Implementation of the National Sexual Health and HIV Strategy- Implications for Health advisers

1. Implementation of the National Sexual Health and HIV Strategy-Implications for Health advisers George Kinghorn Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

2. Overview • Current Sexual Health in UK • The national strategy for sexual health & HIV • Headlines • Implementation plan • Health advisers - a view of the future Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

3. National Survey of Sexual Attitudes and Lifestyles 11Changes between 1990-2000 • Earlier age first sexual intercourse • Increased number of lifetime partners • Decline in marriage, growth cohabitation • Increased risky behaviours • Partner change, unsafe sex • Greater changes in women and those living outside London Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

4. Determinants of HIV transmission efficiency • The presence of STIs increases individual susceptibility and HIV transmission. • M-F transmission • GUD x3; NUD x2 • BV flora increases risk x4 • F-M transmission • GUD x4; NUD x3 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

5. Mental Health Anogenital Cancers Unwanted pregnancies STIs/HIV Neonatal Infections Subfertility Linked Sexual Health Pathologies Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

6. STIs in 2003 • Worsening sexual health and increasing STI • Re-emergence of infectious syphilis • Antimicrobial resistance in gonorrhoea • Uncontrolled chlamydia epidemic in young • Long term sequelae of viral STIs • Acceleration in newly diagnosed HIV • HIV treatable but at enormous expense Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

7. Annual New Cases GUM,Sheffield 1972-2001 Thousands 25 + 20 + + 15 + + Male + + + + + + + + Female + + + + + + + + Total + + + 10 + + + + + + 5 + + 0 75 80 85 90 95 00 Year Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

8. Numbers of new episodes seen in GUM clinicsUnited Kingdom, 1990 to 2001 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

9. New diagnoses of selected STIs in GUM clinics, England, Wales & Northern Ireland: 2001 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

10. Diagnoses of uncomplicated genital chlamydial infection in GUM clinics by sex and age group, UK: 1995-2001* Males Females *Data are currently unavailable from Scotland for 2000 and 2001 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

11. Diagnoses of uncomplicated gonorrhoea in GUM clinics by sex and age group, UK: 1995-2001* Males Females *Data are currently unavailable from Scotland for 2000 and 2001 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

12. Projected prevalence of HIV in UK 2000-10 Number of individuals in care Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

13. Lifetime treatment costs of HIV in UK2000-2010 £ Billions Assumes 10 years of treatment 70% eligible Average £15,000 p.a. 3% inflation Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

14. Background to National Strategy Good sexual health is an important part of physical and mental health. Sexual health problems in England have grown in recent years. There are more new HIV infections and sexually transmitted infections are rising. England has the highest teenage birth rates in Western Europe Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

15. Aims of Strategy • Reduce transmission of HIV and STIs • Reduce prevalence of undiagnosed HIV and STIs • Improve health and social care for people living with HIV • Reduce the stigma associated with HIV and STIs • Reduce unintended pregnancy rates Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

16. Headline RecommendationsPrevention New public education campaign Targeted local prevention campaigns More responsive national helplines Development of evidence-base for sexual health promotion Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

17. Headline RecommendationsServices • Widened role for primary care • Closer working between primary and secondary care • Increased community role for sexual health advisers • Targeted chlamydia screening to begin 2002 • Improved access to GUM services • Managed clinical networks for HIV and other services Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

18. Local Sexual Health Networks • Three levels of service with increasing specialisation • Increased patient choice to improve access and uptake • Information about and advertisement of local services • Identification of local sexual health profile of communities • Agreed roles, responsibilities, and referral criteria • Education and training of staff Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

19. Features of Level One services Sexual history and risk assessment Contraceptive information and services STI testing for women Assessment and referral of men with STI symptoms HIV testing and counselling Cervical cytology screening and referral Pregnancy testing and referral Hepatitis B immunisation. Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

20. Features of Level Two Services Intrauterine device (IUD) insertion Contraceptive implant insertion Testing and treating sexually transmitted infections Invasive sexual transmitted infection testing for men (until non-invasive tests are available) Partner notification Management of psychosexual problems Vasectomy Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

21. Features of Level Three services Responsibility for sexual health services needs assessment Supporting provider quality and clinical governance requirements at all levels Providing specialist services, specialised infections management, including • specialised HIV treatment and care. • outreach for sexually transmitted infection prevention • co-ordination of partner notification, in a variety of settings Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

22. STI Foundation (STIF) Courses • MSSVD sponsored • Attitudes, knowledge and skills based • 2-day course regional and local • Multidisciplinary audience • Primary care doctors and nurses • GUM physicians • Sheffield course July 2003 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

23. Headline RecommendationsStandards and Targets • National standards for sexual health services • Development of care pathways • HIV testing to be encouraged • Targets to reduce incidence of HIV and gonorrhoea by 2007 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

24. HIV and STI testing targets in GUM HIV testing Offer to all at first STI screening Uptake target 70% Hepatitis B immunisation Offer to all HS/BS men at first attendance Uptake target 70% Reduction in newly acquired GC and HIV 25% by 2007 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

25. Headline Recommendations:Research and Training Supporting education, training and research agenda MRC Sexual Health and HIV Research Committee To develop evidence-base for implementing strategy STIs to have equal importance to HIV Evaluation of“one-stop” youth clinics and specialist primary care provision Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

