Examination of Witnesses (Questions 260-279)|
WEDNESDAY 17 JULY 2002
260. You spoke earlier about some determinants
of STI transmission. Is there anything else you want to add in
terms of predetermined STI transmission, Dr Fenton?
(Dr Fenton) The distribution of any STI in the population
is an interplay between three main things. One is the degree of
infectiousness of the organism. The second is the patterns of
sexual behaviour in the individual or in that society. The third
is their interaction with curative health services. In groups
which classically have poor access to services or have been marginalised
by services, they are far more likely to have higher rates of
any infectious disease or condition. We see that as well in sexually
transmitted infections and HIV. Some of the groups of concern
are black and ethnic minority communities in Britain, where for
some infectionsfor example, gonorrheawe are seeing
extremely high rates in these communities, exceeding many other
developed and developing countries. These are key issues that
we need to be looking at. The degree of interaction with services
also will play a part in uncovering STIs in the community so interventions
such as contact tracing, partner notification and outreach services
are going to be vital in diagnosing infections in the community.
261. On the effectiveness of the virus, presumably
is it like we see in so many parts of medicine? It is getting
increasingly difficult to control things because they are becoming
more easily transmittable?
(Dr Fenton) Not necessarily. One of the benefits of
working at CDSC is that you see all the STIs in a spectrum. There
are some infections which are highly infectiousfor example,
gonorrheaand there are those which are less infectiousfor
example, HIVand because of these variations in infectivity
or infectiousness we are able to look at variations in trends.
For example, gonorrhea has been argued to be a very good marker
for sexual behaviour change because of its very high rate of infectiousness
and the need for rapid partner change for it to be transmitted
in the population. It is from that level that we are looking at
some of the determinants of transmission.
262. It is not that some of them are becoming
easier to transmit?
(Dr Fenton) No.
263. I wonder how the recommendations in Dr
Cassell's report fit in with what we have just heard.
(Dr Cassell) Would you like me to summarise the recommendations
at this stage?
264. That would be helpful.
(Dr Cassell) The recommendations of the report are
in four main areas. One is services for sexually transmitted diseases
and treatment services. Secondly, adolescent education and service
provision. That includes treatment services for young people,
the education and training of health professionals and the prevention
of STIs. In general, we are very much in agreement with the views
of CDSC as expressed by Dr Fenton and Dr Hughes. I will summarise
first the recommendations on treatment services. First of all,
we think there should be more facilities in genitourinary medicine
sexual health clinics. We think sexual health clinics should have
longer hours, more trained staff and increased funding.
265. Is that because you think they are Cinderella
services at the moment and not properly funded?
(Dr Cassell) Cinderella services is not a term that
I would particularly use. These services certainly have improved
and come out as the mainstream of health services over the last
year, but there is evidence that there is an increasing problem
of access with far higher numbers of diagnosed infections of chlamydia
and gonorrhea being seen; and also strong evidence that people
find it difficult to obtain quick appointments.
That evidence has been obtained by CDSC and
through independent research.
266. Is it true that the service is rather patchy,
depending on which part of the country you are in?
(Dr Cassell) In the context of our report, I would
not like to comment in detail but I know the CDSC have done surveys
that address that directly. The second recommendation is that
sexual health clinics should pay increasing attention to publicity,
that we should make sure that people know about us and also it
would be important that services are provided outside city areas.
This is particularly important in areas of the country where there
is a long distance between the cities that have services. At the
moment, there is no other developed service and it can be a long
way to go for specialist care. The third recommendation on treatment
is that risk reduction counsellingin other words, advice
on safe sex, on routes of transmissionshould be a standard
part of management of sexually transmitted infections, whether
those are managed in primary care, in sexual health services or
elsewhere. The second area is specifically about services and
education for adolescents. We think that there should be improvement
in school sexual education and this should cover the full spectrum
of sexually transmitted infections, not just HIV, because these
infections are very common amongst young people. Sexual health
services need to be available for all people, including young
people. This means there must be increased willingness to refer
on the part of school nurses, for example, and other groups who
young people contact more easily in their daily lives than clinic
services. We also recommend improved and targeted servicesfor
example, drop in clinics and perhaps dedicated young people sessions
in family planning clinics and such like. Our main area of concern
is the lack of representation of sexually transmitted infections
as a significant health problem in the media. We think the Broadcasting
Standards Committee should survey this and make recommendations
that this is addressed and sexuality is raised and represented
in programmes targeted at young people. Thirdly, we have some
recommendations for training professionals which I am sure would
be in line with what has been said so far. We think there should
be increased training for GPs, for all primary care staff with
regard to sexual histories, the management of sexually transmitted
infections and referral. There should be increased awareness of
the need to maintain confidentiality in this field and to be non-judgmental.
