APPENDIX 56
Memorandum by the London Communicable
Disease Control Group (SH 91)
1.INTRODUCTION
1.1The evidence has been prepared by Dr Helen Maguire,
Regional Epidemiologist for London, and Dr Donal O'Sullivan, Consultant
in Communicable Disease Control for Lambeth, Southwark and Lewisham,
both of whom are members of the London Communicable Disease Control
Group.
2.RECOMMENDATIONS
2.1We recommend the following:
—The Department of Health ensure appropriate
funding of the National Sexual Health Strategy, particularly in
London.
—Sexual health targets be set as a priority
for the NHS in London.
—Timely implementation of population based
screening for genital chlamydia infection
—Clearer financial and strategic links
between all those responsible for commissioning sexual health
services in London. At the very least, the London HIV Consortium
and the pan-London arrangements for HIV prevention in gay men
and in African Communities should be maintained.
—Clear financial risk management procedures
to support those commissioning and providing sexual health services
in London to tackle this major public health issue. This is particularly
important for high prevalence areas of London.
—Encouragement of PCTs to support providers
of services in primary care who wish to provide second level sexual
health services. PCTs should also be encouraged to support and
collaborate with the voluntary sector and those working on community
development and user involvement.
3.OVERVIEW
3.1London is currently experiencing a large and ever-increasing
burden of sexual ill health and this is a major public health
issue for the city. Numbers of new cases of HIV infection rise
relentlessly in the UK, with more than two thirds of cases occurring
in London.
3.2At the same time, new diagnoses of gonorrhoea
and genital chlamydia infection in London rise inexorably, with
an almost doubling of new diagnoses of chlamydia between 1995
and 2000. Young women and Black Caribbeans living in the Capital
are disproportionately affected by both gonorrhoea and chlamydia.
3.3These high levels of bacterial sexually transmitted
infections, co-factors for HIV transmission, in groups which are
as yet relatively unaffected by the HIV epidemic are a matter
of grave concern, as they may facilitate the emergence of a major
new epidemic of HIV infection in these groups. This may affect
certain parts of the city to a greater extent than elsewhere.
HIV and STIs are undoubtedly the biggest infectious disease risk
in London.
3.4Effective screening is available for chlamydia,
a major cause of infertility and ectopic pregnancy, and an important
co-factor for the transmission of HIV. In a context of increasing
high-risk behaviours and rising levels of sexually transmitted
infection, such innovative interventions should be implemented
without delay.
3.5Pregnancy in the under 18s and under 20s in London
occurs at a rate almost 25% higher overall and in some parts of
London three times those for England and Wales.
3.6Successes are possible. Initiatives such as that
aimed at increasing the uptake of antenatal screening for HIV
have achieved much. The development of the National Sexual Health
Strategy has acted as an impetus to support innovative, evidence
based and participatory interventions to prevent and treat infection
in populations most at risk. The National Teenage Pregnancy Strategy
is providing a focus for improvements to services for young people,
with at least some success in reducing teenage pregnancy rates
in certain parts of the capital and engaging young people in a
variety of new ways. Sexual health services are, however, under
enormous pressure and it is becoming increasingly difficult in
London to respond to this major public health problem which affects
some of the most excluded groups in society. This pressure is
reflected in long and increasing waits in GUM clinics; these,
at the very least, demand attention.
3.7For those commissioning or providing sexual health
services the financial risk is very high. This is particularly
so in relation to HIV and genito-urinary medicine (GU) services.
These services are open access and national strategy is to promote
HIV testing so people can avail of the advantages of highly active
antiretroviral therapy (HAART). At the same time HAART ensures
that people with HIV live longer. As a consequence, the number
of people known to be living with HIV in London, the vast majority
of whom receive NHS care in the Capital, is predicted to rise
from around 15,000 in 2001 to almost 22,500 in 2005.
