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NIHR HPRU for STIs and BBVs: Academy PhD project proposals 1. Supervisors Dr Elaine Genders (Reader in Criminology, UCL) and Dr Eamonn O’Moore (Director Health & Justice, PHE). Research Proposal A longitudinal qualitative study to explore lived experiences of the Cascade of HIV Care, within prison institutions and between prison and community settings Summary Background: The Cascade of Care is a novel means of monitoring the HIV epidemic, offering estimates of people living with HIV across the different phases of care. Although the burden of blood-borne viruses (BBVs) in UK prisons is reportedly high, HIV surveillance systems specific to prisons are undeveloped. The introduction of opt-out BBVs testing in April 2014 is likely to have significant implications for current understandings of HIV epidemiology in prisons, with similar interventions in the US seeing a dramatic increase in case identification. There is little known about the individual, social and systemic factors that shape experiences of HIV care in UK prisons. Current HIV service deficiency compromises the health of prison populations and heightens risk of further HIV transmission with prisoners living with HIV thought to face considerable social and structural barriers to HIV treatment and care. Reentry into the community, and possible recidivism, are likely to pose additional complications for continuity of care. There is a critical need for further evidence relating to HIV treatment experiences in UK prison settings. How is HIV treatment navigated in the context of the prison environment? How does the prison setting shape treatment vulnerabilities and the capacity to engage in care? How are meanings of HIV treatment and the care cascade shaped by the prison experience and across ‘transitions’ between prison and community contexts? Proposal: The proposed study will adopt a longitudinal qualitative approach, using ethnographic methods and in-depth interviews, to explore prisoners’ lived experiences of the Cascade of HIV Care. The study will also seek to examine how treatment experiences and meanings are renegotiated across transitions within/between institutions, following re-entry into the community and, where relevant, re-entry into prison Addressing the gap of undiagnosed HIV, HBV, HCV using enhanced dried blood spot/saliva sampling as a strategy to impact on HIV, HBV, HCV Public Health epidemiology in the UK Background: Reducing the burden of undiagnosed BBVs is important in controlling the public health impact on onward transmission and undetected disease progression. Access to diagnosis and behavioural, attitudinal aspects of various public health population groups are key determinants in formulating strategies to address the gap in undiagnosed infections. The impact of this is more pronounced in the hard to access population such as Black African/Black Caribbean, PWID and those with higher rates of ongoing transmission such as MSM. Traditional diagnostic and screening measures involving venous sampling has not resulted in an increase in the proportion of diagnosed HIV and HCV. The aim of this proposal is to assess non-traditional sampling (e.g. dried blood spot / saliva, home sampling) as effective tools for screening and diagnosis to close the gap of undiagnosed BBVs whilst providing real-time molecular epidemiology information on HIV and HCV, commensurate with current diagnostic methods. Proposal: This PhD proposal would involve sexual health providers covering populations with higher ongoing transmissions for HIV, HCV (as mentioned above). Health care seeking behaviours will be assessed by questionnaires and through Professor Tim Rhodes Head of SEHR and Professor of Public Health Sociology LSHTM 2. Dr Greta Rait (UCL), Dr Tony Nardone, Dr John Parry and Dr Noel Gill, PHE Colindale (PHE) Samuel Moses (Virology) Virus Reference Department HIV/Viral STI, Antiviral Units Public Health England Reference Microbiology Services 1 3. Dr Cath Mercer (UCL), Dr Stephanie Chisholm (PHE Colindale), Prof Nick Thomson (The Wellcome Trust Sanger Institute and LSHTM) and Dr Simon Harris (The Wellcome Trust Sanger Institute). Dr Gwenda Hughes STI Section Head, PHE Colindale Use of whole genomic sequencing to understand the relationship between sexual attitudes and behaviours on spatial and phylogenetic clustering of gonorrhoea in high-risk sexual networks Respondent-Driven Sampling [RDS] where preference for DBS/saliva sample in community/home sampling has been indicated, sampling for such will be undertaken with a control arm randomisation for routine blood sampling. Where participants do not state a preferred choice, consent would be obtained for both non-traditional and venous sampling. Part of the PhD student’s time will be employed in refining the serological and molecular tests for HIV, HBV, HCV in non-traditional samples at PHE Colindale and working with laboratory and epidemiology colleagues to analyse the prevalence estimates, molecular epidemiology and viral resistance/polymorphisms using Sanger/Next Generation Sequencing comparing it to outputs from paired blood samples where available within the study testing algorithm. Within