There are many standards for confidentiality both for young people
and for other people and these need to be respected and known
to be respected in sexual health. Services outside sexual health
services need to be proactive in the prevention of infection and
detection through appropriate advice. Finally, we also make some
recommendations about prevention. Firstly, we think it is important
that policy makers take account of rising STI prevalence and particularly
its costs. This is something that members of the Association have
particularly talked about. The costs of infertility, ectopic pregnancy,
and pelvic inflammatory disease to the general practitioner are
very little. Particularly, people should realise that there is
an overlap between the risks of STIs and HIV. We think the cost
effectiveness of this is something that really needs to come out
into the open at the top of the agenda. Finally, partner notification.
That is, making sure that a patient is enabled to tell their partner
and ensure their partner's treatment, which is extremely important
in cases of sexually transmitted infections because without that
we risk losing control of infections for onward transmission and
patients continuing to suffer complications.
267. Would it be fair to say that there is pretty
good agreement between you all and not a lot of conflict?
(Dr Cassell) I think so.
268. I am a Member of Parliament representing
an inner south London constituency. From what I have heard so
far, particularly what Dr Fenton said about infectivity, I have
heard a lot about the mechanics of dealing with STIs and their
consequences. We are humankind. We surely must know more now than
we ever did about sexual health. Why are we suffering such a problem
when we should be wiser than we were? I do not wish to sound like
somebody who has just stepped off The Mayflower but rather than
the mechanics of it there is the essence of promiscuityfor
example, the fewer partners you have, the less risk you are likely
to face in incurring STIs and related diseases.
(Professor Johnson) We do know a great deal more about
sexual behaviour in the population than we did many years ago.
There have been two major surveys done in this country, unlike
many other countries in the world. One of the things that we found
in the recent survey which was carried out in the year 2000, and
we were able to compare this with data from 1990, is that there
has been an increase in the numbers of partners that people report
over that recent time period. It is important to understand and
to refer back to what Dr Fenton said that, in the late 1980s,
we saw plummeting rates of gonorrhea and other infections in this
country. That was a result of concerns about the AIDS epidemic
in the early 1980s. During that time, we were experiencing major
education campaigns targeted at those at greatest risk, primarily
gay men in the early1980s, but also more generally, in the general
population. Probably, when we measured sexual behaviour in 1990,
we may have been seeing lower rates of partner change than had
we measured sexual behaviour in just before the AIDS epidemic.
As you have heard, we are seeing now a higher rate of sexual partner
change and that fits in with everything that we observe about
increasing sexually transmitted infections. However, the rates
of sexually transmitted infectionsI will be corrected by
Dr FentonI do not think are as high now as they were at
their peak prior to the AIDS epidemic. The changes in numbers
of partners we believe are genuine though we think they are partly
a result of the improved methods and they are also partly a result
of the changing of attitudes towards sex in this country. We are
a society that has become more tolerant. For example, we are a
less homophobic society. We are more tolerant of homosexual behaviour
and I think that has been very important in the openness with
which we can address homosexual health issues. People may be more
happy now to report. Attitudes have changed. People have become
more tolerant of casual sex. We live in a society exposed to sexual
images from many different sources. We have become an increasingly
intolerant society of sexual infidelity within long term relationships.
We live in a society that is changing, in which the role of men
and women has altered. People are getting married later. They
have kids later. Women are increasingly involved in higher education
and so on. There are good sides and bad sides to some of those
changes. We live in a society in which women in particular suffer
much less dangers of things like childbirth, termination of pregnancy
and so on than we did 50 years ago. In the long term, there have
been major benefits, but these are complex issues in society which
are the interface between attitudes, demography and sexual practices.
269. Are you saying that in the 1980s the intervention
or arrival of HIV, because of its cataclysmic potential, forced
a serious rethink of how people behaved, not just those communities
most readily associated with it, but for everybody, but because
we prepared for a dreadful scenario which never arrived people
then assumed that it never would arrive.
