John M Saunders

• PhD, MBBS, MRCP, DFSRH, DipGUM
• Clinical Champion, National Chlamydia Screening Programme at Public Health England

Objectives Trans and/or gender diverse (T/GD) people in the UK are less likely to access sexual health services (SHS) than cisgender people and are more likely to report negative experiences. The British Association for Sexual Health and HIV (BASHH) developed expert recommendations for T/GD-inclusive SHS, but these lack service user perspectives. T...

Background The ability to access and navigate online sexual health information and support is increasingly needed in order to engage with wider sexual healthcare. However, people from underserved populations may struggle to pass though this “digital doorway”. Therefore, using a behavioural science approach, we first aimed to identify barriers and f...

Background: Chlamydia is the most diagnosed bacterial sexually transmitted infection in England, but opportunistic testing remains low in general practice despite high prevalence among young people. Attempts to increase testing have been met with little success; therefore, there is a need to explore why rates remain low and how this may be improved...

Background The ability to access and navigate online sexual health information and support is increasingly needed in order to engage with wider sexual healthcare. However, people from underserved populations may struggle to pass though this “digital doorway”. Therefore, using a behavioural science approach, we first aimed to identify barriers and f...

Objectives Trans and/or gender diverse (T/GD) people in the UK are less likely to access sexual health services (SHS) than cisgender people but are more likely to report negative experiences. The British Association for Sexual Health and HIV (BASHH) developed expert recommendations for T/GD-inclusive SHS, but these lack service user perspectives. T...

Introduction Trans and/or gender diverse (TGD) people in the UK are less likely to access sexual health services (SHS) than cisgender people and more likely to report negative service experiences. The BASHH Gender and Sexual Minorities Special Interest Group (GSM SIG) developed expert recommendations for TGD-inclusivity but lacked evidence from ser...

Background Widely accessible, acceptable, equitable, HIV pre-exposure prophylaxis (PrEP) services are central to HIV transmission elimination. Multi-stakeholder collaboration, activism and government support enabled Scotland to implement a publicly-funded national PrEP programme delivered through sexual health services from 2017. Although innovatio...

Background Pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV acquisition. Studies are underway to investigate the effectiveness of HIV antiretrovirals, including Tenofovir-based PrEP, for treating and preventing COVID-19. We investigated the association between HIV-PrEP use and COVID-19 among men who have sex with men in the UK....

Background Accelerated partner therapy (APT) is a partner notification (PN) method whereby healthcare professionals assess sex partners by telephone, then send or give the index patient antibiotics and self-sampling kits for their sex partner(s). We determined the effect of APT on proportions of: index patients who test positive for chlamydia at 12...

Background Accelerated partner therapy (APT) is a partner notification (PN) method whereby healthcare professionals assess sex partners by telephone, then send or give the index patient antibiotics and self-sampling kits for their sex partner(s). APT was implemented within a cluster cross-over randomised control trial in 17 sexual health clinics in...

Background The introduction of social distancing in response to the COVID-19 pandemic led to reduced STI/HIV service provision in the UK. We investigated sexual risk behaviours among MSM and unmet need for sexual healthcare during the pandemic. Methods A cross-sectional online survey (N=2,018) fielded via social media and dating apps (23/06–14/07/...

Background Accelerated partner therapy (APT) is a partner notification (PN) method whereby healthcare professionals assess sex partners by telephone, then send or give the index patient antibiotics and self-sampling kits for them. We described characteristics and outcomes of people choosing APT in an RCT. Methods We did a cross-over cluster-random...

Background Syndemic theory highlights the potential for health problems to interact synergistically, compounding impact. Young adults not in education, employment or training (NEET) are more likely to experience disadvantage and poorer general health outcomes. However, there is little research on their sexual health, or the extent to which this clu...

Introduction HIV pre-exposure prophylaxis (PrEP) is an effective intervention to reduce acquisition of HIV. PrEP provision has increased in recent years, however, it is not known whether PrEP implementation has been equitably implemented across all risk groups, particularly groups experiencing high levels of health inequity. A PrEP care continuum (...

Purpose This paper illustrates initial steps of an intervention optimisation process. Self-sampling packs for sexually transmitted infections (STIs) and blood borne viruses (BBVs) are widely offered within the UK, yet have problems with reach and sample return rates. They have arisen without any formal intervention development. Methods Eleven focu...

