House of Commons - Health

Select Committee on Health Third Report

3 WHAT IS THE CURRENT SITUATION?

Trends in Sexually Transmitted Infections

45. The last decade has witnessed a dramatic rise in diagnoses of all major diseases. One in ten of the UK population have at some time had an STI.[27] A summary of trends from the Public Health Laboratory Service (PHLS), which reveals that diagnoses of chlamydia, gonorrhea and syphilis have more than doubled over the past six years, presents a stark picture.[28] Annual diagnoses of gonorrhea increased by 86% from just under 12,000 to just over 22,000 cases between 1996 and 2001; chlamydia increased by 108% (from around 32,000 to 67,000 cases) and infectious syphilis by 500% (116 to 696 cases).

46. The table below gives the trends over the last six years; figures in the first six columns give actual numbers, with percentage increases appearing in the final two columns:Summary of selected conditions by sex: England 1996-2001.

Condition		1996	1997	1998	1999	2000	2001	2000-2001	1996-2001
Syphilis (primary and secondary)	Total males	84	98	87	156	247	598	143%	612%
	of which homo-sexually acquired	20	18	23	52	119	341	187%	1605%
	Total females	32	49	44	55	75	98	31%	206%
	Total	116	147	131	211	322	696	116%	500%
Gonorrhoea (uncomplicated)	Total males	7,911	8,418	8,446	10,677	14,290	15,476	8%	96%
	of which homo-sexually acquired	1,683	1,779	1,677	1,812	2,867	3,435	20%	104%
	Total females	3,977	3,981	4,089	4,880	6,225	6,642	7%	67%
	Total	11,888	12,399	12,535	15,557	20,515	22,118	8%	86%
Chlamydia (uncomplicated)	Total males	13,946	16,180	18,937	21,808	26,632	29,166	10%	109%
	of which homo-sexually acquired	275	353	454	621	962	1,343	40%	388%
	Total females	18,526	22,659	24,975	29,196	34,815	38,248	10%	106%
	Total	32,472	38,839	43,912	51,004	61,447	67,414	10%	108%
Herpes (first attack)	Total males	5,755	5,597	6,140	6,039	6,190	6,492	5%	13%
	of which homo-sexually acquired	384	334	301	338	384	397	3%	3%
	Total females	9,453	9,482	9,675	9,852	9,976	1,0558	6%	12%
	Total	15,208	15,079	15,815	15,891	16,166	17,050	6%	12%
Genital Warts (first attack)	Total males	27,133	30,239	30,782	31,908	32,067	32,636	2%	20%
	of which homo-sexually acquired	1,290	1,472	1,501	1,565	1,673	1,761	5%	37%
	Total females	27,583	28,472	28,899	29,322	28,711	29,568	3%	7%
	Total	54,696	58,711	59,681	61,230	60,778	62,204	2%	14%
All Diagnoses	Total males	202,465	216,916	228,963	242,087	260,899	276,342	6%	36%
	of which homo-sexually acquired	12,778	12,957	12,464	13,223	15,740	18,739	19%	47%
	Total females	249,438	264,976	277,945	291,703	309,173	329,719	7%	32%
	Total	451,903	481,892	506,908	533,790	570,072	606,061	6%	34%

Source: PHLS

47. The general trends are startling enough, but in certain areas rises have been even greater. Brighton GUM/HIV clinic, for example, recorded an increase of 318% in chlamydia in the last four years and an increase of over 700% in recorded cases of syphilis, this in an area with high HIV/AIDS; the Department of GUM at Mayday University Hospital, Thornton Heath witnessed a doubling in diagnoses of gonorrhoea and chlamydia between 1999 and 2001; the Wolverton clinic in Kingston has had to cope with a 400% increase in chlamydia in the past six years alongside an increase of 77% in HIV diagnoses.[29] The huge increase in syphilis is actually concentrated in a small number of 'hotspots' but these areas also have high rates of other STIs and HIV, placing heavy burdens on staff locally.

