol, drug, and self-harm involvement in emergency department (ED) attendances, and quantify prevalence. Design Two-phase diagnostic accuracy study. In a validation week, the identification strategies were assessed against a conflict-adjudicated reference standard (n=2,256); the LLM was then applied to n=105,096 annual attendances at the same site. Setting UK Type 1 Emergency Department treating patients [&ge;]16yrs. Main outcome measures Prevalence quantification compared with the reference standard; sensitivity, specificity, and balanced accuracy of each strategy; monthly identification rates and adjusted annual prevalence. Results The reference standard identified 12.1% of attendances as involving alcohol, drugs, or self-harm (coding 6.0%; clinician 10.0%, LLM 15.6%). LLM balanced accuracy matched or outperformed clinician review in all three domains (alcohol 0.942 v 0.930, p=0.635; drug 0.959 v 0.791, p<0.001; self-harm 0.982 v 0.908, p=0.004). Coding recorded 1.07 domains per identified patient against 1.32 in the reference standard. Adjusted annual prevalence corresponded to 12,890 domain involvements per year not identifiable in coded data. Subdomain classification found at least 81.6% of self-harm attendances required medical assessment for injury or overdose before psychiatric review. Conclusions Clinical coding identified fewer than half of presentations involving alcohol, drugs, and self-harm and rarely captured co-occurring domains; under-recording was present across a full year. A locally deployed LLM generated more complete structured data from existing clinical text within NHS infrastructure, at a scale which is not feasible for manual review.