Sexually transmitted infections (STI) update


March 2006

Note: This update is based on STI data for 2004, which became available at the end of 2005. The Health Protection Agency has yet to complete data collection for 2005. Preliminary results are expected in July 2006 and confirmed data due in late November 2006. Introduction
In February 2002 the BMA’s Board of Science published a report on Sexually transmitted infections for healthcare professionals. It provided an up-to-date summary of the most common sexually transmitted infections (STIs) in the UK; presented new BMA recommendations to assist the profession in informing people about health risks associated with unsafe sexual activity; and called for improved services.

Since the 2002 BMA report, there has been a continuing increase in almost all STIs. The latest report from the Health Protection Agency[go to reference 1] (HPA) which presents data for 2004 paints a grim picture. ‘This 2005 annual surveillance report for the United Kingdom (UK) describes a worrying situation with undiminished and high levels of transmission of HIV and other STIs among men who have sex with men (MSM), a steady increase in the number of HIV-infected black Africans in the UK, limited but compelling evidence that heterosexual transmission of HIV within the UK is slowly rising, and continuing high transmission of other STIs, especially chlamydia among young people’ [go to reference 2]. Fast access to genitourinary medicine clinics (GUM clinics) remains an acute problem with less than half of those attending GUM clinics being seen within the recommended 48 hours.

The HPA in November 2005 published a report entitled 'Health Protection in the 21st Century' Health Protection in the 21st Century: Understanding the Burden of Disease; preparing for the future. November 2005. Health Protection Agency [go to reference 3] which aims to highlight those conditions causing significant morbidity and mortality in the UK and which pose an ongoing and future threat. It reports that HIV continues to be one of the key communicable diseases in the UK:

‘It is an infection associated with serious morbidity, high costs of treatment and care, significant mortality and a high number of potential years of life lost. Each year, many thousands of individuals are diagnosed with HIV. The infection is still frequently regarded as stigmatising and has a prolonged ‘silent’ period during which it often remains undiagnosed. Highly active antiretroviral therapies have resulted in substantial reductions in AIDS incidence and deaths in the UK.

In 2004 there were an estimated 58,300 people living with HIV in the UK, of whom 19,700 were unaware of their infection [go to reference 4]. ‘This figure is rising each year as a result of increased numbers of new diagnoses and decreasing deaths due to antiretroviral therapies. Although the percentage of the population living with HIV is low, the cost to the NHS is high. Over the years, especially since the introduction of combination antiretroviral therapies in 1996, costs of in-patient treatment have declined and out-patient costs have increased. A number of studies have investigated the cost of treating a person with symptomatic HIV [go to reference 5] with an average of £14,000 per patient a year being accepted as reasonable. Thus, the approximate cost in the UK per annum for those diagnosed is £400 million and, if all were diagnosed, £580 million.’ [go to reference 6]. It is estimated that each HIV infection prevented saves £0.5-1.0 million in terms of individual health benefits and treatment costs [go to reference 7].

‘In 2004 there were more than 780,000 new episodes of Chlamydia, gonorrhoea, syphilis, herpes or warts diagnosed in England, Wales and Northern Ireland, which is an increase of approximately 20% since 1999. When both initial appointments (£90 million) and follow-up visits (£75 million) are taken into consideration, this costs the health service approximately £165 million per annum.’ [go to reference 8].

This update from the BMA Board of Science provides an indication of some recent trends and acts as a signposting resource to key publications.

Background
STIs are infections that are passed on through sexual contact [go to reference 9]. UK surveillance data show that levels of STIs have been rising since the mid 1990s [go to reference 10] [go to reference 11]. A 2003 House of Commons Health Select Committee (Health Committee) inquiry into sexual health described a nation-wide state of ‘crisis’ constituting a ‘major public health issue’ [go to reference 12].

STIs are a principal public health problem because:
  • some STIs have potentially serious outcomes for physical and psychological health and may have an adverse impact upon relationships
  • some STIs favour the spread of HIV infection
  • some STIs cause serious ill health in mothers and babies, and may cause infertility [go to reference 13].
Recent trends
Over four years on from the launch of the government's National Strategy for Sexual Health and HIV, diagnoses of HIV and the major acute STIs continue to rise across the UK, driven by high-risk sexual behaviour and delays in access to diagnosis and treatment. The available data on rates of STIs significantly underestimate the overall levels of disease (see Box 1). This is because they relate to patients seen in GUM clinics and do not include the large number of cases treated in primary care, nor those that remain undetected due to the lack of any obvious symptoms [go to reference 14]. A recent population based study [go to reference 15] using data from the UK general practice research database which examined trends in STI infection in general practice from 1999-2000 showed that the percentage increase in STIs diagnosed in primary care during 1990-2000 was greatest for genital chlamydia (1253% in men, 2495% in women) and consistent with the increases found in GUM clinics. (See Appendix 2).