Objectives The use of antibiotics as pre-exposure or postexposure prophylaxis for sexually transmitted infection (STI) prevention (STI prophylaxis) is not currently recommended in the UK, but there is evidence that self-prescribing occurs among those at greatest risk. We present the prevalence and factors associated with STI prophylaxis among a com...

Objectives: To develop a classification of sexual partner types for use in partner notification (PN) and other interventions to prevent sexually transmitted infections (STI). Methods: A four-step process: 1) an iterative synthesis of five sources of evidence: scoping review of social and health sciences literature on partner types; analysis of rela...

This study shows how contemporary understandings of relationships are wrought with the legacies of the past, while also being shaped by an increasingly complex, often technologically-mediated, novel social environment. Understanding these shifts in the social organisation of sexual relationships is vital to inform policies, tailor effective interve...

Objective The objective of this study was to explore young people’s perspectives barriers to chlamydia testing in general practice and potential intervention functions and implementation strategies to overcome identified barriers, using a meta-theoretical framework (the Behaviour Change Wheel (BCW)). Methods Twenty-eight semistructured individual...

Introduction Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics...

This guideline offers recommendations for the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of gonorrhoea in people aged 16 years and older. For individuals under the age of 16 years please see the British Association for Sexual Health and HIV (BASHH) guideline on STI and Related Conditions...

Chlamydia trachomatis is the most common bacterial sexually transmitted infection, causing significant morbidity and economic burden. Strategies like national screening programs or hometesting kits were introduced in some developed countries, yet their effectiveness remains controversial. This systematic review examined reviews of chlamydia screeni...

We identified two new Chlamydia trachomatis (CT) variants escaping Aptima Combo 2 (AC2) assay detection, in clinical specimens of two patients. One had a C1514T mutation the other a G1523A mutation, both within the AC2 23S rRNA target region. The prevalence of such variants among persons tested for CT in England was estimated to be fewer than 0.003...

Background: Bacterial sexually transmitted infections (STI) have been increasing over the past two decades in gay, bisexual, and other men who have sex with men (MSM). With the widespread use of early HIV treatment, which virtually eliminates transmission risk, and the availability of HIV pre-exposure prophylaxis there have been attitudinal change...

Background The development of antimicrobial resistance (AMR) to macrolides and extended-spectrum cephalosporins (ESC) in Neisseria gonorrhoeae (NG), is a major public health concern. While macrolide AMR is increasing globally, ESC AMR is low and extensive drug-resistance (XDR) rare. Methods We report the clinical management and microbiology of two...

Background Repeat chlamydia infections are common, and the risk of receiving complications increases with the number of lifetime infections. However, retesting rates in the UK remain low and interventions to increase retesting have had variable effects. In order to change behaviour (e.g., to increase retesting), behavioural-science theoretical mode...

Background HIV and other sexually transmitted infections (STIs) do not operate in isolation, particularly as people with risk-taking sexual behaviour may be co-infected. In this complex landscape, policy makers are limited by resource constraints while trying to find optimal coverage solutions. Disease modelling could help in this context. We aim t...

Background STI/HIV self-sampling has the potential to improve sexual health by increasing access to testing, yet uptake and sample return rates are currently sub-optimal. Our inter-disciplinary research team explored home-based self-sampling from the user perspective, to inform its optimisation (within the context of LUSTRUM, a UK based trial of Ac...

Background Young gay, lesbian, bisexual, transgender, and other sexuality/gender minority identities (LGBT+) exhibit poor sexual health outcomes (e.g., higher STI/HIV rates). In the UK, there is currently an effort to shift high-volume, low-cost testing (i.e., asymptomatic STI testing) away from expensive specialist settings and into primary care....

Background Accelerated Partner Therapy (APT) is a method of partner notification (PN) which includes remote assessment, self-sampling and treatment of the sex partner(s) of a person diagnosed with STIs. Using the Behaviour Change Wheel approach, we sought to understand, and then systematically moderate, the psychological and behavioural challenges...

BACKGROUND: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among th...

