Memorandum by the Department of Health
SEXUAL HEALTH AND HIV STRATEGY (SH 1)
INTRODUCTION
1. The first ever, national strategy for
sexual health and HIV was published for consultation on 27 July
2001. The strategy proposes a comprehensive and holistic model
for modernising sexual health services in line with the principles
set out in the NHS Plan.
2. The NHS Plan set out the Government's plans
to develop a health service for the 21st century, offering fast,
high quality and patient centred care. The core principles underpinning
the NHS Plan form the basis of the key aims and objectives of
the Sexual Health and HIV Strategy. These include providing a
comprehensive range of services, shaping services around the needs
and preferences of individual patients, responding to the needs
of different populations and continuously improving quality services.
3. Tackling poor sexual health is an important
part of broader work to tackle health inequalities. Poor sexual
health disproportionately affects disadvantaged communities, and
there are inequities in service provision from area to area.
4. This memorandum presents an analysis of sexual
health in England today, and sets out the action the Government
is taking to tackle the main problems identified.
SEXUAL HEALTH
IN ENGLAND
TODAY
Sexually Transmitted Infections and HIV
5. In the year 2000, there were over 1.1 million
visits to Departments of genito-urinary medicine (GUM) in England.
The most common conditions diagnosed in Departments of genito
urinary medicine (GUM) were chlamydia, non-specific urethritis
and wart virus infections. New diagnoses of sexually transmitted
infections (STIs) such as gonorrhoea, chlamydia and syphilis are
currently showing an upward trendi.
6. An estimated 33,500 people in the UK were
living with HIV at the end of 2000, of whom 72 per cent were aware
of their HIV status. About 400 people a year die as a result of
their HIV infection. Although there is still no cure, combined
therapy has improved the life span of people living with HIV.
For the last three years the number of new infections acquired
through heterosexual sex has outnumbered those acquired through
homosexual sex, and over 80 per cent of heterosexual infections
were probably acquired abroad. Sex between men remains the major
transmission route for HIV in this countryii.
7. The average lifetime treatment costs for an
HIV positive individual is calculated to be between £135,000
and £181,000iii, and the monetary value of preventing a single
onward transmission is estimated to be somewhere between £1/2
and 1 million in terms of individual health benefits and treatment
costs.
International comparisons
8. France, the Netherlands, Sweden and Switzerland
all reported increases in gonorrhoea between 1995 and 1999iv particularly
among men having sex with men. The same group has also suffered
outbreaks of syphilis, for example new diagnoses doubled in Sweden
between 1996 and 1999. Between 1995 and 2000, new diagnoses of
sexually acquired HIV infections increased by 20 per cent in Western
Europe and numbers of people living with HIV are rising by around
3 per cent a year.
9. Data from the UNAIDS Report on the Global
HIV/AIDS epidemic (June 2000) shows that at the end of 1999, the
UK had an HIV rate of 0.11 per cent compared to rates of 0.74
per cent in Portugal, 0.58 per cent in Spain and 0.44 per cent
in France. This reflects prompt action on a number of fronts:
health promotion, needle exchange schemes and other harm minimisation
initiatives, screening of blood and clinical interventions, the
availability of open-access GUM clinics and careful surveillance
and analysis of trends.
Sexual behaviour & knowledge
10. Studies suggest there has been an increase
in risky sexual behaviour, and that there is still ignorance about
the possible consequences. The average age at which people start
having sex is now 16. Forty years ago it was 21 for women and
20 for menv. In 1999 most people questioned in a national study
did not know what chlamydia wasvi.
11. Further important data have recently been
published from the National Survey of Sexual Attitudes and Lifestyles
(Natsal 2000) vii, which can be compared with information from
a similar survey undertaken in 1990. This showed that between
the two surveys there had been an increase in behaviours associated
with increased risk of HIV and STI transmission, including increases
in numbers of partners and concurrent partnerships. In particular,
there were considerably higher rates of new partner acquisition
among those younger than 25 years and this is reflected in the
substantially higher incidence of STIs in this age group.
12. Natsal also recorded increases in consistent
condom use, which were greatest for men with multiple partners
in the last year. Four in five 16 to 24 year olds used a condom
at first intercourse and around 90 per cent used some form of
contraception. These are significant increases from 1990 when
over a third of teenagers reported not using any contraception
at first intercourse. However, the increase in numbers of sexual
partners may have offset some of the advantages of increased condom
use.
13. A 1999 survey of gay men showed that 58 per
cent of those under 20 did not always use a condomviii. A recent
study indicated that 44 per cent of HIV positive men had anal
sex with a new partner in the last month, of whom 40 per cent
reported no or inconsistent condom useix.
