Memorandum by HIV/STI Division PHLS Communicable
Disease Surveillance Centre (SH63)
SEXUAL HEALTH IN BRITAIN: THE CHANGING EPIDEMIOLOGY
OF HIGH-RISK SEXUAL BEHAVIOURS, AND STIs INCLUDING HIV
1. SUMMARY OF
KEY POINTS
1. The past decade has seen substantial
increases in high-risk sexual behaviours in the British population.
Although condom use has increased, it is likely the increase in
unsafe sex has been even greater.
2. Although substantial declines in STI
incidence were observed throughout the 1980s and early 90s, new
diagnoses of STIs have risen continually since 1995. Diagnoses
of chlamydia, gonorrhoea and syphilis have all more than doubled
over the past five years.
3. Distinct "core-groups" (eg
young people, gay and bisexual men, some ethnic minorities) bear
a disproportionate burden of disease.
4. New treatments have had a major impact
with rises in HIV prevalence (due to decreasing numbers of deaths
at a time when new diagnoses are increasing). As a result, the
number of people requiring long term treatment is increasing rapidly.
5. Gay men remain the group at highest risk
of acquiring HIV in the UK, and there is evidence that transmission
through sex between men is continuing at a substantial rate.
6. Over 70 per cent of heterosexually acquired
HIV infections diagnosed in the UK in 2000-01 were in people from,
or associated with exposure in, Africa.
7. Although the potential still exists for
HIV transmission through injecting drug use there is no evidence
of significant current spread amongst IDUs in the UK.
8. London, Edinburgh, Brighton and Manchester
are the cities in the UK with the largest HIV infected populations,
although other metropolitan areas have significant numbers of
HIV infected residents.
9. Although preventable HIV infections are
still occurring in children, the proportion of maternal HIV infections
detected in pregnancy has increased especially in London.
10. Poor GUM clinic access is now widespread
throughout England. The median time to first appointment in 2002
has lengthened to 12 days for men and 14 days for women.
2. INTRODUCTION:
THE PHLS COMMUNICABLE
DISEASE SURVEILLANCE
CENTRE
2.1 The Public Health Laboratory Service
is a network organisation consisting of nine Group Laboratories
based on 49 sites strategically located throughout England and
Wales, which are linked to specialist microbiological reference
units and epidemiological experts. The Communicable Disease Surveillance
Centre, CDSC, was set up by the PHLS on 1 January 1977 to provide
a highly active centre for the surveillance and control of infectious
disease in support of public health physicians and others involved
in the investigation and control of communicable disease. It now
forms a unified central epidemiological unit of the PHLS and is
the national centre for the surveillance and control of communicable
disease in England and Wales.
2.2 The main objectives of the HIV/STI Division
of the CDSC are to determine and describe the geographic, demographic
and risk factor distributions of STIs and BBVs; to monitor the
progression of STIs and BBVs in "at risk" populations
and to estimate incidence of particular infections (especially
HIV) in important behavioural risk groups; to provide data and
analyses for planning and targeting preventative activities (health
promotion) aimed at reducing risk behaviours and interrupting
transmission of STIs and BBVs; and to establish and maintain appropriate
surveillance mechanisms to facilitate the early detection of significant
changes in the epidemiology of STIs and BBVs.
2.3 This report presents the most up-to-date
information on the status of the HIV and STI epidemics in England
and Wales, as well as the behaviours that transmit them. The evidence
is based upon data derived from existing HIV/STI surveillance
programmes as well as recently published research studies. Further
information on the structure of the HIV/STI Division, or about
the nature, range and outputs of our surveillance programmes may
be obtained from the PHLS website located at www.phls.co.uk.
3. RECENT CHANGES
IN POPULATION
SEXUAL BEHAVIOUR:
A MAIN DRIVING
FACTOR FOR
RISING HIV AND
SEXUALLY TRANSMITTED
INFECTIONS (STIS).
3.1 Population patterns of sexual behaviour
are major determinants of sexually transmitted infections (STI)
and HIV transmission. The most recent data on sexual behaviour
in Britain are derived from the MRC funded second National Survey
of Sexual Attitudes and Lifestyles (Natsal 2000). This study confirmed
that there have been many changes in both social norms, reflected
in more tolerance towards sexual diversity, and in sexual behaviour
in the UK in the past decade. 1 There has been an increase in
a wide range of behaviours associated with HIV and STI transmission,
including numbers of heterosexual partners, age at first sexual
intercourse, homosexual partnership, concurrent partnership, heterosexual
anal sex, and payment for sex. 1
Key point one
The past decade has seen substantial increases
in high-risk sexual behaviours in the British population. Although
condom use has also increased, this is likely to have been offset
by greater increases in unsafe sex.