The National Survey of Sexual Attitudes and Lifestyles [go to reference 16] (Natsal) published in 2001, showed that more people were using contraception when having sex for the first time ever and for the first time with new partners. The previous survey was carried out in 1989/90 at a time of concern about the rising epidemic of HIV/Aids. Since then the proportion of men and women reporting two or fewer lifetime partners has fallen while the proportion reporting five or more has increased. For women the median increased from two to four lifetime partners, while men reported an increase from four to six.

The latest study using data from the Natsal survey, which was published in the Lancet in April 2005 [go to reference 17] suggests that levels of sexual risk behaviour and the chance of acquiring an STI vary among the UK’s ethnic (White, black Caribbean, black African, Indian and Pakistani) communities.
‘The study found that Indian and Pakistani groups had the lowest levels of risk behaviours and reported STI infections, probably reflecting cultural norms characterised by later age of first intercourse and fewer reported sexual partners compared with other ethnic groups.

‘Differences were also found by gender. Black African and black Caribbean men reported higher levels of sexual risk behaviour and higher incidence of STIs compared to white, Indian and Pakistani men. White women reported higher levels of risk behaviours than other ethnic groups; however, they were less likely to report STIs than black Caribbean and black African women. Key findings include:
  • Approximately one in 25 white women reported being diagnosed with an STI in the past 5 years compared with one in 11 black Caribbean women and one in 13 black African women; and fewer than one in 50 Pakistani and Indian women.
  • Fewer than one in 50 Indian and Pakistani men reported being diagnosed with an STI in the past 5 years, compared with one in 34 white men, and one in 13 black African and black Caribbean men.
  • White women reported an average of 5 lifetime partners compared with 4 reported by black Caribbean women, 3 by black African women and 1 by both Indian and Pakistani women.
  • Black Caribbean and black African men reported an average of 9 lifetime sexual partners compared to 6 reported by White men and 2 by Indian and Pakistani men.
‘Although the study found that the main factor influencing an individual's risk of reporting STIs was the number of sex partners, this factor alone did not fully explain the variations in STI incidence in different ethnic groups. In addition to cultural and demographic influences, other factors likely to influence risk of infection include how people choose sexual partners, the background level of untreated STI in different communities and the speed and completeness of treatment.’ [go to reference 18]. The investigators conclude by calling for the promotion of culturally competent services, behavioural modification and risk reduction strategies to be firmly placed within targeted prevention efforts.

Analysis from the 2004 Mayisha II study [go to reference 19], 'a community-based survey of sexual attitudes and lifestyles among black African communities in England conducted in collaboration with community organisations and academics, reveals high levels of service use among both men and women and differences in the sexual behaviour of male and female respondents. More men than women reported two or more sexual partners during the past year (33% compared to 18%, base 1290) and more men than women reported two or more new sexual partners in the past year (20% and 8% respectively, base 1149). Same sex partners were reported by 8% of men and women; 6% reported only having same sex partners and 2% had sex with both men and women’.

Box 1: The major acute STIs in the UK
The UK Collaborative Group for HIV and STI Surveillance: Mapping the Issues: HIV and other Sexually Transmitted Infections in the United Kingdom: London: Health Protection Agency Centre for Infections. November 2005.

STI Key Points
 
HIV

In 2004 there were an estimated 58,300 (range: 54,700 – 63,400) people living with HIV in the United Kingdom (UK), of whom 19,700 (range: 16,100– 24,800) were unaware of their infection.

Numbers of diagnoses of HIV infections acquired through heterosexual contact remained high; in 2004 three-quarters of these were probably acquired in Africa.

A total of 42,182 HIV-infected individuals accessed treatment and care services in the UK during 2004, a 14 per cent increase since 2003.
Among men who have sex with men (MSM) having routine syphilis tests in sentinel gentio-urinary medicine (GUM) clinics across the UK in 2004, the prevalence of previously undiagnosed HIV infection was 4.7 per cent in London and 2.4 per cent elsewhere in the UK.
Previously undiagnosed HIV prevalence among UK-born heterosexuals attending sentinel GUM clinics in London rose to 0.5 per cent in 2004, from 0.3 per cent in 2003.