3.8Commissioning of HIV treatment and care services
in London is dealt with as a specialist service, with the focus
of commissioning at regional and sectoral levels. At the same
time, commissioning of HIV prevention, GU and other sexual health
services is now largely led by primary care trusts. Borough-based
groups deal with teenage pregnancy, which often disproportionately
affects the same population sub-groups as those most at risk of
sexually transmitted infections. There is a need for a strategic
overview of sexual health at sectoral level, and across the city
as a whole, taking into account the need of all marginalised groups,
including prisoners.
3.9There are other important challenges for those
tackling this public health issues for London: funding of the
National Sexual Health Strategy is a concern; the Strategy is
not a National Service Framework, and none of the 22 National
and London NHS targets relate to sexual health. Although the London
HIV Strategy sets targets for London, and Borough based targets
have also been set in relation to teenage pregnancy, these do
not carry the same influence as National NHS targets. Any development
monies that will be available will be spent on National NHS targets;
it is very unlikely that any new monies will be available for
investment in sexual health in the Capital.
4.HIV AND AIDS
4.1London figures show a relentless rise in new diagnoses
(figure one) with new treatments allowing more infected people
to live longer, feel healthier, and die later. Co-infection with
other diseases remains a concern (up to half of recent syphilis
cases were found to be HIV positive, and 10-25% of cases of TB
in inner London are also infected with HIV).
4.2Young people are putting themselves at risk more
often now than in the 80s and early 90s, perhaps thinking new
treatments mean HIV is less of a risk. Nothing could be further
than the truth.
4.3Gay men (a relatively small population, approximately
10% of males in London) are most at risk but numbers of new cases
of HIV in heterosexuals now outstrip those in gay men.
4.4Over 4,000 new diagnoses of HIV were made in the
UK in 2001 (more than two thirds of these were in London) more
than half in heterosexuals mainly from sub-Saharan Africa but
there is an increasing epidemic in South Asia as well, not yet
reflected in London (figures two and three). Already over 1,400
new infections have been diagnosed in the first quarter of 2002
(over half in heterosexuals and a third in gay men).
4.5The Public Health Laboratory Service (PHLS) estimates
that the number of people living with an HIV diagnosis nationally
may rise from 23,000 in 2000 to almost 34,000 in 2005. It is likely
that more than 66% (approximately 22,500) will live in London.
4.6There are estimated to be about half these numbers
again with HIV but not yet diagnosed most of whom are heterosexual
(figure 4).
4.7The Unlinked Anonymous (UA) 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.
4.8Among the UK IDU population it is estimated that
around 50% (30 to 70,000) are resident in London. In addition,
data from the UA programme indicates a much higher prevalence
of HIV (3.6% compared to 0.21%), Hepatitis B (26% compared to
20%) and Hepatitis C (48% compared to 30%) in London resident
IDUs compared to the rest of England and Wales.
4.9HIV in pregnancy
—National and regional targets (for December
2002) to diagnose more than 80% HIV infections in pregnancy already
have been exceeded through great efforts at many levels in inner
London.
—Data for the first half of 2001 for inner
London showed that of 111 maternal infections (detected through
the dried blood spot survey) 83% were diagnosed prior to or during
pregnancy thereby allowing choices to be made about treatment
and preventing onward transmission to the baby. In outer London
and elsewhere in England rates of diagnosis prior to delivery
were 61 and 33% respectively. This shows that London can respond
to major issues.
—Variation in the burden of infection in
heterosexuals across the city is marked, this is shown by the
HIV infections in pregnant women by health authority (data from
the dried blood spot survey) (figure 5).
—Monitoring data in London shows that in
2000, 75% pregnant women were tested for HIV with one in 191 women
found to be positive.
—London can be proud of the response to
the problem but the challenge now is to diagnose the remaining
infected women.
—Future GUM and HIV service provision must
take into account the needs of HIV infected children and families.
5.TEENAGE PREGNANCY
5.1London conception rates in under 18 year olds
(51.8/1000) in 2000 are substantially higher than the national
average (43.8/1000).