the participant care pathway, the testing algorithm will allow for subsequent blood sample access for saliva samples alone as molecular yield for HIV, HCV is poor in saliva. Background: The overarching aim of the 'Risk and risk reduction theme' of the Health Protection Research Unit on STIs and BBVs is to improve understanding and the knowledge-base of the behaviours, attitudes, and factors that influence the risk of STI and BBV acquisition and transmission in key population groups, to inform and support the targeting and delivery of interventions. In the short term the aim is to develop a system for periodic, in-depth exploration and assessment of behaviours, attitudes, decision-making, and factors related to STI and BBV risk in black Caribbeans (BCs) and men who have sex with men (MSM) using qualitative and quantitative methods. The aim is to implement a bio-behavioural rapid risk assessment system (RRAS) in selected sexual health clinics and link this behavioural data to socio-demographic and clinical data available in the genitourinary medicine clinic activity dataset – GUMCAD. Proposal: This mixed methods PhD proposal will seek to develop this work further by investigating how whole genomic sequencing can be used to enhance behavioural and other contextual risk information to determine sexual networks which could be targeted by specific, tailored interventions. The study will investigate the degree to which specific risk behaviour profiles are correlated with spatial clustering and phylogenetic relatedness, and whether they are useful markers of high-risk sexual networks. Using gonorrhoea as an example, the study will link the data collected on BC and MSM populations diagnosed with gonorrhoea in the combined RRASs/GUMCAD dataset, to data on sequence types from specimens collected through the gonococcal resistance to antimicrobials surveillance programme (GRASP). The relationship between risk behaviour and antimicrobial resistance profiles will also be explored. 2 4. Dr Greta Rait (UCL), Katy Turner (SCCM/CVS), Sarah Woodhall (PHE) Development and evaluation of a Chlamydia Control Cascade Dr John Saunders Clinical Champion National Chlamydia Screening Programme Public Health England 5. Dr Fiona Burns Dept of Infection & Population Health, UCL Alison Rodger (UCL), Tony Nardone (PHE), Chris Bonnell (UCL) Meeting the HIV prevention needs for those of black African ethnicity in London Background: In England the National Chlamydia Screening Programme (NCSP) recommends opportunistic testing of women and men aged <25 years annually or on change of sexual partner. The aim is to identify and treat infected individuals and their partners to prevent serious reproductive outcomes in women and to reduce the burden of population disease by reducing transmission and incidence of infection. There is still uncertainty about the effectiveness and cost-effectiveness of programmes to control chlamydia transmission at a population level and to prevent reproductive sequelae following a diagnosed and treated chlamydia infection. Part of the reason for this uncertainty is the multiple elements to control activities which can act synergistically or antagonistically and thus affect the apparent impact of the programme. The notion of care cascade has been successfully used to prioritise control activities for HIV and to locate areas for service improvement. A chlamydia control cascade would encompass all elements of a chlamydia control programme within a simple structure. The key elements of chlamydia control include effective case management and prompt treatment, opportunistic screening and diagnosis, effective partner notification and retesting of positives at three months Proposal: We will develop and validate a chlamydia control cascade and apply the tool to regional and national level data in the UK. We will use national data collected by PHE to better estimate maximal and minimal rates of chlamydia testing and diagnosis since the inception of the NCSP in 2003. We will also use data from the NATSAL surveys (UK national surveys of sexual attitudes and lifestyles) to inform sexual behaviour data and an individual cohort from regional and local settings to inform testing behaviour in a UK setting. We will populate the model with data from local areas to assess a fully integrated dataset of chlamydia control activity regionally. We will explore differences observed and analyse which variables have the greatest influence on reported positivity. Background: In the UK, the HIV epidemic is largely concentrated in London with nearly half (32,500) of the 77,600 people living with a diagnosed HIV infection living in London and 42% (2,832) of the 6,360 new HIV diagnoses in 2012 made in London clinics. The two communities who remain most at risk from HIV are men who have sex with men (MSM) and Black African heterosexual men and women. The prevalence of HIV in both communities is high (>5%). The London-wide HIV Prevention Programme (LHPP) is an evidence based behavioural intervention (using media, condom distribution, and outreach programmes) being established to interface with and complement the biomedical (test and treat) services commissioned by Local Authorities