In England and Scotland in 2004 an estimated 0.1 per cent of women had an undiagnosed HIV infection prior to antenatal testing.
The year on year increase in the uptake of voluntary confidential HIV testing (VCT) among all attendees at sentinel GUM clinics in the UK continued in 2004, reaching 79 per cent and 75 per cent among MSM and heterosexuals, respectively.
 
Genital chlamydial infection

In 2004, genital chlamydial infection remained the most common sexually transmitted infection (STI) diagnosed in genitourinary medicine (GUM) clinics in the United Kingdom (UK).

Between 2003 and 2004, diagnoses of uncomplicated genital chlamydia in the UK rose by 8.6 per cent, from 95,879 to 104,155.

Highest rates of diagnoses in 2004 were in men aged 20-24 (1,026/100,000) and in women aged 20-24 (1,139 / 100,000) and 16-19 (1,310/100,000).
Results from the English National Chlamydia Screening Programme (NCSP) have demonstrated a high level of infection that would have been missed in the absence of a screening programme, reinforcing the need for screening in community settings as well as GUM clinics.
 
Gonorrhoea

Between 2003 and 2004, diagnoses of gonorrhoea in the UK decreased by 11 per cent (24,956 to 22,335).

Highest rates of diagnoses in 2004 were among men aged 20-24 (229/100,000) and women aged 16-19 (168/100,000). In 2004, 42 per cent of women with gonorrhoea were aged under 20.

The effective treatment of gonorrhoea is complicated by resistance to antimicrobial agents. In 2004, 14 per cent of isolates in England and Wales from sentinel GUM clinics demonstrated resistance to ciprofloxacin; compared to 9.0 per cent of isolates in 2003. The highest prevalences of ciprofloxacin resistance were in the North East, South East and London regions.
 
Syphilis

Between 2003 and 2004, syphilis diagnoses in the UK rose by 37 per cent, from 1,641 to 2,254.

In 2004, 88 per cent (1977) of all diagnoses were in men, of which more than half were in MSM.

Rates of diagnoses were highest among men aged 25-34 (17/100,000) and 35-44 (16/100,000), and in women aged 20-24 (4/100,000).
The rise in diagnoses is associated with continued outbreaks in the UK.
 
Genital warts

Genital warts are the most frequently diagnosed viral STI in the UK.

Between 2003 and 2004, new diagnoses of genital warts rose by 4.2 per cent, from 76,457 to 79,678.

Highest rates were in men aged 20-24 (783/100,000) and women aged 16-19 (703/100,000).
Diagnoses seen in GUM clinics represent a small proportion of the total pool of sexually acquired human papilloma virus (HPV) infection within the population
 
Genital Herpes

Between 2003 and 2004 there was a 1.0 per cent decrease in diagnoses of genital herpes in the UK, from 19,180 to 18,991.

Rates were highest among men and women aged 20-24 (87/100,000 and 177/100,000, respectively) in 2004.

Significant numbers of those with symptomatic infection experience frequent recurrent disease that can be severely debilitating.
Diagnoses of genital herpes simplex virus (HSV) infection seen in GUM clinics represent a small proportion of the total pool of infection within the general population.

Current and ongoing work
England
England: standards
Recommended standards for sexual health services [go to reference 20]
These Recommended standards for sexual health services (published in March 2005) by the Medical Foundation for AIDS & Sexual Health (MedFASH) will support healthcare organisations to implement the national strategy for sexual health and HIV and to deliver the Public Service Agreement (PSA) 2005/06-2007/08 target for sexual health, which includes specific commitments arising from the government’s White Paper Choosing health. The recommended standards are not setting-specific and can be applied wherever sexual health services are provided or sexual health need may be identified, including general practice, hospital and community-based clinics, pharmacies, voluntary and independent sector organisations.

England: targets & priorities
The Public Health White Paper: Choosing Health: making healthier choices easier (November 2004) [go to reference 21] sets out a number of commitments on sexual health, which are reflected in NHS targets for 2005-8 [go to reference 22] and should be included in Local Delivery Plans (LDPs), specifically:
  • access to a GUM clinic appointment within 48 hours of requesting an appointment for everyone by 2008
  • roll-out of the national chlamydia screening programme across the whole of England by March 2007
  • a reduction in rates of STIs (to be measured by new diagnoses of gonorrhoea)
  • reducing the under-18 conception rate by 50 per cent (from the 1998 baseline) by 2010.
Building on this, the NHS operating framework for 2006/7 [go to reference 23] identifies six LDP priorities for action in order to ensure delivery of national targets by 2008 and beyond. One of these is sexual health and access to Genito-Urinary Medicine (GUM) clinics, the priority being ‘to deliver the 2006/7 LDP trajectories so that by 2008 everyone referred to a GUM clinic (and those seeking self-appointments – see Appendix 1) should be able to have an appointment within 48 hours’.