3.2 For both men and women the numbers of
lifetime heterosexual partners have increased substantially since
1990 (Figure 1), and these increases have been highest in young
people. 1,2 The mean number of lifetime partners has increased
from 8.6 and 3.7 partners ever for men and women respectively
in 1990 to 12.7 and 6.5 in 2000. 1
3.3 Concurrent partnerships (having more
than one sexual partner at the same time) are important for STI
transmission dynamics, as they increase the probability that an
infection will be passed on to more than one person. The proportion
of men and women who had concurrent relationships in the past
year has also increased since 1990 and was 14.6 per cent and 9.0
per cent respectively in 2000 (Figure 2). The rate was highest
in young people, with over 20 per cent of 15-24 year old men and
15 per cent of 15-24 year old women having a concurrent partnership
in the last year. 1
3.4 While condom use has increased in the
UK, the increase in numbers of sexual partners may have served
to discount some of the public health advantages of this increase.
Overall the proportion of the population, who reported two or
more partners in the past year and did not use condoms consistently,
had increased since 1990, from 13.6 to 15.4 of men and from 7.1
per cent to 10.1 per cent of women (Figure 3).
3.5 Age at first intercourse has declined
from 21 for women and 17 for men surveyed in 1990 to 16 for men
and women born in the early to mid 1980s. 2 Young people do not
always have the negotiation skills to ensure the use of condoms
consistently and effectively, and yet are a group with both higher
rates of partner change, and more concurrent partners. 1, 2
3.6 The proportion of men in Britain who
had ever had a homosexual partner increased from 3.6 per cent
in 1990 to 5.4 per cent in 2000, and the proportion that had had
a homosexual partner in the last five years also increased (Figure
2). 1 Community surveys of men who have sex with men have seen
high risk sex increase since 1996. 3,4,5
3.7 Unsafe sex amongst men who have sex
with men, particularly occurring with a partner of unknown HIV
status, has increased in London since 1996. 1,4 The proportion
of gay men in London reporting unprotected anal intercourse (UAI)
in the past year increased from 32 per cent in 1996 to 44 per
cent in 2000 (Figure 4). Evidence suggests that these increases
in UAI are with both regular and casual partners. 4 Recent growth
in traditional (such as saunas and cruising grounds) and new (websites
and internet chat rooms) sexual market places has increased the
opportunity for men who have sex with men to acquire new sexual
partners. 6
3.8 Implications for GUM services: The observed
increases in high-risk sexual behaviour have driven, and continue
to drive, global increases in HIV and STI transmission. In turn,
these place additional pressures on existing services.
4. RECENT EPIDEMIOLOGY
OF SEXUALLY
TRANSMITTED INFECTIONS
4.1 One of the most sensitive markers of
changes in high-risk sexual behaviour is the resultant increase
in transmission and diagnosis of sexually transmitted infections.
Sexually transmitted infections (STIs) cause considerable reproductive
morbidity and poor health outcomes including pelvic inflammatory
disease (PID), infertility, ectopic pregnancy, cervical cancer,
neonatal disorders and death. 7 Early diagnosis and treatment
of STIs, as well as targeted prevention efforts, can significantly
reduce the likelihood of these complications occurring.
4.2 The long established network of over
200 GUM clinics in England and Wales, and the robust STI surveillance
(KC60) programme are well placed to identify these increases early.
Unsurprisingly, the past decade has seen substantial changes in
the epidemiology of STIs and HIV infection.
Key point two
Although substantial declines in STI incidence
were observed throughout the 1980s and early 90s, new diagnoses
of STIs have risen continually since 1995. Diagnoses of chlamydia,
gonorrhoea and syphilis have all more than doubled over the past
five years.
4.3 Diagnoses of acute bacterial STIs in
genitourinary medicine (GUM) clinics in England, Wales and Northern
Ireland more than doubled between 1995 and 20008 and specifically:
gonorrhoea increased by 102 per cent (10,204 to 20,663 cases)
(Figure 5); chlamydia increased by 107 per cent (30,877 to 64,000
cases) (Figure 6), and infectious syphilis increased by 145 per
cent (136 to 333).