in clinics since 2013, to achieve a combination intervention package across London focused on MSM and Black Africans. This PhD will focus on assessing if current initiatives meet the HIV prevention needs of those of black African ethnicity living in London and spans two HPRU theme areas, theme A (understanding risk and risk reduction for STIs and BBVs) and theme B (Reducing the burden of undiagnosed STIs and BBVs) Proposal: To explore whether HIV prevention needs for black Africans in London are currently being met. This will be a mixed methods programme of work involving (i) 3 analysis of PHE databases (GUMCAD and HIV) to assess changes in GUM service use, HIV testing patterns and late HIV presentation in those of black ethnicity, (ii) a mapping exercise followed by the development and implementation of a large scale cross-sectional survey of Black African communities in a variety of social and community settings and (iii) qualitative work including focus group discussions and semi-structured interviews to assess the reach and impact of the LHPP. 6. Prof Andrew Philips Dept of Infection & Population Health, UCL How frequently should individuals living with HIV be seen for clinical care? What is the most cost-effective approach to monitor such patients? Valentina Cambiano, Alec Miners (LSHTM), PHE 7. Prof Caroline Sabin Dept of Infection & Population Health, UCL Fiona Burns (UCL), Jonathan Sterne Are sub-optimal out-patient attendance patterns ‘bad’ for HIV patients? Background: The introduction of combination antiretroviral therapy (cART) has led to a dramatic reduction in HIV-associated morbidity and mortality. The life expectancy of those living with HIV has increased to the extent that it is now similar to that of the general population. This has resulted in a burgeoning clinical population of patients who are well on therapy, but are required to attend for care for follow-up visits. As there have been no increases to the resources available to clinics, many clinics have had to make changes to the way their HIV service. These changes have commonly included less frequent scheduled visit dates, and a reduction in the numbers of laboratory tests. These changes have generally been made based on expert opinion rather than on evidence. It is generally felt that a policy of less frequent patient visits is unlikely to introduce safety concerns for patients. It is possible that the identification of virological failures on cART, should they occur, may be delayed with less frequent patient monitoring, which may lead to an increase in the development of drug resistance at the population level. Whilst this may have only a limited effect on the outcomes of the person’s next cART regimen for most people, there may be longer term implications for these people. Unfortunately, assessment of the associations between the frequency of clinic visits and/or laboratory monitoring and resistance development and clinical outcomes are fraught with problems due to the presence of confounding and issues around missing and incomplete data. Use of mathematical modelling may provide an alternative means to address this issue. The HIV Synthesis model is an existing model for HIV disease progression developed by Prof Phillips, which simulates the full course of an individual’s HIV infection. Proposal: This project will involve the modification of the existing model structure for HIV Synthesis to introduce different patterns of monitoring and attendance, and to assess the impact of these on virological failure, resistance development, CD4 count responses to therapy and subsequent clinical progression. The student will apply utility scores and NHS costs to clearly defined health states within the model to allow the student to model disease progression, quality-adjusted life years and NHS costs, at different levels of engagement. The final model will then be broadened to consider other models of care that may be used within the HIV setting. Background: Combination antiretroviral therapy (cART) has revolutionised the care of people living with HIV (PLWH). In addition, cART has been recognised as an effective means of reducing HIV transmission. Yet these individual and public health benefits can only be achieved if PLWH are aware of their infection and have sustained engagement with HIV care. Good engagement with health care is 4 (Bristol), Valerie Delpech (PHE) associated with improved adherence, virological and immunological outcomes on cART and survival. Poor retention in care represents one of the major challenges of optimising patient outcomes. Traditionally, retention in care has been defined in terms of attendance data over an arbitrarily defined time period. However, this simple approach may hide many different patterns of attendance, some of which may be associated with poorer outcomes than others. The REACH study (Exploring patterns of Reach and Engagement Across specialised Care services of HIV positive patients in the UK) aims to explore, describe, and understand HIV out-patient attendance in people living with HIV, in order to develop cost effective interventions to optimise their engagement in care. To date, study researchers have described typical