To support implementation of the White Paper, the Rt. Hon. John Reid, the then Health Secretary, announced on 26 November 2004 a new £300 million programme spread over three years, to modernise and transform sexual health services in England. The extra funding would include a £50m advertising campaign to tackle the rise in STIs; £80m for chlamydia screening, including piloting of screening in non-traditional settings such as pharmacies; £130m for modernising GUM services; and £40m for upgrading prevention services such as contraceptive services [go to reference 24].

The White Paper envisages the delivery of sexual health services in future through a flexible multidisciplinary workforce in a range of settings, with action to break down the boundaries between primary and specialist services and increasing delivery of services like STI testing and screening in the community. The NHS will strengthen the infrastructure for sexual health and contraceptive services in primary care. An audit of contraceptive service was undertaken in 2005, and a national review of GUM services is already underway, commissioned by the DH and managed by the Medical Foundation for AIDS and Sexual Health (MedFASH), a charity supported by the British Medical Association.

England: targets achieved to date
The White Paper builds on the National Strategy for Sexual Health and HIV (2001) [go to reference 25] and its 27-point implementation action plan (2002) [go to reference 26]. Implementation of this plan to date includes:
  • publication of two annual reports of the Independent Advisory Group (IAG) set up to advise the government on the strategy’s implementation [go to reference 27] [go to reference 28]
  • the national Sex lottery campaign, launched in 2002 and supported by a website (www.playingsafely.co.uk), to raise awareness of the risk of STIs and encourage the use of condoms
  • publication of toolkits on sexual health and HIV commissioning [go to reference 29] and on sexual health promotion [go to reference 30]
  • dissemination of guidance on the provision of advice & treatment to young people under 16 on contraception, sexual & reproductive health [go to reference 31] (recently upheld in a High Court ruling which was welcomed by the BMA [go to reference 32])
  • the first two annual reports of the national chlamydia screening programme [go to reference 33] [go to reference 34]
  • publication by the Health Development Agency (now the National Institute for Health and Clinical Excellence) of reviews of the evidence base for HIV and STI prevention [go to reference 35] [go to reference 36]
  • publication by MedFASH of recommended standards for NHS HIV services [go to reference 37] and recommended standards for sexual health services [go to reference 38] (see below)
  • publication of recommended quality standards for sexual health training: Striving for Excellence in Sexual Health Training [go to reference 39].
  • targeting of groups at special risk through partnerships with the voluntary sector, including publication of a new framework and action plan for work with African communities (2004) [go to reference 40] and continued support for targeted work with gay men through the Community HIV and AIDS Prevention strategy (CHAPS)
  • implementation of the offer of an HIV test for all GUM attendees on their first screening for STIs, in order to reduce the rate of undiagnosed HIV infection
  • publication of a paper on integrating The national strategy for sexual health and HIV with primary medical care contracting [go to reference 41]
  • consultation on an action plan to combat HIV-related stigma and discrimination [go to reference 42]
For a BMA analysis of matters relating to sexual health as contained in the White Paper on
Public Health – Choosing health: making healthy choices easier: November 2004 see Appendix 1.

Independent Advisory Group on Sexual Health and HIV Annual Report 2004 -2005 (October 2005) [go to reference 43]

