• hepatitis B
• MEN
• homosexuality, male
• vaccination
• diagnostic screening programs

There were 1142 cases of acute hepatitis B (HBV) reported in Europe in 2021 and 16% were between men who have sex with men (MSM).1 Recently, the prevalence of HBV in London emergency departments has been shown to be 0.72%. It is estimated that >1% in people diagnosed with HBV in primary care are from high-prevalence countries, MSM, close HBV contacts, people with a history of injecting drug use or living with HIV, hepatitis C virus or syphilis. These studies also highlight undiagnosed HBV and poor linkage to care.2–4 Several safe and effective vaccines for HBV are available and since August 2017 have been offered as part of the childhood vaccination schedule in the UK. This late introduction of HBV vaccination into the childhood programme relative to other countries means that a substantial proportion of at-risk adults remain susceptible. MSM are a priority population for vaccination in UK sexual health clinics. A cross-sectional study in the UK among 1497 MSM using HIV home-testing kits demonstrated that anti-HBV surface antibodies (anti-HBs) were below the level of protection (30%) suggesting suboptimal vaccination.5 Recent outbreaks of HBV among heterosexually identifying MSM have highlighted gaps in vaccination.6 Brighton has a population of ~300 000, a large MSM subpopulation and a single sexual health clinic. Our clinic guidelines originally suggested that MSM attending for the first time with no HBV vaccination history should be offered HBV testing including HBV antisurface (anti-HBs) and anticore (anti-HBc) antibodies. More recently, the provision of HIV pre-exposure prophylaxis (HIV-PrEP) has driven a change in this guidance to all MSM being screened for HBV. Vaccination is offered to those with anti-HBs levels <10 IU/L. Between 2012 and 2019, 10 MSM in Brighton were diagnosed with acute HBV and 10% of 3342 newly attending MSM had detectable anti-HBc indicating previous exposure.7 Factors associated with anti-HBc included age >30 years, previous HCV/syphilis and being non-UK born.7

In this cross-sectional study, we aimed to survey anti-HBs levels in MSM who attended our clinic for the first time between 2012 and 2022 who were anti-HBc negative to estimate the extent of susceptible MSM in our local population prior to accessing sexual health services. We collected data on year of attendance, age, country of birth and anti-HBs levels. We considered anti-HBs levels ≥10 IU/L to confer protection. We explored differences in anti-HBs levels using Kruskal-Wallis, Pearson’s χ² and Fisher’s exact tests.

Among 7941 MSM who attended our clinic for the first time in 2012–2022, 3430/7941 (43%) underwent anti-HBs testing and 1961/3430 (57%, 95% CI 55.5% to 58.8%) had anti-HBs levels ≥10 IU/L. The median protective anti-HBs level was 216 IU/L (IQR=51–948). There were no significant changes in the proportion of MSM having anti-HBs ≥10 IU/L (p value trend=0.706) throughout the study period. Non-UK born MSM were more likely to have anti-HBs ≥10 IU/L than UK-born MSM (69% vs 51%, p>0.0001). The proportion of non-UK born MSM with protective anti-HBs titres varied significantly through the study period (p value trend, p<0.02) (table 1).

It is important to understand local HBV immunity among MSM to assess susceptibility. We have shown that among MSM attending our clinic for the first time who were tested for anti-HBs, levels are higher (57% have anti-HBs ≥10 IU/mL) compared with recent UK national data.5 We also found that non-UK born MSM were significantly more likely to have anti-HBs ≥10 and this varied significantly through the study period which may be due to their country of origin vaccination programmes adopting childhood vaccination earlier than in the UK. Sexual health clinics provide a vital contribution to HBV control, however only if access to clinics is preserved.8 9 More work is needed to improve the access to HBV vaccination by working with communities to understand the barriers to vaccination including sexual orientation disclosure.10 Widening access to HIV-PrEP is likely to improve HBV testing and vaccination. Increasing access to HBV vaccination in non-traditional settings such as community settings is likely to improve HBV control.4

There are several limitations to this analysis including being a single-centre clinic-based population study. We were not able to control for HIV serostatus or HBV vaccination history (which may have affected testing rates). Given the varied anti-HBs levels found in this study, it is clear that all MSM attending for the first time to sexual health clinics should be offered HBV testing regardless of vaccination history to improve testing and vaccination opportunities.

Locally, anti-HBs levels in our sexual health clinic population of MSM at their first attendance are relatively high and are likely to improve following vaccination of non-immune individuals. This, coupled with the low prevalence of HBV locally suggests adequate MSM community HBV protection. However, more effort is needed to improve access to HBV vaccination in susceptible adult MSM in primary care and the community.