Memorandum by Sigma Research (SH 101)
BACKGROUND
1. Sigma Research is one of the US only
social research groups specialising in the policy and practice
aspects of HIV and sexual health. Sigma Research is affiliated
to the University of Portsmouth and based in South London. During
the last seven years, Sigma has undertaken more than 50 research
and development projects concerned with the impact of HIV on the
sexual and social lives of a variety of populations. Our research
includes needs assessments, audits, evaluations and service reviews
funded from a range of sources. We have published more than 75
research-into-practice reports, journal articles and book chapters.
2. Sigma Research is the main research partner
in CHAPS, the Community HIV and AIDS Prevention Strategy co-ordinated
by the Terrence Higgins Trust and funded by the Department of
Health. The CHAPS partnership undertakes targeted HIV prevention
work with gay men and other homosexually-active men. As part of
CHAPS, Sigma has been instrumental in producing and disseminating
the Making it Count model for local commissioning of gay
men's HIV prevention. Making it Count is endorsed in The
national strategy for sexual health and HIV as a best practice
model for national and local HIV prevention with gay men.
3. Since 1997, as part of CHAPS, Sigma Research
has undertaken the National Gay Men's Sex Survey (GMSS).
Undertaken annually, GMSS is the World's largest on-going HIV
prevention needs assessment of gay and other homosexually active
men, recruiting over 15,000 men in the latest survey in 2001.
Sigma also undertakes the largest on-going national survey of
the needs of people with HIV and undertakes survey work with African
people with HIV.
4. Peter Weatherburn is the Director of
Sigma Research and a Senior Research Fellow at the University
of Portsmouth. He has worked in HIV and sexual health policy research
(continuously) since 1989.
1. HIV EPIDEMIOLOGY
AND HOMOSEXUALLY
ACTIVE MEN
1.1 Homosexually-active men (HAM) are the
group at greatest risk of acquiring HIV infection in the UK. They
constitute about 1.6 per cent of the population of England but
bear an estimated 56 per cent of the burden of new HIV infections.
Approximately 1,400 new HIV infections are reported to the Public
Health Laboratory Service (PHLS) per year, giving an HIV incidence
on par with gay men in San Francisco and New York. Gay men are
50 times more likely to acquire HIV infection than the rest of
the population.
1.2 Some of the factors contributing to
HIV incidence are becoming more common thanks to successful interventions
in other areas. The number of men acting on their homosexual desire
appears to be increasing, as does the prevalence of HIV due to
reduced mortality in people with HIV because of anti-HIV therapy.
Men with HIV infection are sexually active for longer and an increase
in well-being will be accompanied by an increase in sexual activity.
1.3 Awareness of the on-going national CHAPS
mass media campaigns is remarkably high (averaging about 50 per
cent of all gay men in England). Awareness of small media (leaflets)
and other HIV-related educational resources is less consistent
and more dependent of voluntary sector infra-structure. The geographic
availability of other HIV prevention interventions resemble the
infamous "postcode lottery"—arising from a lack
of voluntary sector infra-structure and from historic and continuing
inconsistencies in Health Authority (now Primary Care Trust, PCT)
commissioning. Overall, there are more opportunities in the gay
population for sexual HIV exposure than ever before. This means
that change in incidence is a poor indicator of the worth of current
HIV prevention programmes.
2. SEXUAL HEALTH—WHAT
IS IT?
2.1 One of the original stated aims of the
strategy was to develop a broader public health understanding
of sexual health. However, it was ultimately structured to limit
the meaning of sexual health to those aspects addressed by NHS
clinical services. Although paragraphs 1.1 and 1.2 suggest the
strategy will adopt a broad and inclusive definition of sexual
health, this is quickly reduced to concern about infections and
unwanted conceptions. In addition, while the proposed approaches
to meeting people's HIV and unwanted pregnancy needs are chiefly
educational and community-based, the strategy concentrates on
describing the funding and infrastructure of clinical diagnostic
and treatment interventions.
2.2 This limiting of sexual health to the
absence of infection/conception and the limiting of interventions
to clinical NHS providers runs throughout the strategy and causes
"blind-spots" and gaps which seriously limit its likely
effectiveness. Below, we outline how this might be addressed during
the implementation phase, especially in the Health Promotion and
Commissioning toolkits that are promised in the strategy's Implementation
plan. If the strategy's ambitious targets are to be achieved
these toolkits must provide future PCT commissioners and health
promoters with a template against which to assess and prioritise
local need and deliver services.
3. HIV HEALTH
PROMOTION (HIV PREVENTION)
3.1 Health promotion (HIV prevention) is
neither art nor a science. It is both far less exact than medical
services, and far less mature a discipline. The strategy assumes
that "prevention" = "information giving" and
"services" = "clinical interventions". These
assumptions lead to a belief that any provider of a clinical service
is qualified to deliver any non-clinical prevention service. This
is not the case and most prevention interventions require specific
expertise. These skills and expertise must be acknowledged, valued
and fostered if we are to collectively increase our impact on
sexual health.