48. The presentation of these and similar data in the written memoranda is consistently that of 'an explosion' in sexually transmitted infection. However, a caveat was raised by Dr Kevin Fenton of the Communicable Disease Surveillance Centre at the PHLS. He pointed out that when the public first became aware of the HIV pandemic this triggered a substantial decline in the numbers and rates of both bacterial and viral STIs so that the figures for 1994—which tends to be around the base year used by those submitting evidence—represented "a nadir or bottoming out of STI incidence" with figures for the early 1990s seeing "some of the lowest rates and numbers for sexually transmitted infections".[30]

49. It is also worth bearing in mind that the UK is not alone in witnessing a recent dramatic rise in the rates of sexually transmitted diseases. Although good quality data are not available for all countries, gonorrhoea rates in France rose by 92% in 1998. In Sweden, gonorrhoea rates show a rise of 154% from 1995-2000. Notable rises have occurred in gonorrhoea amongst men having sex with men in studies in Greece, the Netherlands, Sweden and Switzerland. Syphilis outbreaks have recently been reported in the Netherlands, Ireland, France and Norway.[31]

50. The figures for sexual ill health compiled by the PHLS, which form the basis of much of our analysis, are not in fact comprehensive. They relate only to people attending departments of genito-urinary medicine. Screening surveys outside normal GUM clinic environments also show high levels of chlamydia in antenatal and gynaecology clinics, general practice, family planning and termination of pregnancy clinics, ranging from 4.5% to 16%. We were also told that STIs within the armed forces are separately recorded and not forwarded to the PHLS.[32] We recommend that the Army Medical Services forwards to the Public Health Laboratory Services its figures for STIs. We also recommend that the PHLS looks at how a more comprehensive surveillance system can be developed to cover all areas of sexual health and possible service providers. This will give a more complete picture of trends, prevalence and service utilisation.

51. Finally, and most importantly, the official figures for diagnoses will greatly understate the overall burden of diseases since many sexually transmitted infections are asymptomatic.

Trends in HIV/AIDS

52. According to the PHLS Communicable Disease Surveillance Centre:

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 lost.[

53. Cumulatively, by the end of December 2002, 45,625 people in the UK had been diagnosed HIV positive with sexual transmission as the probable route of infection. Of these people, 42,764 were diagnosed in England. Reported deaths in HIV-infected patients numbered 11,219 in England and 11,982 in the UK as a whole, as reported by the end of December 2002.

54. In England at the end of 2001, an estimated 12,900 adults were living with an undiagnosed HIV infection, 4,200 infected through sex between men, 8,300 infected heterosexually and 400 infected through intravenous drug use.[34]

55. Since the widespread introduction of combination therapy in 1996, mortality rates have decreased: in England in 1995 there were 1,285 reported deaths in HIV patients with sexual transmission as the probable route of infection, compared with 188 in 2002. However, the numbers of new diagnoses in England have been increasing: there were 2,147 new diagnoses in 1995 and 3,158 in 2001.[35] For 2002, reports of new diagnoses of HIV in the UK (all routes of transmission) number 4,200. After adjustment for delayed reports, PHLS estimates that there will have been 6,500 new diagnoses for 2002 - the highest ever number of new diagnoses in a single year.[36]

56. It is projected that the number of people living in the UK with diagnosed HIV will have increased by 47% between 2000 and 2005. Advances in diagnosis and treatment have meant that although HIV is often perceived to be a condition which affects younger people, nearly 11% of people with AIDS are now aged 50 or over.[37]

57. Cumulatively, the majority of HIV infections reported to the Communicable Diseases Surveillance Centre in the UK have occurred in gay men. This group remains at greatest risk of acquiring HIV infection within the UK and the PHLS estimates that there will have been about 1,800 new infection reports in 2002. Despite general levels of awareness of the risks for HIV acquisition about a quarter of HIV infected men who have sex with men have not had their infection diagnosed.

58. It is estimated that nearly half of all HIV infections acquired heterosexually are currently undiagnosed. Many people remain undiagnosed until testing is prompted by HIV-related symptoms late in the course of illness. With the rise in the numbers of those who acquired their infections heterosexually there has been an increase in the number of women diagnosed. The male:female ratio for all new infections diagnosed in 1985-86 was approximately 14:1 whereas in 2000-01 it was about 1.7:1.[38]

59. Most of those people diagnosed in the UK who have acquired infection heterosexually were not infected in this country. In answering our questions on heterosexual infection abroad, Dr Vicki King, a microbiologist in the Communicable Diseases branch of the Department of Health, confirmed this.[39] In the late 1980s and early 1990s the majority of the African infections were acquired in East Africa but more recently the impact of the HIV epidemic in South Eastern Africa has been greater.