4.4 Preliminary analyses of the latest data
suggests there were further significant increases in 2001. 9 These
rises are mostly associated with an increase in higher risk sexual
behaviour although greater testing for chlamydia has also contributed.
10 Diagnoses of STIs had fallen sharply in the mid to late 1980s
in the wake of the HIV and AIDS epidemic and had remained at low
levels until the mid-1990s. 11
4.5 However, chlamydial and gonococcal infections
in females usually show no symptoms which means they often do
not get diagnosed. The chlamydia screening pilot in Portsmouth
and Wirral, which was funded by the Department of Health and co-ordinated
centrally by the Public Health Laboratory Service Communicable
Disease Surveillance Centre, tested all sexually active young
women attending a range of health care settings, including general
practice and family planning clinics, regardless of whether they
had symptoms. Approximately 17,000 women were tested between September
1999 and August 2000, equivalent to about 45 per cent of the sexually
active female population aged under 25 years in those areas. 12
The results suggested that between 10 per cent and 11 per cent
of women aged under 25 and attending health care services may
be infected with chlamydia. 13 Many of these women would have
been unaware of their infection and therefore at risk of developing
chlamydial complications.
4.6 Implications for GUM services: Increasing
STI diagnoses reflect increasing GUM clinic throughput as well
as rising disease prevalence in the community. As many clinics
are now operating at maximum capacity, the effectiveness of GUM
clinic based prevention interventions such as partner notification
and behavioural counselling are at risk as clinics fail to cope
with demand.
Key point three
Distinct "core-groups" (eg young people,
gay and bisexual men, some ethnic minorities) bear a disproportionate
burden of disease.
4.7 Certain groups in the population tend
to be at particular risk of infection and re-infection with STIs.
These include:
4.8 Young people, particularly teenage females.
The highest rates of gonorrhoea and chlamydia occur among teenage
females. 14 Over 40 per cent of the 6,313 females diagnosed with
gonorrhoea in 2000 were under 20 years old, and among 12 to 15
year old females diagnosed with gonorrhoea, almost a quarter will
return with another episode of gonorrhoea within a year. 15,16
4.9 Gay men. There have been numerous large
outbreaks of syphilis in England over the last few years, notably
in Manchester, Brighton and most recently in London, where over
290 cases were diagnosed in the last year. 17,18 These outbreaks
have predominantly involved gay men, many of whom were also infected
with HIV. 19
4.10 Black ethnic minorities. Several studies
have shown particularly high rates of bacterial STIs, especially
gonorrhoea, among the black Caribbean population. 20, 21, 22,
23 In London, gonorrhoea rates are thought to be 10 times higher
in black ethnic groups than in whites. 24 A quarter of black Caribbeans
diagnosed with an acute STI will be diagnosed with another acute
STI within a year. 25
4.11 Although sexual behaviour is a key
determinant of STI transmission, other factors may be associated
with an increased probability of disease spread. These include:
high levels of asymptomatic infection; ineffective partner notification
measures; poor access to GUM clinic services. 26, 27, 28, 29,
30 Consequently, the development of prevention measures should
always consider not only the behavioural context, but the provision
and utilisation of sexual health services as well.
4.12 Implications for GUM services: Inequalities
in GUM service provision are exacerbated in poor urban areas where
high disease prevalence, increasing demand, poor access times
and overstretched staff result in a negative feedback loop of
service deterioration. The inverse-care law, whereby those in
greatest need often have the poorest access to GUM services, applies
equally well to Britain today.
5. RECENT EPIDEMIOLOGY
OF HIV INFECTION
5.1 Population changes in sexual behaviour
will also influence the transmission of HIV infection, however
other factors eg HIV testing behaviours, patterns of health service
utilisation, in-migration from high-prevalence areas, patterns
of injecting drug use, and vertical (mother to child) transmission
also influence the distribution of this disease in the population.
5.2 Nevertheless, HIV continues to be the
most important communicable disease in the UK. It is an infection
associated with serious morbidity, high costs of treatment and
care, significant mortality and, since it affects mainly younger
adults, high number of potential years of life lost. Because HIV
is a chronic disease, diagnosis of HIV does not necessarily represent
recent infection.