This report reflects on progress at the half way point since the publication of the 10 year national strategy for sexual health and HIV in July 2001. In addition to those mentioned above the report makes a number recommendations including:
  • The Government to focus on how to ensure delivery of the LDP targets. Part of this is ensuring the funds reach the intended services
  • The Government has been asked to consider calls for the abolition or reduction of VAT on contraceptives from a number of key organisations, including the IAG, retailers and the voluntary sector, given the significant benefits which would be realised for the country’s sexual health overall, and that the Exchequer is likely to gain and not lose from such a move.
  • SHAs to monitor Primary Care Trusts (PCTs) to identify their current spend and planned investment in sexual health, and ensure that PCTs deploy the extra funding effectively in delivering services and achieving improvements
  • The Government to determine what sanctions should be incurred against PCTs that fail to reach their targets on sexual health services
  • The Government and the Department of Health to use the performance monitoring information generated by the National Review of GUM Services and the Contraceptive Audit when formulating the revised Implementation Plan
  • PCTs to ensure the continued expansion of Sexually Transmitted Infections Foundation (STIF) courses throughout the UK to introduce an equitable supply of training opportunities, in basic knowledge, skills and attitudes for medical and nursing practitioners in primary care.
  • PCTs to be involved in local level delivery of the new national Sexual Health Media Campaign
  • The DH to ensure robust and effective monitoring mechanisms are in place to monitor how effective the campaign is.
England: future targets and funding
‘£15million funding for genito-urinary medicine’
On 20 July 2005 [go to reference 44], the Public Health Minister, Caroline Flint, announced £15million capital funding for GUM services for the 2005/06 financial year. This is in addition to the £130million capital and revenue funding for 06/07 and 07/08 for GUM which was announced as part of the Choosing Health allocations.
Funding was split equally across the 28 Strategic Health Authorities (SHAs), with each SHA receiving £535,000 capital funding this financial year for GUM. SHA’s were given responsibility for deciding how to allocate the funding with the following considerations:
  • GUM waiting times data indicates that most areas have a long way to go to meet the 48 hour access target. Funding would therefore be most appropriately focused on capital projects that can deliver tangible results for progress towards meeting this target in a short space of time.
  • The funding should be used on projects that already have plans developed, given that additional capital money will be available over the next two years.
  • SHAs may wish to be guided by feedback from any MedFASH GUM service reviews that have taken place locally in terms of prioritising allocation of this funding.
  • Consideration can be given to proposals that also support wider sexual health integration and development as part of capacity enhancement in GUM.
Competencies for providing more specialised sexually transmitted infection services within primary care [go to reference 45]
This best practice framework which was published on 30 September 2005 has been developed by a multidisciplinary working group. It sets out competencies, including recommendations for theoretical and practical training and suggested assessment methods, as a basis for developing more specialised sexually transmitted infection services within primary care.

Note: Endnotes for individual publications listed above contain web addresses. A list of DH publications about sexual health can be found at
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthAssociatedPublications/fs/en?CONTENT_ID=4001942&chk=NFpe8R (date accessed: January 2006)

Scotland
On 27 January 2005, Scotland’s first strategy for sexual health [go to reference 46] was launched by Health Minister, Andy Kerr and Education Minister Peter Peacock. The overarching aims of Respect and Responsibility - Strategy and Action Plan for Improving Sexual Health are:
  • to improve the quality, range, consistency, accessibility and cohesion of sexual health services from primary care to specialist GUM services, in line with the principles of providing services which are safe, local and appropriate
  • to support everyone in Scotland, including those who face discrimination due to their life circumstances or their gender, race or ethnicity, religion or faith, sexual orientation, disability or age, to acquire and maintain the knowledge, skills and values necessary for good sexual health and wellbeing
  • to positively influence the cultural and social factors that impact on sexual health.
The document is in two parts, starting with a strategy containing sections on promoting respect and responsibility, preventing STIs and unplanned pregnancy, and providing better sexual health services. This is followed by an action plan setting out responsibilities for the Scottish Executive, NHS Boards, local authorities, other national agencies and parents. It is also made clear that individuals have a responsibility for their own health and for the safety of others.

Actions taken to implement the strategy have included:
  • Two stakeholder events held on February 16 [go to reference 47] and March 24 [go to reference 48] 2005
  • NHS Boards have submitted their clinical service plans and these are being examined by the Executive
  • £15m has been set aside over the next three years to help implement the strategy and action plan, this includes £4.5m already made available to NHS Boards to take forward their clinical service plans in 2005/06
  • NHS Boards have appointed an Executive Lead Director and Lead Clinician to take forward sexual health developments in their own areas
  • All councils have appointed/are designating a strategic lead for sexual health
  • Interagency sexual health strategies are being developed by NHS Boards and their strategic stakeholders including local authorities and voluntary sector partners. Access to these will be made available in due course.
National Sexual Health Advisory Committee (NSHAC) [go to reference 49]
The Ministerially-led Committee was established in June 2005 to provide advice on policy, to monitor and support the implementation of the national strategy 'Respect and Responsibility', as well as taking forward some key aspects around influencing Scottish culture, sex and relationships education and clinical services.