Defining HIV prevention as a discrete and highly
specialised activity
3.2 By adopting an inclusive approach to
sexual health, the strategy fails to state unequivocally what
constitutes HIV prevention and who should be concerned with it
as a specific endeavour. Throughout the strategy, HIV prevention
is confused with information provision. In turn, information-provision
is confused with the methods used to achieve it (most notably
outreach). Greater uptake of HIV testing is also championed as
a panacea for preventing HIV infections on the basis of very little
evidence and without ever articulating the process whereby it
might serve to reduce the number of new infections.
3.3 The health promotion toolkit needs to
define HIV prevention and its purpose, scope and rationale. It
also needs to specify key target populations and outline acceptable
methods to increasing access to, and the quality, of HIV prevention
and other sexual health interventions. That the specialism of
non-clinical HIV/STI prevention be recognised, valued, and included
in the levels of interventions, rather than described separately.
Financing and prioritising HIV prevention in wider
sexual health provision
3.4 It is widely recognised that the long-established
ring-fence around HIV prevention funds has not prevented their
misuse. When these funds have been used to address HIV prevention
needs, they have often failed to address those populations most
likely to acquire HIV infection in the future: namely gay men
and Africans.
3.5 The strategy eliminates the ring-fenced
HIV prevention allocation and trusts that current changes in the
NHS will improve HIV prevention services. In addition HIV prevention
is "mainstreamed" with other sexual health services
administered by PCTs out of their main financial allocations.
It is our view that this can only exacerbate historic inefficiency
and under-investment in HIV prevention, as well as existing inequalities
in HIV infection, by:
— removing the very limited financial
accountability that exists;
— substantially reducing the likely
national spend on HIV prevention; and
— increasing already substantial competition
for funds by placing HIV prevention in direct competition with
other, less stigmatised, concerns such as unwanted pregnancy.
3.6 There is a real and pressing danger
that HIV prevention will be lost within broader moral and financial
imperatives of PCTs.
Targeting groups at substantial HIV prevention
need
3.7 The strategy provides an opportunity
for historically mis-allocated HIV funds to be further diverted
away from those who will become HIV infected. Hence, it is feasible
that the strategy will foster HIV incidence, not reduce it.
3.8 The cessation of ring-fenced funding
and the transfer of commissioning responsibility to PCTs has the
potential to affect adversely the targeting and effectiveness
of HIV prevention. The strategy conflates the causes of morbidity
(sexually transmitted infections including HIV and "unwanted"
conceptions) in one section, the conflated groups experiencing
them in another, and finally puts all these needs in competition
with each other and all other health needs for very finite funds.
Because of the lack of expertise and/or prejudice amongst PCTs,
"young people" will come to mean "heterosexual
young women" who may become pregnant rather than "young
gay men" who may get HIV.
4. USING RESEARCH
TO SUPPORT
CHANGE
4.1 It was not helpful in this complex strategy,
which will be implemented over very many years, to state specific
research priorities or areas. These will inevitably change as
the epidemic develops, as research is undertaken and published
and as interventions become more focussed in areas of practice.
The listing of potential research priorities was also at odds
with the very welcome statement that the research agenda should
be "identified by consultation".
5. THE WAY
FORWARD (PROPOSED
ACTIONS)
5.1 The Health Promotion and Commissioning
toolkits announced in the Implementation action plan are
urgently needed. They need to address fundamental flaws in the
strategy that mean the current target of reducing new HIV infections
by 25 per cent seems unlikely to be met.
They should:
— Stress that while HIV prevention
activity is probably best provided by specialists with health
promotion experience, it is also a function of all sexual health
services including primary care and specialist out-patient services
(such as HIV and GUM clinics). Specialist training needs arise
from this recommendation and will need to be addressed.
— Stress unequivocally that targeted
HIV prevention activity is a necessary and vital part of every
local sexual health strategy.
— Stress that HIV prevention is very
cost effective even where it is only partially successful, given
the costs associated with the treatment and care of people with
HIV.
— Separate the targets of the strategy
(rates of unwanted pregnancy, and the incidence of HIV, chlamydia,
HPV, NSU, HPV, gonorrhoea and syphilis) from the priority groups
that they affect. This involves stating specific priority target
groups for each of the targets.
— State unequivocally that local HIV
prevention activity should be guided by national patterns of HIV
incidence and what is known of the existence of priority groups
in local communities. Thus, as a general rule, interventions targeting
gay men and African communities should take precedence over interventions
targeting groups who are easier to access but at little risk of
HIV such as "the general public".
5.2 Finally, recognising that research priorities
will change constantly, the Department of Health should set-up
a forum where researchers, key policy and intervention practitioners,
Departmental officials and key research funders meet on an on-going
basis to develop and refine research priorities.
July 2002
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