5.3 It is estimated there are about 33,500
HIV infected people alive in the UK of whom about 9,400 have not
yet had their infection diagnosed. The HIV epidemic in the UK
is broadly similar to that of much of Northern Europe (Germany,
Holland and the Scandinavian countries), while South West Europe
(Spain, Portugal, Italy, France) has experienced a much larger
epidemic, especially among IDUs. A rapidly spreading mainly IDU
epidemic is currently occurring in the Baltic States, the Russian
Federation and other Eastern European countries but this has not
so far impacted on the UK. The sub-Saharan epidemic however has
had a large impact as the detailed notes below illustrate.
Key point four
The impact of new treatments on AIDS incidence
and deaths—New treatments have had a major impact with rises
in HIV prevalence (due to decrease in death rates) and increases
in the number of people requiring long term treatment.
5.4 Beginning in 1995, highly active antiretroviral
therapies began to have a major impact on AIDS incidence and deaths
from AIDS in the UK. Figure 7 shows the reduction for the period
1996-01. There were dramatic falls in 1996-98 and the lower numbers
of AIDS cases and deaths have been sustained since then. That
this is an effect of treatment is evidenced by the fact that the
reduction is only seen in those who have their infection previously
diagnosed. A large proportion of the AIDS cases now are in those
who don't have their HIV diagnosed until they develop an AIDS
defining illness.
5.5 The decrease in deaths and increasing
new diagnoses has resulted in rising numbers of diagnosed HIV
infected people. The increase was from 14,206 in 1996 to 23,017
in 2000, and if the trend continues will result in almost 34,000
diagnosed HIV infected people alive in 2005.
5.6 Despite the enormous promise of treatment
advances, the problems of side effects, compliance and the development
of resistant strains of HIV, all temper optimism at this stage.
5.7 Implications for GUM services: As people
live longer with HIV, the increasing prevalence have placed substantial
pressures on existing services to fund expensive anti-retroviral
therapy, often at the expense of other HIV/STI prevention interventions.
Key point five
Gay men remain the group at highest risk of acquiring
HIV in the UK and there is evidence that transmission through
sex between men is continuing at a substantial rate.
5.8 In the 10 years from January 1992 there
were almost 14,000 new diagnoses of HIV infection acquired through
sex between men (Figure 8). Although some of these will have been
acquired earlier in the course of the UK epidemic, there is substantial
evidence pointing to continuing transmission in the 1990s. This
includes:
— infections being diagnosed in those
who have previously tested negative in recent years (seroconvertors)
— infections newly diagnosed in under
25s many of whom will have only recently become sexually active
— no ageing cohort effect (median age
and median CD4 all count have remained fairly constant in those
newly diagnosed in the last 10 years)
— acute STIs are occurring in both
diagnosed and undiagnosed HIV positive men (Fig.5)
— behavioural surveys suggest that
risk taking is increasing
— innovative new tests ("detuned
assay") showing an HIV incidence of around 3 per cent (MSM
attending clinics having syphilis tests)
5.9 88 per cent of HIV reports in men who
have sex with men (MSM) in the last five years for whom we have
reported ethnicity are white. New diagnoses are occurring across
the age spectrum, not only in younger gay men. The annual prevalence
survey shows that men who have sex with men constitute the largest
number of HIV infected people within the UK (table 1).
Key point six
Over 70 per cent of heterosexually acquired HIV
infections diagnosed in the UK in 2000-01 were in people from,
or associated with exposure in, Africa.
5.10 The rapid rise in new diagnoses in
those who have acquired HIV heterosexually is shown in (Figure
8). 71 per cent of the new diagnoses ascribed to heterosexual
transmission in 2000 and 2001 were in people from or who acquired
their infection in Africa (2895 of 4106). Although in the early
1990s this was mainly in people from Uganda, in more recent years
increases have been seen in new diagnoses from other African countries,
especially Zimbabwe.
5.11 The numbers of those newly diagnosed
each year whose only exposure is heterosexual sex within the UK
is small—comprising less than 15 per cent of the total heterosexual
reports. However, those newly diagnosed who have a heterosexual
partner who is an IDU or bisexual man are decreasing in numbers—only
3.5 per cent of the new diagnoses in 1997-01 were in this category.