Wales
In January 2000 the National Assembly published the consultation document, A strategic framework for promoting sexual health in Wales [go to reference 50] The aims of the strategy are:
To improve the sexual health of the population of Wales. This relates to the need to address illnesses and conditions which are a significant cause of physical and mental ill-health and premature death, eg sexually transmitted infections, including HIV infection and unintended pregnancies, particularly among teenage girls.
To narrow sexual health inequalities. It was recognised that prevalence of some of the conditions listed above may be linked to social exclusion, ethnicity and sexual orientation (eg teenage pregnancy rates are higher in areas of social deprivation and gay men are the group in Wales most affected by HIV infection). Prevention initiatives and service provision arrangements need to take account of these inequalities.
To enhance the general health and emotional well-being of the population by enabling and supporting fulfilling sexual relationships. This aim encompasses delivery of appropriate and effective sex education to young people within school and in other youth settings. It also recognises the need to ensure that the population as a whole has access to sources of information and advice on sexual health and relationships
Following consultation a revised strategy action plan [go to reference 51] was produced with six objectives:
  • Ensure that all young people in Wales receive effective education about sex and relationships as part of their personal and social development
  • Ensure that all sexually active people in Wales have access to good quality sexual health advice and services
  • Reduce rates of unintended teenage pregnancy in Wales
  • Reduce incidence and prevalence of STIs in Wales
  • Promote a more supportive environment which encourages openness, knowledge and understanding about sexual issues and fosters good sexual health
  • Strengthen monitoring, surveillance and research to support future planning of sexual health services and interventions.
A progress report on the implementation of the strategy was issued in December 2003 [go to reference 52].

On 7 December 2004, Jane Hutt, Health and Social Services Minister, announced wide-ranging action to strengthen HIV and sexual health services in Wales [go to reference 53]. Following a review of services across Wales, Dr Marion Lyons, Consultant in Communicable Disease Control, has been seconded to the Assembly as Director of the HIV and Sexual Health Services Modernisation Project.

Key elements of the modernisation project include:
  • the integration of sexual health service delivery across Wales, with clear standards for HIV and all sexual health services
  • a single ring-fenced budget for sexual health services (GUM and contraception), with an additional £500,000 to support modernisation
  • a target to ensure access to STI testing within two working days by March 2006
  • developing the role of nurses.
A new campaign to raise awareness of sexually transmitted infections among 16-25 year olds was launched by Health Minister, Dr Brian Gibbons, on 4 August, 2005.

Northern Ireland
The Investing for Health [go to reference 54] (IfH) 2002 strategy contains a framework for action to improve health and wellbeing and reduce health inequalities. The strategy aims to shift the emphasis from the traditional focus on treatment of to the prevention of ill health. It identifies sexual health and teenage pregnancy as important areas for action. The DH, Social Services and Public Safety (DHSSPS), in collaboration with the Health Promotion Agency for Northern Ireland, produced an update in November 2005: ‘Investing for Health Update 2005 [go to reference 55]’ highlighting progress over the years in implementing the IfH strategy. It includes articles from many government departments and agencies, underlining the importance of all sectors contributing to achieving IfH goals and objectives.

In December 2003, a Northern Ireland Sexual health promotion strategy and action plan [go to reference 56] was launched for consultation, with a deadline of March 2004. A budget of £125,000 was to be made available in the first year, with continued support over the plan’s five years, and a multi-agency Sexual Health Promotion Strategy Implementation Group to oversee the implementation of the strategy and action plan.

The strategy’s objectives are:
  • to reduce the incidence of STIs including HIV (with a target of reducing by 25 per cent the number of newly acquired acute STIs, including HIV, by 2009)
  • to reduce the number of unplanned births to teenage mothers
  • to provide appropriate, effective, accessible and equitable information and education to enable people to make informed choices about their sexual health and personal relationships
  • to facilitate equitable access to quality sexual health services.
to be achieved by:
  • promoting openness about sexual health issues, including sexual orientation
  • tackling the determinants of sexual health and linking with other health promotion strategies
  • taking action to reduce the discrimination and stigma associated with HIV, STIs and sexual orientation
  • ensuring that services are focused on people in need, including those disadvantaged and the Section 75 groups (those entitled to equality of opportunity under Section 75 of the Northern Ireland Act 1998).
The strategy comprises a number of actions grouped under four areas:
  • prevention, including a public information campaign to commence in April 2005
  • education and training
  • services
  • data collection and research.
The consultation has been completed and a definitive strategy is awaited.

Teenage pregnancy and parenthood [go to reference 57]
The Northern Ireland Executive in its Programme for Government under the theme ‘Working for a healthier people’ gave a commitment to tackling the problems associated with teenage pregnancy. The IfH strategy provides the framework for the Government’s action on preventable disease, ill health and inequalities in health. It identifies sexual health and teenage pregnancy as important areas for action.