60. Since the mid 1990s there has been an increase in the recorded number of births to HIV infected women from approximately 130 in 1994 to over 300 in 2000. Dr Ade Fakoya told us that between 1 in 150 and 1 in 250 pregnant women seen at Newham General Hospital are HIV positive.[40] This may reflect an improvement in antenatal diagnosis rates, following the success of a Department of Health initiative which directed that all pregnant women should be offered and recommended an HIV test along with other antenatal screening tests, with the aim of reducing the number of babies with HIV acquired from an infected mother during pregnancy, birth or through breastfeeding.[41] In Inner London, the Government target of diagnosing 80% of infections before birth has been met, and diagnosis rates in Outer London and in other regions are rising.[42] Treatment for HIV, caesarean section and avoidance of breastfeeding, can reduce the risk of transmission from mother to baby from 1 in 4 to less than 1 in 50.

61. In the Strategy the Department highlighted the need for research and for a strong evidence base with regard to health promotion, and planning services for HIV/AIDS and STIs. In addition to the funds allocated to the Medical Research Council for AIDS (and in turn to the National Sexual Attitudes and Lifestyles Survey), the Department of Health has directed the Health Development Agency to draw together the available evidence on trends in HIV/STI prevention. The Department will then use this evidence to inform prevention work at local level.[43]

62. We welcome the recognition of the importance of research and evidence with regard to the provision of HIV/STI prevention. We recommend that the Government continues to support the Health Development Agency in developing an evidence base in the long term and that the Department ask the Medical Research Council to commission further research in this area of sexual health.

63. In respect of the monitoring of trends in both STIs and HIV/AIDS we would like to pay tribute to the work of the Public Health Laboratory Service. Their monitoring ensures that the UK has the best data in the world, and this in turn gives great credibility to their research. It would be most regrettable if the absorption of the PHLS within the new Health Protection Agency were in any way adversely to affect its work. In particular, we would be alarmed if the close networks developed between the regional and local laboratories and clinicians and epidemiologists were to be impaired as a consequence of the move to NHS management of the laboratories.

Trends in teenage pregnancy

64. The UK currently has the highest rate of teenage pregnancy in Europe (almost five times higher than the Netherlands), and in the developed world is second only to the United States. The table shows the number of births to women aged below 20 per 1,000 women aged 15 to 19. Data are for 1998, the most recent year for which comparable information is available from all countries:

Country	Teenage birth rate (per 1000 women aged 15-19)
Korea	2.9
Japan	4.6
Switzerland	5.5
The Netherlands	6.2
Sweden	6.5
Italy	6.6
Spain	7.9
Denmark	9.1
Finland	9.2
France	9.3
Luxembourg	9.7
Belgium	9.9
Greece	11.9
Norway	12.4
Germany	13.1
Austria	14.0
Czech Republic	16.4
Australia	19.4
Ireland	19.7
Poland	19.7
Canada	20.2
Portugal	21.2
Iceland	24.7
Hungary	26.5
Slovak Republic	26.9
New Zealand	29.9
UK	30.8
USA	52.1

Source: A League Table of Teenage Births in Rich Nations, UNICEF, July 2001

65. In the year 2000, there were almost 98,000 conceptions to teenage girls, aged under 20, in England and Wales—61% of these led to a maternity and 39% to abortions. There were 8,000 conceptions among girls under the age of 16, less than a tenth of the total number of conceptions to teenagers. Of these conceptions, almost 400 were to girls under the age of 14, 160 of which led to maternities.