Teenage pregnancy and unintended pregnancy
14. Sexual health is not just about disease.
Ignorance and risky behaviour can also have profound social consequences.
Planning parenthood, understanding contraception and the age of
first intercourse can all have an important impact on individuals
and communities. Teenage birth rates in the United Kingdom are
the highest in Western Europe. Conception rates in England have
now started to fall, the rate for under 18s and for under 16s
having dropped by over 6 per cent between 1998 and 2000. This
is encouraging, but the work being undertaken to implement the
Teenage Pregnancy Strategy, such as improvements to Sex and Relationship
Education and services for young people, will need to be sustained
if the goal of a 50 per cent. reduction in rates by 2010 is to
be achieved.
15. In 2001 there were nearly 176,000 abortions
performed in England and Wales. Following a pill scare in 1995,
abortion rates increased until 1998, but now appear to be stabilising.
Abortion rates are highest for women in their early twenties and
late teens.
16. It is estimated that the prevention of unplanned
pregnancy by NHS contraception services saves the NHS over £2.5
billion a year.
Inequalities
17. Sexual ill health is not equally distributed
among the population. The highest burden is borne by women, gay
men, teenagers, young adults and black and ethnic minoritiesx,
xi. The rates of gonorrhoea in some inner city black and minority
ethnic groups are ten or eleven times higher than in whitesxii.
HIV infection also has an unequal impact on some ethnic and other
minority groups. Britain's African communities have been particularly
badly affected by HIV/AIDS, with high rates among both adults
and childrenxiii. There is some evidence to suggest that chlamydia
infection rates are associated with levels of deprivation.
18. There is a strong link between social deprivation
and STIs, abortions and teenage conceptions. Unintended pregnancies
increase the risk of poor social, economic and health prospects
for both mother and child. The risk of becoming a teenage mother
is almost 10 times higher for a girl whose family is in social
class V (unskilled manual), than those in social class I (professional).
NATIONAL STRATEGY
FOR SEXUAL
HEALTH AND
HIV
Development of the Strategy
19. In May 2000 it was announced that the HIV/AIDS
and sexual health strategies had been integrated into a single
programme. The aim of combining the two strategies was to develop
more coherent health promotion messages and more effective service
interventions for sexual health, including HIV/AIDS.
20. A new process for developing the combined
strategies was established, building on existing structures and
work to date, and bringing in additional expertise as required.
An Integrated Strategy Steering Group was established (membership
attached) together with various sub-groups and working groups
to look at specific issues.
21. A wide range of stakeholders was also involved
in the development of the strategy. A written consultation with
health professionals working in the field was undertaken and meetings
held with the Royal Colleges, professional organisations and other
key players. There were specific consultations held with young
people, black and ethnic minority groups and gay men and lesbian
women.
Publication of the Strategy
22. The Strategy was launched for consultation
on 28 July 2001. It was backed by investment of £47.5 million
to support a range of initiatives set out in the strategy. The
main aims of the Strategy are to:
— reduce the transmission of HIV and
STIs;
— reduce the prevalence of undiagnosed
HIV and STIs;
— reduce unintended pregnancy rates;
— improve health and social care for people
living with HIV; and
— reduce the stigma associated with HIV
and STIs.
23. The Strategy proposes to achieve these
aims by:
— providing clear information so that
people can take informed decisions about preventing STIs, including
HIV;
— developing a new information campaign
for the general population;
— producing a sound evidence base for
effective local HIV/STI prevention;
— developing managed networks for HIV
and sexual health services, with a broader role for those working
in primary care settings and with providers collaborating to plan
services jointly so that they deliver a more comprehensive service
to patients;
— evaluating the benefits of more integrated
sexual health services, including pilots of one-stop clinics,
primary care youth services and primary care teams with a special
interest in sexual health;
— beginning a programme of screening
for chlamydia for targeted groups in 2002;
— stressing the importance of open
access to GUM services and, over time, improving access for urgent
appointments;
— ensuring a range of contraceptive
services are provided for those that need them;
— addressing the disparities that exist
in abortion services across the country;
— increasing the offer of testing for
HIV to ensure earlier access to treatment for those infected and
limiting further transmission of the virus;
— increasing the offer of hepatitis
B vaccine;
— setting standards for the treatment
of STIs and for the treatment, support and social care of people
living with HIV;
— setting priorities for future research
to improve the evidence base of good practice in sexual health
and HIV; and
— addressing the training and development
needs of the workforce across the whole range of sexual health
and HIV services.
Consultation
24. The consultation period on the Strategy
ran from 27 July to 21 December 2001. The Strategy was circulated
widely across the NHS, voluntary organisations, Royal Colleges
and social services.