attendance patterns using data from the UK Collaborative HIV Cohort (CHIC) study, a large observational study of individuals attending for HIV care at some of the largest HIV clinics in the UK. Researchers have demonstrated that patients may exhibit several different patterns of attendance, and that the pattern of attendance may change over time within an individual. The challenge now is to correlate these patterns with clinical outcomes. However, assessment of the impact of attendance patterns on clinical outcomes is difficult due to problems of reverse causality (whereby patients who are sicker tend to attend more frequently than those who are well). Furthermore, statistical methodology for assessing the association between changing patterns of attendance and outcomes is restricted. Proposal: The focus of this PhD project is in the development and application of novel statistical methodology to describe associations between patterns of outpatient attendance and long-term outcomes. This would be a joint PhD with the HPRU in Evaluation of Interventions at the University of Bristol. Estimates from this work would be directly used to inform models to be used to assess cost effectiveness of different models of HIV care. 8 Prof Caroline Sabin Dept of Infection & Population Health, UCL Valerie Delpech (PHE) Fiona Burns (UCL) Assessment of HIV patient complexity using routinely collected linked data from several source Background: There is considerable interest in an evidence-based method to describe HIV patients under care as either ‘complex’ or ‘stable’. From a commissioning perspective, the ability to robustly stratify patients into one of these groups would allow funding to be distributed appropriately, to centres with the greatest burden of care. From a patient and provider-perspective, accurate categorization of patients would allow frequency of monitoring to be optimized. Whilst many clinics already have their own definitions of ‘stability’, these are varied and criteria may differ from clinic to clinic. The UK Department of Health National Payment by Results (PBR) working group has proposed a means to classify patients as ‘complex’ – however, the criteria selected largely reflect a compromise between widely differing opinions, and several of the proposed criteria require clinical information that may not always be captured in clinical databases, limiting the use of this definition for research purposes. Proposal: The objectives of this project are to: perform an assessment of the various criteria for ‘complexity’ (or ‘stability’) to determine the likely value of each set of 5 criteria for research purposes; conduct studies to determine clinical perceptions about ‘complexity’ and to see whether these perceptions are affected by the demographics of either the clinician or the patient; use routine clinical data to compare the various different criteria in current use, and their associations with longer-term clinical outcomes and make recommendations for the most appropriate criteria to use in any given setting. Data for the project will come from the UK Collaborative HIV Cohort (CHIC) Study, a large multi-centre study of >45,000 patients with HIV seen for care at one of 15 clinical sites from 1996 onwards, with linkage to HIV surveillance datasets collected by Public Health England (PHE). 9. Prof Caroline Sabin Dept of Infection & Population Health, UCL Use of linked clinical and genotypic databases to understand the genetic contributions to clinical outcomes in individuals with HIV Tamyo Mbisa (PHE), Samuel Moses (PHE) Background: A number of genome-wide association studies have addressed genetic correlates with HIV disease progression. The main driver for such studies has been to identify correlates of natural attenuation of infection, to inform vaccine development. However, little work has been undertaken in the context of combination antiretroviral treatment (cART) or related to specific risks for complications of HIV infection. There is evidence to suggest that suppression of viral replication by cART is insufficient to prevent premature acquisition of cardiovascular events, or hepato-renal pathology and the risk of non-AIDS cancers also appears to be raised. Further, there remains heterogeneity in the immunological response to cART. Proposal: The UK Collaborative HIV Cohort (UK CHIC Study) is a longitudinal study of >45,000 HIV-positive individuals seen for care at many of the largest HIV clinics in the UK. Recently, we have received funding for host genome sequencing of 10,000 participants in this study through the UK BioResource, as well as capture of information on several non-AIDS clinical conditions. Using the information generated through linkage of the genotypic data that will be obtained, with extensive phenotype data from UK CHIC (including longitudinal data on responses and outcomes of cART), this project will investigate the genetic contributions to several outcomes, including (but not limited to): discordant virological and immunological responses to cART; immune reconstitution syndrome; switches in antiretroviral therapy for toxicity reasons; renal disease progression and cART-associated nephrotoxicity; central nervous system