A review of Primary Care Trust Local Delivery Plans 2005-2008 [go to reference 58]
This survey published on 13 January 2006 by Brook, fpa, MedFASH, National AIDS Trust and Terrence Higgins Trust (THT) is a review of a sample of LDPs published by English PCTs.

The report highlights growing concern that PCTs intend to use monies allocated for implementation of the public health White Paper on other local priorities, especially financial deficits

Commenting on the report, the BMA Chairman, Mr James Johnson, said [go to reference 59]:
“At a time when many areas of the health service are showing signs of improvement, it is appalling that sexual health services are actually getting worse, despite clinicians' best efforts to deal with patient demand. This report shows that despite Government pledges, targets and extra resources, primary care trusts (PCTs) in England appear to have plans to use funds allocated for sexual health to balance their books in other areas. The rates of sexually transmitted infections in England are soaring and patients can wait up to six weeks for an appointment. The Government target is 48 hours. Primary care trusts need to get their act together and make plans to increase sexual health services in their areas. The Government has provided PCTs with funds to improve sexual health and I call on ministers to hold PCTs to account and deliver on this public health priority.”

The report concludes by calling on the DH and the NHS to:
Establish sexual health improvement as a top tier priority for the NHS for which PCTs should be specifically accountable
Support PCTs to make a radical shift in thinking about the delivery of sexual health services and implement significant service redesign. This should include the sharing of best practice where PCTs and other agencies have implemented successful changes
Ensure adequate investment within sexual health services to achieve the improvements which are urgently needed
Support PCTs to increase capacity and skills in sexual health service commissioning, planning and service delivery.

Since the publication of this report, the government has published the NHS operating framework for 2006/7 [go to reference 60](see above), which meets the first of these calls.

Key policy activities for the BMA for 2006/07 include:
Re-asserting the recommendations made in the BMA’s 2002 STI report. In particular:
  • Campaigning for education strategies that increase young people’s knowledge of the full spectrum of STIs is essential [go to reference 61]. In particular developing skills, such as negotiating in relationships and accessing/using sexual health services [go to reference 62]. Well-designed sex education programmes have been shown to be effective [go to reference 63] and education tailored for adolescents, which supports and promotes healthy behaviour and attitudes regarding sexual health.
  • Promote positive health behaviours among individuals who are infected with STIs – to seek treatment and to practice safer sex.
  • Lobby to renew ‘safer sex’ campaigns/messages: educating individuals about the importance of using condoms and signs of such diseases as summarised above. Given the rise in the number of STIs recorded, the need for renewed health promotion efforts cannot be over-emphasised. However, as stated above, it is important to ensure clinic capacity is increased in time to cope with the growth in demand that a campaign would generate.
  • Promote openness in discussing sexual matters and practice.
  • Campaigning for improved access to contraceptive and GUM services across the UK. Most importantly that everyone gets an appointment within 48 hours of request.
  • Ensuring that the DH gives clear direction to PCTs so that those funds allocated for sexual health services are indeed used by PCTs to improve sexual health services and not channelled elsewhere.
  • Provide a resource of examples of good practice and actively promote these to PCTs and GUM clinics.
Editorial board
An update from the BMA Board of Science

Chairman, Board of Science, Professor Sir Charles George
Director of professional activities, Professor Vivienne Nathanson
Head of science and education, Dr Caroline Seddon
Research and writing, Nicky Jayesinghe

Acknowledgements
The Board is very grateful for the help provided by Ruth Lowbury, Executive Director, Medical Foundation for AIDS & Sexual Health (MedFASH).
February 2006

Appendix 1
BMA analysis of matters relating to sexual health as contained in the White Paper on
Public Health – Choosing health: making healthy choices easier: November 2004

The proposal to increase capacity and improve access to sexual health services is very welcome and follows consistent calls from the Association to do so. £300m has been pledged to back up these aims. Services could be radically altered. The White Paper says screening services will be expanded and extended to include pharmacies, sports centres, workplaces, shopping malls and universities. There will also be an information campaign around sexual behaviour.

A key reason for the current crisis is because the capacity for treatment is woefully inadequate. Workload (including STI diagnoses) at GUM clinics has increased by 38% since 2002 [go to reference 64], opening times are sometimes limited to 21 hours a week and many operate from portakabins. Those working in the field suggest the problems are critical both in the sense of health problems and the state of service to meet these. The Health Protection Agency (20 November 2004) published the first national audit of GUM waiting times which showed that less than one third of people are currently seen within 48 hours – the new target for treatment from referral. An important question is how the new money to modernise services is going to be spent to rectify the problems.