25. The extended consultation period provided
an opportunity for the Department of Health and other groups to
organise a number of consultation events to supplement the written
exercise. The Department of Health held six events in Warrington,
London (two separate events), Bristol, York and Birmingham. These
events were attended by a wide spectrum of health professionals
and others from the field.
26. In addition we commissioned the Terrence
Higgins Trust, Brook, the African HIV Policy Network and others
to organise more targeted events. Other organisations such as
the fpa and the National AIDS Trust also held events. The
Royal College of General Practitioners held an event for GPs.
Canvassing a wide range of constituencies was important and has
helped us in developing implementation plans.
Summary of responses to the Strategy
27. We received over 400 detailed and thoughtful
written submissions of very high quality. The large majority of
people involved in the consultation welcomed publication of the
Strategy. Many felt that the development of a strategic approach
to improve sexual health is long overdue.
28. There was strong consensus around our analysis
of the problem, in particular the rising trend of infections,
the link between sexual ill health, poverty and social exclusion,
and varying standards of service provision. There was also a large
degree of support for the main interventions proposed, in particular
the development of service standards to ensure consistent quality
of care regardless of the point of access.
29. Many respondents were concerned about exactly
how in practice the Strategy would be implemented, particularly
following the mainstreaming of HIV funding. There were also strong
views that improving clinical services—while important—would
not of itself be sufficient. Implementation of the Strategy will
require partnership working with other government departments,
local government and the voluntary sector in order to succeed.
There are limits to what a single organisation can achieve, particularly
in seeking to change the behaviour of individuals.
30. Given the overall support for the aims, principles
and interventions proposed in the Strategy, we do not propose
at this stage to revise the Strategy itself. We are developing
a response to the consultation and a detailed implementation action
plan which will be published shortly. The Strategy taken together
with the consultation response and implementation plan set out
in this document will provide an overall framework for action.
Action taken during 2001-02
31. During 2001-02, alongside the consultation
exercise and events, we invested £5.5 million to prepare
for implementation of the Strategy as detailed below:
— We provided funding for every local
area to undertake a baseline service mapping exercise, and identify
gaps and weaknesses in existing services. These reports will be
analysed and a summary report published in the autumn. (£1.6
million)
— We have started to develop the information
campaign, including undertaking research on what works. We also
supported the World AIDS Day HIV prejudice campaign. (£0.8
million)
— We have funded a study to investigate
the incidence and re-infection rates of genital chlamydial infection
in young women attending public health care settings in Portsmouth
and Wirral. This will help to inform the design of the chlamydia
screening programme, particularly screening intervals. (£0.6
million)
— We have funded a range of national and
local interventions aimed at reducing the recent resurgence of
syphilis in England. These include an awareness campaign for groups
most at risk of syphilis, reviewing and updating of national enhanced
laboratory surveillance for syphilis and improving outbreak management
skills. We have also funded local interventions in London, Manchester
and Brighton, which complement national initiatives, but are more
targeted, appropriate and sensitive to local circumstances. We
have also provided more doses of hepatitis B vaccine to GUM clinics.
(£1 million)
— We provided funding to 16 further areas
to start or expand schemes for pharmacy availability of emergency
hormonal contraception under a patient group direction. (£0.75
million)
— We have taken forward other national
initiatives, in particular the development of basic sexual health
skills training for health professionals and introduction of a
more efficient abortion data processing system. (£0.75 million)
IMPLEMENTATION ACTION
PLAN
32. Our implementation action plan, to be published
shortly, will set out in detail how we will work both through
the NHS and in partnership with other Government Departments and
the voluntary sector to tackle sexual ill-health. This is a long-term
programme. We will need to both improve and modernise services,
and also seek to change individuals' behaviour drawing on the
best evidence on what works in achieving this. This will form
an important part of our work to improve public health, tackle
health inequalities and communicable diseases, and deliver the
NHS Plan. The main strands of the implementation plan are summarised
below.
33. The Implementation Action Plan will build
on the arrangements already in place at national and local level
to implement the Teenage Pregnancy Strategy, working in partnership
with a wide range of organisations from the statutory and voluntary
sector. The Plan will also link to implementation of the Infectious
Diseases Strategy Getting Ahead of the Curve which identifies
control of HIV transmission as a key priority.
Framework for delivery
34. Primary Care Trusts (PCTs) will play
a central role in implementing the strategy. PCTs have a unique
perspective across community, hospital and primary care and across
both the NHS and local authorities. They also have a very clear
relationship both with frontline staff and with patients. PCTs
have been given new powers and control over resources to shape
and commission services. These new powers will enable commissioning
to be more responsive to local need and the views of service users.