diseases; cART-associated hepatotoxicity and long-term virological control in the absence of cART. 10. Prof Caroline Sabin Dept of Infection & Population Health, UCL Richard Gilson (UCL), William Rosenberg (UCL), Sam Lattimore (PHE) Ongoing assessment of uptake and outcomes of drugs active against hepatitis B and hepatitis C virus in individuals co-infected with HIV Background: Despite the lack of information on drug-drug interactions and resistance development to the new directly acting antivirals (DAAs) in those coinfected with HIV and HCV, it is likely that use of these drugs will become widespread rapidly. Over the past two years, we have undertaken a detailed review of data for all patients who are co-infected with HCV (n=3299) attending 11 of the participating UK CHIC clinics. As a result, our database now contains detailed information on ultrasound, biopsy and fibroscan results, prothrombin time, INR, alpha-feto protein, HCV treatment, HCV genotype, clinical events and transplants performed. Data collection will continue on this subset (as well as newly identified 6 co-infected individuals) on a two-yearly basis. This dataset will provide a tremendous resource to answer new questions relating to co-infection in the UK. Proposal: The proposed study will examine the following: How frequently are the new DAAs used in this cohort and are there any differences in the characteristics of those who have access to these drugs and those that do not?; What are the virological and clinical outcomes of the new DAAs?; What impact do these drugs have, if any, on response to cART? Is there still a detrimental effect of HCV coinfection on immunological responses to cART; What are the patterns of resistance among individuals with treatment failure on the new DAAs?; How frequent is reinfection with HCV in this population (particularly in MSM and IDU) and does the success of treatment decline with subsequent courses of therapy?; How do the virological and clinical outcomes in those co-infected with HIV compare to those seen in individuals infected with HCV or HBV alone?; Are there any other genetic determinants of clearance/reinfection with HCV other than IL28b? 11. Dr Nigel Field (UCL), Dr Pete Weatherburn (LSHTM) and Professor Nick Thomson (The Wellcome Trust Sanger Institute and LSHTM). Dr Gwenda Hughes STI Section Head, PHE Colindale, Prevalence, risk markers and phylogenetic clustering of Shigella spp. infection among men who have sex with men attending genitourinary medicine clinics: Use of a bio-behavioural rapid risk assessment system to identify opportunities for infection control Background: In 2010, an outbreak of non-travel related Shigella flexneri (a gastrointestinal [GI] infection transmitted through the faecal-oral route which can cause severe dysentery) among adult males in England was associated with sexual transmission among men who have sex with men (MSM). Since then, diagnoses have continued to rise and Shigella flexneri is now considered endemic in this population. In-depth qualitative interviews of a small sample of the infected men have suggested specific sexual activities and drug-use behaviours among HIV-positive MSM played a role in the outbreak. Many questions remain unanswered. It has not been possible to determine the specific risk practices and contextual factors associated with infection, and whether transmission occurs in the same sexual networks as for ‘classical’ sexually transmitted infections (STIs). There is also a lack of understanding of MSM’s attitudes and awareness of the risk of faecal-oral transmission and of the acceptability of proposed interventions. Further, as there is evidence to suggest that some GI infections may be carried asymptomatically, and as such infections will not be routinely tested for in genitourinary medicine (GUM) clinics, the background prevalence of Shigella spp infection and the risk of onward transmission among sexually active MSM is unknown. Proposal: The overall aim of this PhD proposal is to determine the prevalence and associated risk factors of Shigella spp. infection in sexually active MSM attending GUM clinics to improve the evidence base for better infection control. The research will investigate the clinical outcomes, risk practices and risk contexts associated with Shigella spp. infection and how these are influenced by attitudes and awareness. As part of the 'Risk and risk reduction theme' of the HPRU on STIs and BBVs, the study will develop a bio-behavioural rapid risk assessment system (RRAS) on Shigella spp. infections for completion by MSM attending selected sexual health clinics. Those agreeing to participate will also be asked to provide a faecal sample or swab to test for Shigella. Data from the RRAS and Shigella testing will be linked to socio- 7 demographic and further clinical data on STI and HIV co-infection available in the GUM clinic activity dataset (GUMCAD). Whole genome sequencing (WGS) will be used to analyses a sub-set of Shigella samples to identify molecular markers of phylogenetic relatedness and explore whether strain types vary across population groups, and thereby determine which clinical, behavioural and contextual factors characterise distinct sexual networks and might be targeted for interventions. 