Objectives The size of the population of men who have sex with men (MSM) who may be eligible for HIV pre-exposure prophylaxis (HIV-PrEP) in England remains unknown. To plan for a national PrEP implementation trial, we estimated the number of MSM attending sexual health clinics (SHCs) that may be eligible for HIV-PrEP in England. Methods Sexually t...

Objectives The National Chlamydia Screening Programme (NCSP) in England opportunistically screens eligible individuals for chlamydia infection. Retesting is recommended three3 months after treatment following a positive test result, but no guidance is given on how local areas should recall individuals for retesting. Here , we compare cost estimates...

We describe detection in the United Kingdom (UK) of the drug-resistant Neisseria gonorrhoeae FC428 clone, with ceftriaxone resistance and intermediate azithromycin resistance. Two female patients developed infection following contact with UK-resident men from the same sexual network linked to travel to Ibiza, Spain. One case failed treatment with c...

Background Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ide...

The extent to which healthcare professionals (HCPs) and young people (YP) are aware of, and adhere to, National Chlamydia Screening Programme (NCSP) recommendations on testing frequency is unclear. To address this two cross-sectional surveys in 2015–2016: one among genitourinary medicine (GUM) and non-GUM HCPs (n = 109) and the other among YP atten...

Background Partner notification (PN) is a key strategy for sexually transmitted infection (STI) management to reduce transmission and improve population health. It involves contacting sexual partners of people diagnosed with an STI and encouraging testing and treatment to prevent onward transmission, and re-infection. Current UK PN practice tends t...

Person-centred consultations (PCCs) are fundamental to effective healthcare communication, and its use is embedded within key clinical guidance. There are three aspects to PCC: use of the best available research evidence, clinical expertise of the clinician and the patient's circumstances, goals, values and wishes. Balancing theses three aspects in...

BACKGROUND Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among thi...

Background: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among t...

Introduction Disease models can be useful tools for policy makers to inform their decisions. They can help to estimate the costs and benefits of interventions without conducting clinical trials and help to extrapolate the findings of clinical trials to a population level. Sexually transmitted infections (STIs) do not operate in isolation. Risk-taki...

Objectives Chlamydia trachomatis is the most commonly diagnosed bacterial STI. Lack of prevalence and risk factor data for rectal chlamydia in women has testing and treatment implications, as azithromycin (a first-line urogenital chlamydia treatment) may be less effective for rectal chlamydia. We conducted a systematic review of studies on women in...

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium’s natural history is poorly...

Chlamydia trachomatis and Neisseria gonorrhoeae testing guidance recommends extragenital screening with locally validated nucleic acid amplification tests, with anatomical sites tested separately. Evidence supports multi-patient combined aliquot pooled sampling (PS) for population screening; evidence for within-patient PS is sparse. Within-patient...

Objectives In order to assess whether the BioSure HIV Self-Test could be reliably performed by users at home and to determine whether they were able to perform and correctly interpret the test, we carried out an evaluation study among attendees at a sexual health service. Methods A prospective observational study of clinic attendees to determine t...

The objective was to determine whether or not the limited use of urethral microscopy to diagnose asymptomatic and symptomatic non-chlamydial, non-gonococcal urethritis (NCNGU) in men is a cost-effective strategy to avert pelvic inflammatory disease (PID), ectopic pregnancy or infertility in female partners. Outputs from a transmission dynamic model...

Introduction Chlamydia is a key health concern, with high economic and social costs. There were over 2 00 000 chlamydia diagnoses made in England in 2015. The burden of Chlamydia is greatest among young people where the highest prevalence rates are found. Annual testing for sexually active young people is recommended; however, many of those at risk...

Introduction The Public Health Outcomes Framework detection rate indicator (DRI) sets a target of ≥2,300 chlamydia diagnoses per 100,000 15 to 24 year-olds. The 2014 DRI in Nottingham City and Nottinghamshire County was 2,807 and 1,900, respectively. We used the National Chlamydia Screening Programme’s Chlamydia Care Pathway (CCP) approach to revie...

Introduction Chlamydia is a key health concern with high economic and social costs. There were over 200 000 chlamydia diagnoses made in England in 2015. The burden of chlamydia is greatest among young people where the highest prevalence rates are found. Annual testing for sexually active young people is recommended; however, many of those at risk d...