There are several key questions which need to be answered: Will new money be targeted at the chronic under-investment in the clinics that diagnose and treat people with STIs? From a survey conducted with GUM clinics, the British Association for Sexual Health and HIV estimates that a third of the money allocated in 2003-4 to PCTs for GUM services is not getting through to clinics and they are spending the money on alternative priorities. Will this money be ring-fenced to ensure that it is spent on sexual health services? How will this be monitored?

The BMA Chairman of Council wrote to the Secretary of State for Health to seek clarification on the use of the phrase ‘from referral’, in promising 48 hour access. On 7 December 2004 a reply was received from Melanie Johnson MP, Under Secretary of State for Public Health confirming that ‘the 48 hour access target will indeed apply to all those seeking an appointment at a GUM clinic, not just those referred by medical practitioners.’

Whatever the message of the proposed public information campaign, it is bound to generate an increase in demand for services. The BMA is seriously concerned that if a major campaign precedes an increase in clinic capacity, this will result in even longer waiting times for diagnosis and treatment of STIs.

There are also questions about the extent to which the Association is comfortable with the independent sector playing more of a role in public health promotion and prevention, for example, by providing the capacity for Chlamydia screening by March 2007.

The Association needs to stress that sexual health consultations often involve embarrassing encounters for people. It is not the same as visiting a pharmacist or opticians in a supermarket. An appropriate and private place should be provided for sexual health consultations, whatever the setting. This should not be merely a curtained-off area in a pharmacy (or indeed a portakabin, the current location for a number of GUM services).

Much greater emphasis is needed on school-based sex and relationship education (SRE). Results from the first UK-based systematic evaluation of school-based SRE were published in June 2002. It found that a high-quality, experientially based SRE programme was rated highly by the young people who received it, had a positive impact on knowledge, and reduced the level of reported regret over first sexual intercourse. It had no effect on contraceptive use and sexual behaviour. Results suggest that specific programmes on their own are unlikely to reduce conception rates, but are an essential part of a multi-faceted approach [go to reference 65].

Appendix 2
Incidence of selected sexually transmitted infections diagnosed and treated in general practice and in genitourinary medicine clinics, 1998-2000, by sex

Sexually transmitted infections, by sex Estimated incidence (95% CI) per 100 000 in general practice, 1998-2000 Incidence per 100 000 in genitourinary medicine clinics, 1998-2000 Estimated incidence (95% CI) per 100 000 in general practice and genitourinary medicine clinics combined, 1998-2000 Estimated % of total incidence diagnosed in general practice, 1998-2000 % increase in estimated incidence in general practice 1990-2000
Men:          
Gonorrhoea 1.3 (1.0 to 1.6) 42.0 43.2 (42.9 to 43.6) 2.9 129.7
Genital chlamydia 5.0 (4.4 to 5.8) 90.2 95.3 (94.6 to 96.0) 5.3 1253.2
Non-specific urethritis 19.7 (18.4 to 21.1) 205.8 225.4 (224.1 to 226.8) 8.7 65.6
Urethral discharge 190.6 (186.4 to 194.8) 11.8 202.4 (198.2 to 206.6) 94.2 197.3
Non-specific urethritis or urethral discharge 210.3 (204.8 to 215.9) 217.5 427.8 (422.3 to 433.4) 49.2 150.6
Genital warts 50.9 (48.8 to 53.1) 256.7 307.6 (305.5 to 309.8) 16.5 121.3
Genital herpes 10.7 (9.7 to 11.7) 46.0 56.7 (55.7 to 57.7) 18.8 46.9
Trichomonas 1.2 (0.9 to 1.6) 2.0 3.2 (2.9 to 3.6) 36.5 –31.4
           
Women:          
Gonorrhoea 1.1 (0.8 to 1.5) 18.5 19.6 (19.4 to 20.0) 5.7 175.4
Genital chlamydia 34.7 (33.0 to 36.5) 116.4 151.2 (149.4 to 153.0) 23.0 2494.8
Genital warts 49.3 (47.2 to 51.4) 187.0 236.2 (234.2 to 238.4) 20.9 19.2
Genital herpes 31.0 (29.1 to 32.7) 61.3 92.3 (90.7 to 94.0) 33.6 303.9
Trichomonas 14.7 (13.4 to 15.9) 19.9 34.6 (33.3 to 35.8) 42.5 –28.3

Source: PHLS, DHSS&PS, and Scottish ISD(D)5 Collaborative Group. Trends in sexually transmitted infections in the United Kingdom 1990-1999. London: Public Health Laboratory Service, 2000.

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