(Professor Johnson) I think there is no doubt that
this country achieved a great deal in terms of HIV control in
the 1980s. We did better than many countries in Europe. We certainly
did better than the developing world. However, with all prevention
activity, this is not a one shot thing. You cannot just have a
prevention campaign in the 1980s and think the problem has gone
away. We have perhaps to some extent lost our focus in understanding
that we have to continue these health education messages but change
them in a way that is appropriate to the cultural attitudes and
mores of the year 2000, not the year 1982. It is very easy to
lose focus of that. I hear people often say that the AIDS epidemic
is no longer a big problem but how shocked people were last week
at the Barcelona AIDS conference to hear that we have an enormous
epidemic internationally which is having a dramatic effect. We
are not immune from that in this country in so far as we have
very close interactions with many of the countries with big epidemics.
We need investment in our local epidemic and we need to invest
in prevention of the global epidemic which is really devastating
in many countries.
270. Can I go back to the BMA booklet because
I think it is absolutely excellent and will inform our report
tremendously. It is worth noting that three of our panel are acknowledged
not as authors but are thanked for their contributions, so this
has a very wide authorship. I want to go on to think about chlamydia
specifically for a short time. The table that we have been given
from the PHLS official report in March of this year shows that
chlamydia cases in 1990 were about 30,000 and shot up by 2000
to double that, 60,000. We have already hinted that part of that
is because of better availability of the tests, better awareness.
How much of what we used to call non-specific urethritis is covered
by a diagnosis of chlamydia and is it a true increase or is it
just better diagnosis and better awareness?
(Dr Hughes) We think the main reason we have seen
this rise is because of a greater public and professional awareness
of chlamydia. More people are aware of chlamydia and when you
go to a GUM clinic now you will almost certainly be screened for
it and also there are more sensitive tests. The main reason we
are seeing this rise is because we are detecting more infections.
However, we are still only seeing the tip of the iceberg as far
as chlamydia is concerned. Because about 70 per cent of infections
in women will show no symptoms, most people do not go to a GUM
clinic and get diagnosed with it. The only way to get an idea
of how common the infection is is to do a cross section survey
of where you screen people. The sexual behaviour study shows that
three per cent of 18 to 25 year olds in the population are infected
with chlamydia. The chlamydia screening pilot looked at women
under 25 attending various health care sessions, and if you look
at the general practice population, between eight and nine per
cent of those young women were infected with chlamydia. There
are much higher rates with high risk groups like those attending
genitourinary medicine clinics.
271. Infected and probably unaware?
(Dr Hughes) Most of those would have been unaware
because most of them will not have had symptoms and therefore
will not have perceived a problem. You can look at diagnosis in
GUM clinics but you are not getting a full picture of the epidemiology
in the community and it is a much more common infection than was
previously believed. This highlights that if you want to control
an infection like chlamydia you are going to have to screen for
it because most people will not have symptoms.
272. Is there widespread availability of the
screening tests or is this limited by cost?
(Dr Hughes) It is not widespread. If you go to a GUM
clinic, you will be offered a chlamydia screening test.
273. If somebody turns up to a physician or
a GP with symptoms suggestive, even if it is eye problems, they
will be able to get a test, will they?
(Dr Hughes) If symptoms are suggestive of a chlamydia
infection, yes, they should be offered a test but because most
of them will not have the symptoms they will not be.
274. What is the incidence of false positives
or is it a virtually 100 per cent successful test?
(Dr Hughes) The tests are very sensitive and specific,
particularly the new nucleic acid amplification tests being used
in the pilot schemes.
275. Dr Tobin, do you still diagnose NSU or
has that diagnosis gone down?
(Dr Tobin) It has gone down very much. A lot of it
276. Dr Taylor referred to the reported cases
having more than doubled of male and female in the last ten years.
There is also likely to be under reporting. It is suggested in
some of the material that we might need to talk about the figures
and that some of the increase shown in the figures may be because
of increased public awareness; and yet your evidence shows that
the most at risk group is the younger age group. The evidence
suggests that there is a appalling level of ignorance in that
age group, more than three-quarters of young people now knowing
about the infection at all. Are these figures a considerable under-estimate
of the prevalence of chlamydia, particularly in younger age groups?