In contrast numbers acquiring HIV heterosexually from a partner
who acquired their infection heterosexually are increasing slowly
and formed 9.5 per cent of the new diagnoses of heterosexually
acquired infection diagnoses in the five years 1997-01.
5.12 Implications for GUM services: The
changing epidemiology means that GUM services must increasingly
adapt to the new clientele with the provision of culturally competent
services.
Key point seven
Although the potential still exists for HIV transmission
through injecting drug use there is no evidence of significant
current spread amongst IDUs in the UK.
5.13 Drug injecting has played a leading
role in the spread of HIV infection in South Western Europe and
in parts of Eastern Europe and the possibility still exists in
the UK both for explosive outbreaks (as experienced in the mid
1980s in Edinburgh) and ongoing transmission in injecting drug
users. In the UK, data from the Unlinked Anonymous (UA) programme
suggest a prevalence of about 1 per cent among injecting drug
users (IDUs) in contact with drug agencies.
5.14 Over recent years the percentage of
IDUs sharing needles or syringes has risen dramatically. In 2000,
almost a third (31 per cent) of current injectors reported sharing
within the previous month, the figure was higher in women (39
per cent) and in London (41 per cent). In addition laboratory
reports of acute Hepatitis B in IDUs are rising as well as the
prevalence among recent injectors (7 per cent, in 2000).
5.15 Injecting drug use is also the main
transmission route for the hepatitis C virus (HCV). UA data has
demonstrated an overall prevalence of 33 per cent of HCV among
current injectors and a linear relationship with injecting duration
which is indicative of ongoing transmission (Figure 10).
5.16 There is little doubt that, were it
not for needle exchange programmes, we would have seen much larger
numbers of HIV infected IDUs with the potential for transmission
to their sexual partners. The experience of other countries shows
that it is imperative that these programmes are sustained, and
surveillance maintained to a high level in order to detect any
increase in HIV infection in IDUs in the UK.
Key point eight
London, Edinburgh, Brighton and Manchester are
the cities in the UK with the largest HIV infected populations,
although other metropolitan areas have significant numbers of
HIV infected residents.
5.17 There is a very great variation in
geographical distribution of HIV infected people. 63 per cent
of the cumulative total of diagnosed HIV infected people are resident
in London (Fig. 11). Furthermore the Unlinked Anonymous testing
programme shows that among STD clinic attenders, HIV positivity
rates are about five times higher in gay men, and eight times
higher in heterosexual men and women in London than they are in
the rest of England and Wales.
5.18 Among the UK IDU population it is estimated
that around 50 per cent (30 to 70,000) are resident in London.
Further, data from the UA programme indicates a much higher prevalence
of HIV (3.6 per cent compared to 0.21 per cent), Hepatitis B (26
per cent compared to 20 per cent) and Hepatitis C (48 per cent
compared to 30 per cent) in London resident IDUs compared to the
rest of England and Wales.
Key point nine
Although preventable HIV infections are still
occurring in children born in the UK, the proportion of maternal
HIV infections detected in pregnancy has increased especially
in London.
5.19 HIV infection among pregnant women
has assumed greater public health importance since it became known
that the use of treatment by the mother, caesarean section and
the avoidance of breast-feeding reduces the risk of mother to
child transmission of HIV to from one in four to less than one
in 50.
5.20 The prevalence of HIV infection among
pregnant women is greatest in inner London. Of women delivering
during the first half of 2001, almost 0.5 per cent of pregnant
women delivering in inner London, 0.3 per cent of women in outer
London and 0.04 per cent outside London were infected with HIV.
Prevalence has increased steadily in all areas of England, with
the greatest increase occurring outside inner London (Figure 12).
5.21 There has been a steady increase in
the proportion of HIV-infected women diagnosed before delivery,
allowing the women to access treatment to prevent transmission
to the baby. During 2000, an estimated 87 per cent of HIV-infected
pregnant women in inner London were diagnosed before they gave
birth, thereby exceeding the national target of 80 per cent set
by the Department of Health for 2002. In outer London and the
rest of England, an estimated 69 per cent and 56 per cent of pregnant
women respectively, had their infection diagnosed prior to delivery
(Figure 13). However, because of the increasing prevalence, the
number of HIV infected infants has not fallen. More than half
of the children diagnosed with AIDS aged less than one year and
born in 2000 were born in what have been regarded as low prevalence
areas.