66. Historical data show that despite the overall trend towards later childbearing, after fluctuating in the 1970s the proportion of teenage girls becoming pregnant rose significantly in the 1980s. By 1990 there were 68 conceptions per 1,000 women aged 15 to 19 in England and Wales; in 1999 the rate was slightly lower at 63. The Government has chosen particularly to target pregnancies in girls under 18. In 1999 the rate of conceptions to teenagers under 18 was 45 conceptions per 1,000 women aged 15 to 17 years. This rate has remained within the range of 42 to 48 conceptions for the last ten years.

Year	Conceptions under 16		Conceptions under 18
	Number	Rate[44]	Number	Rate
1992	6,747	8.3	35,165	43.2
1993	6,802	8.0	33,495	42.1
1994	7,290	8.3	33,794	41.6
1995	7,484	8.5	35,371	41.6
1996	8,213	9.4	40,558	45.9
1997	7,707	8.9	40,463	45.8
1998	7,855	8.9	41,089	47.0
1999	7,408	8.2	39,247	45.3
2000	7,620	8.3	38,700	43.9
2001[45]	7,396	7.9	38,439	42.3

Source: Office for National Statistics

67. These statistics reveal that in England and Wales conceptions for under 16s fell by 4.5% between 2000-01; the corresponding figures for under 18s show conception rates fell by 3% in the same period. Since 1998, the year before the launch of the Government's teenage pregnancy strategy, conceptions for under 16s have fallen by 10%, and for under 18s by 9%, demonstrating the steady success of the teenage pregnancy strategy in its aim to halve teenage pregnancy rates by 2009.[46]

Trends in unintended pregnancy

68. It is difficult to measure rates of unintended pregnancy objectively, and there are no national statistics which do this, although the BPAS estimates that 50% of pregnancies are unplanned.[47] Abortion rates, which have been rising steadily since the early 1970s, give an indication of rates of unwanted pregnancy, although of course they may be influenced by cultural and legal factors as well.

69. Statistics show that abortion rates in England and Wales have almost quadrupled in the thirty years since abortion was legalised, increasing from 49,829 in 1969 to 173,701 in 1999. There has been a relatively steady increase during that time, but the rate appears to have stabilised in recent years at approximately 175,000 per annum, or 16.9/1000 women aged 15-44. Internationally, the abortion rate in England and Wales is well over double that in the Netherlands (6/1000 women aged 15 44), although not as high as Sweden (18.8/1000) or the US (25.9/1000). In the UK rates are highest amongst women in their twenties, making up 48.9% of all abortions, as opposed to 21% for under twenties and 30.3% for women of 30 and over. But unplanned pregnancy is not a problem confined to young, single women without families. According to the BPAS, approximately 20% of women having abortions are married, 46% already have one or more children, and 28% have had a previous abortion.[48]

27 Ev 346 (Medical Research Council) Back

28 www.phls.co.uk. Back

29 Ev 309; Ev 351; Ev 336 Back

30 Q 250 Back

31 Angus Nicholl and Francoise F Hamers, "Are trends in HIV, gonorrhoea and syphilis worsening in western Europe?", BMJ, vol. 324 (2002), pp 1324-27 Back

32 Ev 309 (Dr James Bingham, Civilian Consultant Adviser in GU Medicine to the Armed Forces) Back

33 Ev 59 Back

34 PHLS, HIV and AIDS in the UK in 2001. An Update: November 2002. Estimates of the total number of undiagnosed HIV infections in the population are based on figures derived from the Unlinked Anonymous Prevalence Monitoring Programme. The programme monitors undiagnosed HIV infection in homosexual and bisexual men and in heterosexual men and women attending GUM clinics, in injecting drug users attending specialist treatment and support agencies or GUM clinics, and also in pregnant women or women having a termination of pregnancy. Each year material left over from more than 600,000 diagnostic samples taken for other purposes is irreversibly unlinked from patient identifying information and then tested for HIV infection. Back

35 Ibid. Back

36 Ibid. The delay in reporting newly diagnosed cases is taken into account when assessing the extent of the epidemic. Within a given year, only two-thirds of the reports for that year become available. A year later 95% of the reports will be available. Back

37 Age Concern England, Opening Doors: working with older lesbians and gay men - a resource pack, 2001 Back

38 PHLS, HIV and AIDS: epidemiological data, http://www.phls.co.uk/topics_az Back