(Dr Fenton) There is quite likely to be an under-estimate
because the surveillance data really depends on attendance to
a GUM clinic. Therefore, we only get information from the STI
surveillance systems on attendances and diagnoses in that setting.
If we look at chlamydia diagnoses made in microbiological labs
in the country, we do see even more diagnosis of chlamydia in
young people, which reflects the fact that they are going to youth
services, general practices etc., and are being screened for chlamydia
in those settings as well. Yes, the STI surveillance data that
we obtain from the GUM clinics are likely to under-estimate the
truth occurrence of the disease in the general population. In
this regard, the chlamydia study which was done as part of the
second national survey of sexual actions and lifestyles for the
first time gave us a picture of the burden of the disease in the
general population. In that study, we were not able to ask young
people under the age of 18 to provide a urine sample for chlamydia
screening. I think this is an area for further work.
277. Dr Fenton and Dr Hughes, would you go as
far as to say that chlamydia was a public health problem and,
if so, how best can it be controlled?
(Dr Hughes) Yes, I think it is a public health problem.
Looking at pilots in general practice populations, the prevalence
of infection in women under 25 was between eight and nine per
cent so that does suggest that it is a public health problem.
Also, most of those infections would not have been detected without
screening because most of those women would not have symptoms,
which suggests that if you are going to control this infection
you need to be looking at screening women for the infection.
(Professor Johnson) One of the points to emphasise
to the Committee is that chlamydia is a major cause of pelvic
inflammatory disease and tubal infertility in women. That is its
major public health burden. You know how much the NHS is increasing
spending on infertility problems. One of the things we have seen
in this country is rather a piecemeal approach to testing for
chlamydia outside of GUM clinics. We have talked about these new
tests which are a tremendous advance in terms of having a better
test that can also be carried out without having to do genital
examinations on patients and therefore is much more applicable
in general practice, but the new tests that we have been talking
about are not widely available in general practice. People are
still relying on less sensitive tests. If one wants to role out
this programme, one of the differences between chlamydia and syphilis
and gonorrhea is that we have had very good control of syphilis
and gonorrhea over the last 50 years because of the availability
of penicillin and tests which identify them. Chlamydia is still
widely disseminated in the population and therefore we need a
different strategic approach, one that relies more heavily on
primary care by more active screening programmes, particularly
amongst young people, and which engage not only women but also
the men. Dr Fenton has pointed out the results of the national
survey. One of the key findings is we have as much asymptomatic
infection in men as in women. If we focus the screening solely
on women, we will miss half of the problem. Partner notification
is what one would like to do but this is much more difficult than
one imagines, even in experienced hands. It is very difficult
in general practice, where partners may not use the same general
practitioner. We need to think not just of screening women but
of screening men, of looking for chlamydia, raising awareness
in young people. We need to raise awareness, dare I say it, in
some of our professional bodies across the range of services.
We need to look for chlamydia in antenatal settings, in abortion
clinics and other settings and, in primary care, possibly also
in the contraception service, if we are going to push the prevalence
down in the population to the stage that we have now got to with
gonorrhea and syphilis, where one could do much more focused work
to try and drive some of these infections to extinction. The Swedes
have done it and they have good public health indicators that
they are driving down their rates of pelvic inflammatory disease.
They are driving down their rates of gonorrhea almost to extinction
by really well coordinated screening programmes and that is something
we do not yet have in this country.
278. Can I clarify why the tests are difficult
and still not widely used? Are they difficult to obtain? Is it
an ignorance on the part of practitioners or is it a cost issue?
(Professor Johnson) I do not think it is ignorance;
it is availability of tests. These tests have become developed
in the last ten years and available in clinical practice perhaps
in the last five years but have been available largely in laboratories
with a specific interest in developing and buying the kit to do
them. They are considerably more expensive than some of the previous
technologies. However, this is a very rapidly advancing field.
It is not my specialist area at all but one would hope to see
some of the costs of these tests coming down. I think it is fair
to say that in many health authorities the funding may not be
available for widespread use of these tests, and certainly not
in the context of broad base screening programmes.
279. Are you implying that there is a long term
cost saving because of the pelvic inflammatory disease?
(Professor Johnson) Yes. There are questions about
how best to deliver all these programmes because one wants to
try and use them in those sectors of the population where we anticipate
the prevalence would be highest and we know that is likely to
be the youngest sectors of the population and those we predict
might be changing partners more frequently.