5.22 Implications for GUM services: Although
the uptake of antenatal screening in inner-London continues to
exceed set targets, there are concerns regarding the provision
of these services outside of London. Future GUM and HIV service
provision must take into account the needs of these HIV infected
children and families.
6. IMPACT ON
EXISTING GUM CLINIC
SERVICES
6.1 Recent increases in sexual behaviour,
rapidly increasing STI and HIV diagnoses, coupled with the sexual
health promotion and growing awareness of GUM services have lead
to substantial increases over the past decade. Although services
have largely coped with the increases, there is now growing evidence
that GUM services are now over-stretched resulting in delayed
access times and a failure to effectively control STI spread in
the community.
6.2 The delay in access time to curative
service is important in STI transmission as this increases the
duration of infectiousness (since the individual remains untreated
for longer) and increases the probability of disease transmission
(since infected individuals continue to have sexual intercourse).
Key point 10
Poor GUM clinic access is now widespread throughout
England. The median time to first appointment in 2002 has lengthened
to 12 days for men and 14 days for women.
6.3 The total number of episodes seen in
GUM clinics in the UK nearly doubled between 1990 and 1999, rising
from 624,269 to 1,169,53731 (Figure 14). This rise has almost
certainly contributed to the large increase in patient waiting
times recently reported by GUM clinics. 32 If patients wait longer
to get treated this may increase the likelihood of STIs being
passed on to sexual partners and of the development if STI-related
complications. 33, 34
6.4 During 2002, the unprecedented demand
for GU Medicine services has increased with a corresponding deterioration
in patient access times, especially in London and other major
conurbations. For most GUM clinics, the numbers of women attending
exceeds that of men. Consequently appointment delays for women
are longer because of their longer examination times
6.5 Poor access is now widespread throughout
England. The median time to first appointment in 2002 has lengthened
to 12 days for men and 14 days for women, compared with five and
six days respectively in 2000 when concern was first expressed.
The majority of the 700,000 new attenders at GU Medicine clinics
each year are having unacceptable delays for initial assessment
and treatment. 35
6.6 Poor access to curative services frustrates
STI prevention and control. Persons at increased risk fail to
obtain timely treatment and may continue to spread their STI.
This is particularly worrisome in areas experiencing STI outbreaks
(eg syphilis outbreaks in Manchester and London) or in hyperendemic
areas (eg South London) since early and effective treatment of
disease should be the primary goal of STI control.
6.7 In the absence of any increase in GUM
capacity, the problems of GUM clinic access are likely to worsen,
not improve, given the current trends. It is also of concern that
the government's Sexual Health and HIV Strategy proposes to introduce
a range of HIV/STI prevention initiatives including Hepatitis
B Screening, HIV testing promotion, and chlamydia screening. Taken
in concert, these interventions will further increase pressures
on overstretched services. Consequently, the benefits of screening
and sexual health promotion are likely to be offset by the frustration
and delays experienced by GUM clinic attenders and those providing
curative services.
7. CONCLUSIONS
7.1 Sexual health in Britain is deteriorating
as evidenced by the recent marked increases in bacterial and viral
sexually transmitted infections, focal outbreaks of syphilis in
metropolitan areas, and the increasing diagnoses of HIV infection,
particularly among homosexual men and heterosexuals who may have
acquired their infection abroad.
7.2 Whilst increases in high-risk sexual
behaviour are key determinants of this deterioration, other factors
for example changes in health seeking behaviour, as well as true
increases in the prevalence of disease in the community are also
contributing to the observed increases in STIs.
7.3 Placed in concert, the behavioural changes
and increases in STIs have placed substantial pressures on the
available Genitourinary Medicine Clinics. Evidence of this increased
burden include: delays in GUM clinic access times (currently two
to three weeks); increases in workload for GUM clinic and administrative
staff.
7.4 The impact of these increases have had
a deleterious effect on service provision and have resulted in
a vicious circle in which the increased workload increases staff
stress; overstretched staff are leaving the service;
8. RECOMMENDATIONS
8.1 In view of the available evidence we
recommend the following:
8.2 Urgent investment into existing GUM
services to reduce waiting times and improve access to STI screening,
diagnosis and treatment. This has been identified as a priority
area in the governments Sexual Health and HIV strategy, and must
be implemented urgently. GUM clinic waiting times are increasing
and many clinics, particularly those in worse affected areas,
turn patients away on a daily basis. Planned initiatives outlined
in the Sexual Health and HIV Strategy such as HIV testing promotion,
chlamydia screening and Hepatitis B Screening will severely exacerbate
the lack of GUM capacity due to the resultant increased demand.