Wrapped: Development and specification of an intervention to increase condom use amongst young people accessing chlamydia self-testing websites Katie V. Newby1*, Julia V. Bailey2, Rik Crutzen3, Katherine Brown1, Ala Szczepura1, Jonny Hunt4, Tim Alston5, John Saunders6, Tariq Sadiq7 and Satyajit Das8 • 1 Coventry University, United Kingdom • 2 Uni...

Background Sexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men. Aim To improve the sexual health of young men in the UK by determining optimal strategies for STI testing and care Objectives To d...

Where did it all go wrong? Azithromycin, a second generation macrolide antimicrobial, has been demonstrated to be highly efficacious both in vitro (low minimum inhibitory concentration (MIC)) and in vivo against the common bacterial STIs Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG) and has good treponemicida...

Introduction Chlamydia trachomatis and Neisseria gonorrhoeae testing guidance recommends extragenital screening with locally validated nucleic acid amplification tests for patients reporting receptive oral and/or anal sex, with anatomical sites sampled and tested separately. Within-patient pooled sampling (PS) could be more cost effective for tripl...

Background A national programme to provide Truvada HIV pre-exposure prophylaxis (PrEP) is currently being considered in England. Some men already access PrEP and some sexual health clinics already offer PrEP monitoring. Aim(s)/objectives We created a Theory of Change (ToC) to define the key components of a clinic-based PrEP programme to reduce HIV...

Background/introduction Mycoplasma genitalium (MG), a sexually transmitted infection (STI), is increasingly recognised as a cause of major reproductive health sequelae. Treatment has become increasingly difficult due to macrolide and fluoroquinolone antibiotic resistance. MG is not routinely tested for in most UK genitourinary medicine (GUM) clinic...

Background/introduction The FTD™ Urethritis Plus (FTDU) nucleic acid amplification test (NAAT) detects seven pathogens associated with urethritis, including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium, Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum. Aim(s)/objectives To per...

Background Chlamydia trachomatis is the most commonly diagnosed STI in the UK. While men-who-have-sex-with-men are known to be at-risk of rectal chlamydia infection (ReCT), the prevalence and risk-factors in women are incompletely-understood. This may have important implications for testing and treatment approaches since azithromycin and doxycyclin...

Background The National Chlamydia Screening Programme (NCSP) aims to prevent and control chlamydia through detection and treatment of infection. The NCSP recommends that under 25 year-olds test annually, upon change of partner and re-test three months after treatment. Healthcare professionals’ (HCP) knowledge of and adherence to NCSP guidance is un...

Background In the UK, Chlamydia is most prevalent in those aged 16–24 years. However, 1.5% of women and 1.0% of men aged 25–34 years are estimated to be infected. Attending healthcare venues may be challenging in rural settings and internet-requested tests may help individuals to access testing. We report results from a pilot of internet-requested...

Background: Pre-exposure prophylaxis (PrEP) has proven biological efficacy to reduce the sexual acquisition of the human immunodeficiency virus (HIV). The PROUD study found that PrEP conferred higher protection than in placebo-controlled trials, reducing HIV incidence by 86 % in a population with seven-fold higher HIV incidence than expected. We p...

Introduction There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, PID, infertility and ectopic pregnancy. Currently there is no licensed test specific for M. genitalium in the UK, where urethral smear microscopy is recommended in GUM clinics, for symptomatic men only. NAATs testing has been advocated, partic...

Background: In Britain, young people continue to bear the burden of sexually transmitted infections (STIs) so efforts are required, especially among men, to encourage STI testing. The SPORTSMART study trialled an intervention that sought to achieve this by offering chlamydia and gonorrhoea test-kits to men attending amateur football clubs between...

Background/introduction Timely treatment of sexually transmitted infections (STI) is an important factor in reducing sequelae and transmission. British Association for Sexual Health and HIV (BASHH) standards for the management of STIs recommends treatment “in as short a timescale as possible”. The National Chlamydia Screening Programme (NCSP) sets...

Background/introduction The National Chlamydia Screening Programme (NCSP) recommends opportunistically screening sexually active 15 to 24 year olds annually and on change of partner. Through a number of changes to the delivery of screening, Leeds has maintained a higher than average detection rate indicator (DRI) despite declining spend. We describ...