35. We have asked PCTs to identify a sexual health
and HIV lead to drive forward implementation at local level. We
are encouraging PCTs to collaborate in commissioning consortia
in order to make best use of existing expertise in sexual health
and HIV commissioning. A key element of the implementation plan
is the development of a Sexual Health and HIV Commissioning Toolkit
to support PCTs in this new role.
36. We will carefully monitor levels of investment
following the mainstreaming of HIV budgets. This will include
revised arrangements for monitoring under the AIDS Control Act.
Strategic Health Authorities will be responsible for performance
managing implementation.
Better prevention
37. We are working towards launching a national
information campaign in the autumn. The campaign will highlight
the risks of unprotected sex, and will target young adults in
particular. This will build on the success of the teenage pregnancy
media campaign which has secured recognition of 78 per cent with
its target audience, and good understanding of the key messages.
We are also taking forward more targeted campaign work, including
promoting HIV testing among high risk groups.
38. The Health Development Agency is undertaking
a review of the evidence base for local HIV and STI prevention.
The main findings will be disseminated to local areas by the autumn,
supported by a regional seminar programme. We are also developing
a health promotion toolkit to support implementation.
Better services
39. We will work with professional bodies and
service users to develop and publish a set of recommended service
standards. Work on updated standards for HIV treatment is already
underway in partnership with the BMA Foundation for AIDS and other
key partners. The updated standards will be published later this
year. We will also disseminate details of effective managed service
networks to upport implementation of the standards.
40. The national chlamydia screening programme
will start to be introduced in 10 sites, selected from those areas
which have expressed an interest. The programme will build on
the learning from the successful pilots in Portsmouth and the
Wirral. This will be an opportunistic screening programme which
will primarily target women who access services, but will also
promote greater uptake of testing among men.
41. We will start to address variations in abortion
services, working towards a maximum waiting time of 3 weeks by
2005. We will also develop the role of health advisors within
GUM services, informed by the recommendations from the Health
Advisors Working Party, and will work towards shorter waiting
times for urgent appointments. We are extending the availability
of hepatitis B vaccine, and have recently notified GUM services
of the arrangements for this.
42. We will develop three models for One Stop
Shop sexual health services providing advice, contraceptive and
GUM services on a single site. The models will cover youth services,
specialist primary care teams and specialist services which meet
the needs of all age groups.
Better support for people living with HIV
43. We will commission a report on the support
needs of adults living with HIV, and develop services standards.
This will include access to good quality sexual health advice
and supporting adherence to drug regimes. We will also develop
service standards to meet the support needs of children living
with HIV. We are reviewing the administration of AIDS Support
Grant, with the aims of minimising bureaucracy and ensuring the
needs of people living with HIV are met.
44. Drawing on consultation responses, we will
develop a more detailed action plan to tackle stigma and discrimination
working in partnership with other Government Departments.
Supporting change
45. We are undertaking a mapping exercise of
current availability of basic sexual health skills training and
other professional training to inform a national sexual health
training strategy. The strategy will encompass the training needs
of doctors, nurses (including family planning specialists and
school nurses), midwives, health visitors, health advisors, youth
and social workers and other relevant professionals, and will
link to the work on teacher training already underway as part
of the Teenage Pregnancy Strategy.
46. The content of the joint Medical Research
Council and Department of Health research programme is being reviewed
to ensure that it effectively supports implementation of the Sexual
Health and HIV Strategy. New projects to support the Strategy
will be commissioned from 2003. Further annual reviews will be
undertaken by the Medical Research Council on an annual basis,
informed by progress on systematic reviews of the literature in
relevant subject areas.
CONCLUSION
47. This is an ambitious and wide-ranging Strategy
which sets out a long-term programme working towards safer sexual
behaviour, modernised services and better sexual health for the
whole population. Improving sexual health and changing behaviour
is not something that can be brought about by the Department of
Health and NHS services alone: other government departments, local
government and the voluntary sector have a crucial role to play
too.
48. Devolving new powers and resources to Primary
Care Trusts provides an important new opportunity to make the
commissioning of sexual health services much more responsive to
local needs. Service users will be involved at both national and
local level in redesigning services around their needs. This work
will build on existing models of excellence in GUM, health promotion
and reproductive health services which are highly responsive to
users' needs and concerns, and have made such a major contribution
to controlling the HIV epidemic in this country. By supporting
local implementation and building a broad partnership to drive
forward the Strategy, we can succeed in reversing the upward trend
of infections, tackling inequalities and modernising sexual health
and HIV services.
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