Shifting sexual health care into primary care is unlikely to adequately
meet these increased needs given similar burdens on those services.
8.3 Timely implementation of population
based screening for genital chlamydia infection among young women.
The government's proposals to implement a national screening programme
for Chlamydia trachomatis infection are welcome, however, it is
of utmost importance that this be implemented as quickly as possible.
The DH funded Chlamydia Pilot Study has confirmed the feasibility
and acceptability of opportunistic screening. In a context of
increasing high-risk behaviours and rising STIs, such innovative
interventions should be implemented without delay.
8.4 Target interventions with population
sub-groups vulnerable to sexual ill-health. Available surveillance
and research data confirm significant inequalities in the distribution
of STIs and HIV in the England and Wales. Young people, gay men
and ethnic minorities in particular, appear to be at substantially
increased risk of poor sexual health outcomes. Funds should be
made available urgently to support innovative, evidence based
and participatory prevention interventions with population sub-groups
at increased risk.
8.5 Tackle regional variations in sexual
health outcomes. STI and HIV surveillance data confirm the disproportionate
burden of STIs in "hot-spots"—socio-economically
deprived, inner city areas in Britain. In such settings, STI rates
are among the worst in Western Europe, rivaling levels seen in
deprived areas in the US and some developing countries. Plans
to roll-out sexual health provision outside of GUM clinic sector
in these areas are unlikely to be successful as general practice
services are also overstretched. We therefore recommend that consideration
is given to increasing the capacity (ie increasing GUM clinic
sessions, clinics etc.) in worse affected areas with the piloting
and evaluation of innovative models of GUM service provision and
partner notification.
8.6 Sustain and improve HIV and STI surveillance.
There is a need to maintain and enhance the surveillance effort
as the HIV epidemic grows in size and complexity. We must maintain
the ability to retain anonymised tissue specimens (in tissue which
would otherwise be discarded) on the large scale necessary for
the unlinked anonymous programme. The ability to evaluate and
monitor the outcomes of prevention programmes at a national level
also needs to be enhanced.
Table 1
END OF YEAR HIV PREVALENCE OF DIAGNOSED INFECTION
IN RESIDENT ADULTS, ENGLAND, WALES AND NORTHERN IRELAND: 1996-2000
AND EXTRAPOLATIONS TO 2001-05*
| Year | 1996
| 1997 | 1998 |
1999 | 2000 | 2001
| 2002 | 2003 |
2004 | 2005 |
| MSM | 9,202 | 10,489
| 11,434 | 12,473 | 13,309
| 14,440 | 15,460 | 16,480
| 17,500 | 18,520 |
| Hetero | 3,502 | 4,406
| 5,336 | 6,620 | 8,154
| 9,060 | 10,210 | 11,360
| 12,520 | 13,670 |
| All other | 1,502 | 1,534
| 1,639 | 1,651 | 1,553
| 1,640 | 1,670 | 1,690
| 1,720 | 1,740 |
| Total | 14,206 | 16,429
| 18,410 | 20,745 | 23,017
| 25,140 | 27,340 | 29,530
| 31,740 | 33,930 |
| | |
| | | |
| | | |
Table 2
ESTIMATED PREVALENT HIV INFECTIONS, DIAGNOSED AND UNDIAGNOSED,
AMONG ADULTS* IN THE UK AT END OF 2000 (ROUNDED TO NEAREST 100)
| Route of Infection | Number Diagnosed
| Number Undiagnosed (percentage of total)
| Total |
| Sex between men | 13,800 |
3,200 (19%) | 17,000 |
| Injecting drug use males and females | 1,300
| 200 (13%) | 1,500
|
| |
| |
| male | 3,300
| 3,100 (48%) | 6,400 |
| Sex between men and women | female
| 5,200 | 2,900 (36%) |
8,100 |
| total | 8,500
| 6,000 (41%) | 14,500 |
| |
| | |
| Blood products males and females | 500
| 0 (0%) | 500
|
Grand Total | 24,100
| 9,400 (28%) | 33,500 |
| | |
|
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35 Informal communication. Dr. George Kinghorn. MSSVD
Past President.
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