Background The National Chlamydia Screening Programme (NCSP) updated its guidelines in 2013 to recommend retesting for all chlamydia positive individuals around three months after treatment, due to the risk of reinfection. Objectives Investigate the impact of implementing new retesting guidance on chlamydia screening activities and the economic co...

Background National gonorrhoea treatment guidelines recommend ceftriaxone with azithromycin as first-line therapy, but doxycycline is recommended instead of azithromycin for patients with gonococcal pelvic inflammatory disease (PID). In 2013, 86.5% of patients in the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) were treate...

Background Uptake of chlamydia screening by men in England has been substantially lower than by women. Non-traditional settings such as sports clubs offer opportunities to widen access. Involving people who are not medically trained to promote screening could optimise acceptability. Methods We developed two interventions to explore the acceptabi...

The objective of this study was to compare the costs and outcomes of two sexually transmitted infection (STI) screening interventions targeted at men in football club settings in England, including screening promoted by team captains. A comparison of costs and outcomes was undertaken alongside a pilot cluster randomised control trial involving thre...

Current UK National Guidelines for HIV Testing recommend universal HIV testing for all medical admissions where the local diagnosed HIV prevalence exceeds 2 per 1000 population and that those with indicator diseases should always be offered testing in any setting.1 The Royal London Hospital serves a population with a high local HIV prevalence of 6....

Uptake of chlamydia screening by men in England has been substantially lower than by women. Non-traditional settings such as sports clubs offer opportunities to widen access. Involving people who are not medically trained to promote screening could optimise acceptability. We developed two interventions to explore the acceptability and feasibility o...

The significance of asymptomatic non-chlamydial non-gonococcal urethritis (NCNGU) is unclear. Organisms associated with NCNGU, e.g. Mycoplasma genitalium, for which there is no widely available test, are linked to reproductive sequelae in women but UK guidance no longer recommends urethral smear microscopy to screen for asymptomatic NCNGU. This cas...

Background UK National Guidelines for HIV Testing recommend that an HIV test should be considered in all general medical admissions where diagnosed HIV prevalence in the local population exceeds two in 1000 population as well as for all patients presenting with certain indicator diseases. The aim of this audit was to determine if HIV testing rates...

Background Many non-clinical, including sports, settings have been used in an attempt to screen more men for Chlamydia. While feasible there is very little research exploring their acceptability among users of these settings. Objective We explored the acceptability of, and the best way to deliver, Chlamydia screening in soccer clubs among young men...

We report a case of a 34-year-old HIV-positive patient undergoing treatment for pulmonary and lymph node Mycobacterium tuberculosis infection, who developed loss of vision secondary to a tuberculous choroidal granuloma.

Rates of sexually transmitted infections (STIs) in UK young people remain high in men and women. However, the National Chlamydia Screening Programme has had limited success in reaching men. The authors explored the acceptability of various medical, recreational and sports venues as settings to access self-collected testing kits for STIs and HIV amo...

Background UK prevalence of STIs in young people is rising. Although a similar number of infections are diagnosed in men and women, men account for only 20% of National Chlamydia Screening Program tests. New strategies are required to increase uptake of STI screening in young men. Methods Stratified random probability survey of men (18–35 years) us...

Background Asymptomatic non-gonococcal non-chlamydial urethritis (NCNGU) is common and can only be diagnosed by urethral smear microscopy. UK guidelines no longer recommend urethral smear microscopy in asymptomatic men, leaving men with this condition and their sexual partners untreated. The clinical and economic significance of this is unclear. We...

Background Non-Chlamydial Non-Gonococcal Urethritis (NCNGU) is as prevalent as Chlamydial urethritis in UK men. Mycoplasma genitalium likely explains 10–46% of cases but there is no UK-licensed molecular test. In women, M genitalium is associated with pelvic inflammatory disease (PID), infertility and ectopic pregnancy. New UK guidelines do not rec...

Opinions are divided on whether to screen asymptomatic men for non-chlamydial non-gonococcal urethritis (NCNGU). We systematically reviewed the literature to determine whether male asymptomatic NCNGU is associated with significant clinical outcomes for men and/or their sexual partners. We searched electronic databases and reference lists from retri...