12. Dr Ali Judd Inst of Clinical Trials &Methodology (UCL) Prof David Dunn (UCL), Valerie Delpech (PHE) 13. Dr Cath Mercer (UCL), Dr Gwenda Hughes STI Section Head, PHE Colindale, Dr. Martine Collumbien (LSHTM) Young people with life-long HIV transitioning to adult care: keeping track of engagement in care and long-term well-being and life expectancy. Type of PhD: Applied statistics or infectious disease epidemiology Background: For young people who acquired HIV perinatally or in early life (PHIV), the process of transition from paediatric to adult care is key to shaping HIV care engagement as well as health outcomes. Evidence suggests considerable morbidity and mortality in PHIV transferring to adult care, in excess of that seen in paediatrics and in horizontally HIV-infected adults. This study will utilise existing cohort studies and datasets within the HPRU to identify who are the most vulnerable PHIV in terms of care disengagement and mortality, in order to help inform future NHS service delivery. Proposal: This PhD project will form part of a wider NIHR-funded mixed methods study evaluating how the health of PHIV changes during and after the process of transition to adult care. The proposed study will include: conducting a literature review describing health outcomes of PHIV following transition to adult care; exploring methods to use routine outpatient attendance data to estimate care disengagement; initiating and validating data linkage of CHIPS/ CHIPS+ to UK CHIC, PHE HARS and mortality data to minimise loss-to-follow-up and maximise the validity of mortality and progression to AIDS estimates; exploring methods to deal with missing data; estimating rates of care disengagement and mortality in PHIV and exploring predictive factors for these outcomes; comparing rates of outcomes in PHIV to those with horizontal infection Identifying social and contextual factors mediating Black Caribbean & Black Other populations’ vulnerability to poorer sexual health outcomes: participatory qualitative research to explore risk and risk reduction capacity. Background: Black Caribbean/Black Other populations in Britain have poorer sexual health outcomes than other ethnic minority groups, including the majority white population. The Black Caribbean (BC) population in particular has a higher prevalence of bacterial STIs. The second British National Survey of Sexual Attitudes and Lifestyles (Natsal-2) completed in 2001 found significant association between the number of reported STIs and ethnic origin with BC most at risk. Evidence from Natsal-2 of specific risk practices showed higher reported numbers of sexual partnerships by BCs in lifetime than other ethnic groups, as well as higher reported concurrency for BC men than white men. Questions remain about the contextual vulnerabilities and behaviours which lead to negative sexual health outcomes among these two populations. Individual-level behaviours need to be examined; this includes attitudes to and consistency of condom use, age at first sex, drug and alcohol use. Deeper understanding of group-level risk associated with poorer outcomes is essential; topics for exploration would include cultural norms, discrimination, and age mixing. Identification of the most salient social and contextual factors is critical to the improvement of cultural competency in clinics and target interventions. 8 Proposal: The overall aim of this PhD proposal is to identify social and contextual factors which affect the sexual health of two ethnic minority populations: Black Caribbean people and those identifying as Black Other. This work would inform social interventions across the life course and improve the evidence base for tailored sexual health promotion. It would also seek to describe ways to inform improved cultural competence of healthcare workers and best practices in service delivery. The research will describe the sexual networks of these populations, and ascertain their attitudes towards STIs/BBVs risk and use of any risk reduction practices. This will aid understanding of factors mediating risk and risk reduction capacity. The study will consider specific vulnerabilities and routes to risk reduction of subpopulations within these ethnic groups, including women, young people, faith groups, gender and sexual minorities. It will examine other risks associated with poorer sexual health outcomes, such as non-volitional sex and alcohol or drug use. Under the HPRU theme 'Understanding risk and risk reduction' related to STIs and BBVs, the study will investigate how attitudes, behaviours and contextual factors affect sexual health outcomes for two population groups. Research participants will be engaged with using a variety of qualitative methods and participatory approaches. 