26. Sexual Health and HIV Strategy for EnglandFinancial Support • £47.5 million 2000-3 • Half to introduce chlamydia screening • Public Education campaign • £5 million to pump-prime GUM services in 2002-3 Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

27. Current unmet need in GUM • Few non-appointment clinics remaining • Waiting times for routine appointments • Increased from 5-6 days in 2000, to 14 days in 2002 • Numbers waiting longer than 48 hrs calculated to be in excess of 30,000 • Inevitable adverse public health consequences • Increased complications • Increased STI and HIV transmission Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

28. Deterioration in GUM AccessMedian times (days) to first appointment Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

29. Additional GUM Funding required • Average cost of GUM clinic episode = £150 • Number of additional episodes • Current waiting lists 80,000 • New demand from education campaign 50,000 • Total additional capacity required 130,000 • Funding required p.a. c. £20 million Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

30. Pump-priming for GUM 2002/3 Support to expand service access Current unmet need Increased demand from education campaign Clinic allocations According to caseload in 2000/01 DH requirements Support for health advisers New consultant posts to be shared across districts Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

31. Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

32. Implementation PlanImmediate Priorities (1) • Publication of • Commissioning and Health Promotion toolkits • Training mapping and strategy report • African HIV frameworks for prevention and care services, health promotion • Disseminate evidence of effectiveness of HIV and STI prevention • Improve • quality of national helplines • Public information and advice on sexual health Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

33. Implementation PlanImmediate Priorities (2) • Roll out of chlamydia screening in 10 areas • Appoint to Independent Advisory Group • Publish standards for HIV care • Commission further standards for broader sexual health Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

34. Roll out of Chlamydia screening National screening campaign to start in 10 sites opportunistic women aged 20-24 Reinfection study in Portsmouth, Wirral to inform re-screening interval Development of real-time PCR near patient-testing (40 minutes to result) Grant from Capital Modernisation Fund Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

35. Implementation PlanImmediate Priorities (3) • Launch new sexual health information and awareness campaign • Roll out HIV prejudice and discrimination campaign • Monitor investment and progress on strategic implementation nationally Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

36. Best Practice in GUM • Open access services • Same day or next working day attendance following suspicion of an STI • Booked appointment within 7 working days • Diagnosis and management according to national / regional guidelines • Access to female doctor where possible • Provision of data according to local, national requirements Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

37. Health promotion and prevention for GUM / HIV services (1) • Routine offer of HIV testing at sexual health screen • Pre-test discussion with doctor / nurse / health adviser • Ethical HIV testing guidelines with informed consent • Offer of condoms and lubricant in absence of infection • Safer sex advice and risk reduction education at all stages of consultation • Post exposure prophylaxis • Partner notification of any potential risk of infection Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

38. Health promotion and prevention for GUM / HIV services (2) • Support for partners and other family members • Referral to • other agencies in voluntary and statutory sector for support / counselling/ support • Other NHS specialties such as drug services, psychology, health promotion, where relevant • Regular clinic information and clinical updates • Local gay press • Publications for African communities Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

39. Best Practice in HIV services (1) • Initial appointment with specialist within 2 weeks of initial diagnosis • Provision of monitoring and therapy according to national guidelines • Referral to specialist in-patient unit • Provision of emergency walk-in facilities • Encouragement of patient registration and good communication with GPs Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

40. DH Health Advisers Working Group • Set standards for Health adviser practice • Update Health advisers manual • Advise upon future training requirements • Recommendations about future numbers • No less than 1 health adviser for each consultant • Avoid isolated practitioners • Increase to meet outreach community activities Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

41. Changes to Health Adviser role • Partner notification in outreach community settings • Level 2 general practice, contraception clinics • Focus on high prevalence PCTs • Preferably linked to GUM-based team • Closer liaison with sexual health promotion • Performance assessed against national and local standards Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

42. Modernisation of Working Practises in GU Medicine • Extended role of nurses • nurse practitioners • follow-up examinations • HIV treatment adherence support • Reduced follow-ups • telephone results line • home-based treatments • Triage • by qualified nurses and health advisers • HIV testing • use of written pre-test information Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

43. Triage protocols • Triage should only be performed by trained clinical staff • Written protocols essential • Symptoms / conditions for urgent access • Advice if no suitable clinic session Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

44. Suggested triage protocol • Immediate • PEP for HIV infection • Underage attenders • Urgent (within 24 hrs) • Acutely painful conditions • Acute psychological distress related to STI • Within 48 hrs • Known contacts of STI • Routine • All other conditions • Anyone perceiving themselves at risk of STI Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

45. Parliamentary Health Committee Report on Sexual Health • To be published within next month • Likely to • Comment upon crisis in GUM • Emphasize need to growth in consultants and supporting staff • Criticise • PCT Funding mechanisms • Chlamydia screening proposals Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

46. Summary • Sexual health is firmly on the agenda and is currently being reviewed by Health Select Committee • The government views sexual health as “a priority” • Primary care ill-prepared and currently unwilling to provide additional sexual health services • GUM service overload but new opportunities to expand workforce, modernise facilities and practise • Extension of health adviser role and numbers crucial • Major challenge to secure increased recurrent funding Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust