Sexual health covers the provision of advice and services around contraception, relationships, sexually transmitted infections (STIs) (including HIV) and abortion (Department of Health 2013a).
There is a clear relationship between sexual ill health, poverty and social exclusion: the highest burden of sexually related ill-health is borne by groups who often experience other inequalities in health, including gay men, teenagers, young adults, black and minority ethnic groups, and more deprived communities (Department of Health, 2013a).
Sexually transmitted infections (STIs), including HIV, remain one of the most important causes of illness due to infectious disease among young people (aged between 16 and 24 years old). If STIs, including HIV, are not diagnosed and treated early, there is a greater risk of onward transmission to uninfected partners, and a greater risk that complications might occur. Many STIs have long-term effects on health, for example chlamydia can lead to infertility and some infections are associated with cervical cancer (Department of Health 2013a).
The impact of STIs remains greatest in young heterosexuals under the age of 25 years and in men who have sex with men (MSM). The most commonly diagnosed STI in 2013 was chlamydia. The number of gonorrhoea diagnoses increased by 15% between 2012 and 2013. Reducing gonorrhoea transmission, and ensuring treatment resistant strains of gonorrhoea do not persist and spread remains a public health priority (PHE, 2014b). Large increases in STI diagnoses were seen in MSM, including a 26% increase in gonorrhoea diagnoses. Although partly due to increased testing in this population, ongoing high levels of unsafe sexual behaviour probably contributed to this rise (PHE, 2014b).
Current figures show that some sexually transmitted infection rates are increasing in Nottingham City in line with the trend nationally. In 2012, Nottingham was ranked 22 (out of 326 local authorities, number one has the highest rates) in England for rates of acute STIs.
In the UK the overall prevalence of HIV is 1.5 per 1,000 population (1.0 in women and 2.1 in men) and the proportion of people unaware of their HIV infection is approximately 22%. Nottingham City has a ‘high’ HIV prevalence (2.78 per 1,000 population), higher than both the regional (East Midlands) and national (England) averages. Whilst anyone can contract HIV, certain population groups have higher exposure risk including men who have sex with men (MSM), certain ethnic groups including Black Africans, and migrants from high HIV prevalence e.g. counties in Sub-Saharan Africa (Public Health England, 2013). Nearly one in two heterosexuals born abroad acquired their infection in the UK; highlighting the need for further prevention. In 2013, 48% of people diagnosed with HIV were diagnosed at a late stage of infection. Evidence shows that early treatment helps prevent onward transmission, and for People living with HIV can expect a near normal life expectancy and better clinical outcomes if they are diagnosed early
Whilst there has been a decline in the rate of teenage pregnancies in Nottingham City since 2007, the City still ranks as one of the highest teenage pregnancy rates in England. In 2012, the under 18 teenage conception rate for Nottingham City per 1,000 women was 37.7, compared to 27.7 in England.
Provision of sexual health services is complex and there are a wide range of providers, including general practice, community services, acute hospitals, pharmacies and the voluntary, charitable and independent sector.
Domestic Violence, Prostitution and Teenage Pregnancy are considered elsewhere.
Unmet needs and gaps
Key issues concerning unmet needs and gaps are summarised in this section, please see section 8 for full detail.
- HIV testing and diagnosis:
- Efforts need to focus on addressing the City’s high HIV prevalence (2.78 per 1,000 population), and late diagnosis (65.8% of new cases)
- HIV testing needs to be increased within general practice and sexual health services
- There is currently a limited amount of provision around HIV awareness, prevention and campaigns, including work to reduce stigma associated with HIV in those most at risk
- More training and education is required to reduce stigma, promote the prevention of HIV and encourage earlier presentation
- Chlamydia screening:
- In order to meet the Public health Outcomes Framework indicator, a good level of coverage for Chlamydia testing is required, ensuring that services are accessible and provided across a range of venues
- Primary care services:
- There are potential gaps in provision of STI screening and LARC services in some localities of Nottingham City
- There is potential to increase the uptake of STI screening, particularly within general practice, especially in areas of highest need
- There is a low rate of GP prescribed LARC, compared to the England average (2012/13)
- Reporting requires improvement in relation to all primary care provision of STI screening (and for Chlamydia treatment) and LARC provision
- Secondary care services:
- Whilst the current GUM and CASH services cover most of the areas of highest need in the city, there are some potential gaps in provision in the high need areas of Aspley and Basford.