14 Dr Greta Rait Dept of Primary Care and Population Health, UCL Prof Jackie Cassell (PHE) HIV diagnosis and management in primary care Background: HIV testing in primary care is advocated by NICE in high prevalence areas and in people presenting with clinical indicator conditions or at risk of HIV. Around 50% of people with HIV present late. This is associated with increased morbidity, and contributes to a high proportion of HIV related deaths. There majority of new HIV diagnoses had attended primary and secondary care previously, with missed opportunities for earlier diagnosis. While testing at registration with a GP has been piloted and trialled, many undiagnosed individuals will be registered with the same GP long term. Clinical indicator diseases (CIDs) provide a robust opportunity to offer an HIV test with a higher chance of a positive result, without stigmatising people since this would be a universal offer based on their clinical condition. Increasingly people with HIV are known to their general practice and with increasing life expectancy are presenting in primary care with other long term conditions. Proposal: There is potential to use electronic health records to such as the THIN (The Health Improvement Network) primary care database linked with Hospital Episode Statistics to examine HIV testing and management in primary care. The THIN database derives data from routine clinical practice in the UK and contains the records of nearly 12 million patients. The proposed study will examine the delivery of HIV testing to people with CID in general practice; examine HIV testing patterns and also investigate how patients with HIV known to their general practice are managed, particularly regarding other long-term conditions. 15 Dr Greta Rait (UCL) Dept of Primary Care and Population Health, UCL Exploring the sexual health needs of young bisexual, gay and other men who Background: Gay, bisexual and other men who have sex with men (MSM) are disproportionately affected by infection with HIV and other sexually transmissible infections (STIs). For this reason many sexual health prevention strategies target this 9 have sex with men Dr John Saunders National Chlamydia Screening Programme (PHE) Prof Jackie Cassell (PHE) risk group. Ensuring that these men understand how to protect themselves from infection is an important part of helping to reduce incident infection and diagnose new infections. Providing this information before initiation of same sex activity may be particularly important. However, the development of sexual identity and the debut of same-sex sexual activity may mean that young men with sexual attraction to other men do not yet identify as gay or bisexual, and indeed may never do so. This may limit their access to relevant sexual health information or services available to them. Proposal: This PhD would use a mixed method approach to better understand how young men with sexual attraction to other men navigate the available information on sexual health. It would also explore the knowledge, attitudes and behaviours of young men with sexual attraction to other men to better understand how to produce relevant and appropriate sexual health messages for this group. 16 Dr Greta Rait (UCL) Dept of Primary Care and Population Health, UCL Prof Jackie Cassell (PHE), Dr Julia Bailey (UCL) Dr John Saunders National Chlamydia Screening Programme (PHE), Dr Lorraine McDonagh (UCL) Development of a theory-based and evidence-based digital intervention to increase screening for sexually transmitted infections and blood borne viruses among young men who have sex with men. Background: The impact STIs and BBVs is greatest among young people (aged 1524 years) and men who have sex with men (MSM) where the highest prevalence rates are found. Younger MSM (YMSM) have been identified as a particularly vulnerable subgroup with even higher rates of STIs. To detect and reduce the transmission of STIs/BBVs, annual or more frequent screening for YMSM is recommended in several countries; however, many of those at risk do not receive screening. Innovative approaches to reach YMSM and increase screening among this population are needed. The use of new digital technology (e.g., the Internet, text messaging, applications) may be particularly beneficial in this regard as it holds special appeal for sexual minority youths. For example, due to its anonymity and perceived sense of safety against the stigma that surrounds same-sex activity, the Internet is increasingly being used by YMSM to seek out romantic or sexual partners. Thus far, however, the use digitally-based interventions to increase STI/BBV screening remains unexplored among YMSM. Proposal: The overall aim of this PhD proposal is to develop an intervention(s) which will enable effective, efficient, and early diagnosis of STIs/BBVs for YMSM. The first phase of the research will involve a systematic synthesis of evidence relating to STI/BBV screening in YMSM. Information will be gathered relating to current provision of screening services for YMSM, barriers and facilitators to screening, and the effectiveness of interventions to increase screening. In the second phase of research, a multifaceted qualitative approach using within-method triangulation will be employed. Specifically, semi-structured individual interviews and focus groups will be conducted. The qualitative component will focus on expanding upon any gaps identified throughout the evidence synthesis. Furthermore, screening location preferences and the acceptability of the use of new technologies to increase screening will be explored. 10