5.2The national teenage pregnancy strategy target
is to reduce the rate by 15% by 2004 and by 50% by 2010. London
is making some progress in parts of the city, but there have also
been big increases in the rate in certain areas (figure six) which
now have the highest rates in the country.
5.3London is the only region to have shown an overall
increase from 1999 to 2000.
5.4The first year of local implementation of teenage
pregnancy strategies was 2001-02 and mainstreaming improvements
to sexual health services for young people is a priority.
6.CHLAMYDIA
6.1Infections diagnosed continue to rise year on
year almost doubling from just over 4,000 to nearly 8,000 in females
from 1995 to 2000 and similar rises in men. Young females (aged
16-19) experienced the greatest rises (figure seven).
6.2Socially excluded groups are most affected, including
black ethnic groups in inner-London.
6.3The challenge is to establish screening programmes
linking primary care services and GU services through protocols
and greater understanding.
7.GONORRHOEA
7.1Gonorrhoea is a marker for sexual ill health and
also a co-factor for HIV infection. London accounts for 63% of
gonorrhoea diagnoses, but only 20% of the population. Between
1995 and 2000 diagnoses rose dramatically in males and females,
about a quarter of male cases were homosexual, and rates were
over 1 per cent in young black males and females in inner-London.
7.2The challenge is to tackle this important inequity
and reduce transmission in at risk populations.
7.3A quarter of black Caribbeans diagnosed with an
acute STI will be diagnosed with another acute STI within a year.
7.4Although sexual behaviour is a key determinant
of STI transmission, other issues such as poor access to GUM clinic
services affect probability of disease.
8.SYPHILIS
8.1There has been a resurgence of syphilis in London
with 393 cases reported between April 2001 and 2002 (349 males),
74% of cases were homosexual men, mainly aged between 25 and 45,
white and UK born. More than half were HIV positive and the majority
of cases had acquired infection in London.
8.2Early and rapid action to monitor and control
the emerging epidemic was taken. Enhanced surveillance was instituted
and a campaign to promote safe sex was initiated in gay venues
across the city through joint efforts of voluntary organisations,
and health professionals. This rise in syphilis in London is a
cause for concern. Similar rises have been seen in other European
cities, especially in gay men.
8.3Co-infection with HIV is a real issue and regular
screening of gay men and pregnant women is recommended and needs
to be promoted and monitored.
TABLE 1: CONCEPTIONS IN 2000
| UNDER-18s |
| UNDER-20s | |
| Number
(thou)
| Rate/1000F
15-17yrs | Number
(thou)
| Rate/1000F
15-19yrs |
| England and Wales | 41.3 |
43.8 | 97.6 | 62.2
|
| London | 6.0 | 51.8
| 15.2 | 77.1 |
| London Health Authorities: |
| | | |
| Barking and Havering | 0.4 |
53.3 | 0.8 | 74.4
|
| Barnet, Enfield and Haringey | 0.6
| 48.4 | 1.6 | 72.4
|
| Bexley, Bromley and Greenwich | 0.5
| 41.8 | 1.2 | 60.0
|
| Brent and Harrow | 0.3 |
42.5 | 0.9 | 67.9
|
| Camden and Islington | 0.3 |
56.7 | 0.8 | 81.9
|
| Croydon | 0.3 | 58.4
| 0.8 | 78.6 |
| Ealing, Hammersmith and Hounslow | 0.5
| 48.0 | 1.3 | 76.2
|
| East London and The City | 0.8
| 67.0 | 2.2 | 107.8
|
| Hillingdon | 0.2 | 43.8
| 0.5 | 66.8 |
| Kensington & Chelsea and Westminster |
0.2 | 40.8 | 0.5
| 56.0 |
| Kingston and Richmond | 0.1
| 25.2 | 0.4 | 41.3
|
| Lambeth, Southwark and Lewisham | 0.9
| 79.7 | 2.3 | 114.1
|
| Merton, Sutton and Wandsworth | 0.4
| 51.0 | 1.0 | 70.3
|
| Redbridge and Waltham Forest | 0.3
| 42.0 | 0.9 | 66.9
|
| 