- The sexual health services delivered by NUH are not yet integrated in line with the model proposed during 2012. The services should continue to be integrated in line with best practice to ensure that the model agreed is delivered effectively and according to need.
- The delivery of clinic in a box by School Nurses and Health Visitors is currently inconsistent. In addition, restrictions on delivery in schools and workload are an issue and will need exploring.
Sexual health promotion and sex and relationship education (SRE):
- Sex and Relationship Education (SRE) provision across schools is inconsistent.
- Current websites which provide sexual health information on clinic locations are uncoordinated and out of date. There is no social networking in place for promotion of sexual health clinics and young people’s outreach clinics, this requires development.
- It is important to continue work on increasing awareness around the signs and symptoms of child sexual exploitation.
- Vulnerable groups:
- There is potential to increase engagement with refugees and asylum seekers in terms of early identification of HIV
- Appropriate screening methods should be considered for testing in line with the needs of vulnerable groups
- Local termination of pregnancy services:
- The local authority will need to work closely with the CCG around future commissioning arrangements to ensure services are fully linked into sexual health services in the area
- Local Sexual Health strategy
- There is currently no sexual health strategy for the City
Nottingham City is developing an HIV Strategy and Action Plan.
Recommendations for consideration by commissioners
HIV testing and diagnosis:
- Increase access to HIV testing by targeting vulnerable populations to reduce late diagnosis. Whilst recognising that whilst anybody can become infected with HIV, local trends suggest that some groups have a higher proportion living with HIV such as Black African men and women (many of whom are migrants) and gay and bisexual men.
- Ensure commissioning arrangements support effective HIV prevention and screening services.
- Local Authority Commissioners will need to work with NHS England local Area Teams to ensure effective and coordinated HIV treatment and care and ensure clear pathways exists to facilitate effective HIV treatment and care.
- Ensure systems are in place to deliver effective monitoring of HIV resources and available data within Nottingham City.
- Increase the role of Primary Care including general practice in HIV Testing, therefore increasing both the skills training and the role of GPs and nurses particularly in high prevalence areas.
- Increase Point of Care Testing (POCT); also known as rapid antibody tests, defined as medical testing at or near the site of patient care and allows screening to be taken outside the hospital environment.
- Explore and quantify the health needs for HIV counselling services and clarify the level of support required.
- Ensure data is available to inform service development and commissioning
- Continue to reinforce good practice in line with Chlamydia screening, ensuring that testing remains accessible to young people through a range of commissioned services
- Ensure outreach provision is targeted at young people who have limited access to sexual health services (homeless young people, looked after young people and those leaving care, youth offenders and BME young people)
- Ensure internet testing services are not duplicated. Internet testing kit return rates should be high (approximately 75%) and positivity percentage should match the city average
- Consider expanding internet testing services, which prove to be effective in Nottingham City
- Consider the offer of home testing kits to be sent 3 months following a positive Chlamydia diagnosis, this will aim to reduce reinfection rates
- Ensure the message of annual screening and additional testing on each change of partner is promoted to young people
- Continue to promote adherence to treatment and partner notification professional guidelines
Primary care sexual health services:
- Review overall provision of STI screening and treatment, and LARC provision as part of the re-procurement of LCPHS.
- Commission STI screening and LARC provision in localities where there are some potential gaps in provision
- Ensure a review of primary care provision of existing sexual health ‘Locally Commissioned Public Health Services’ (LCPHS)
- Develop commissioning plans for the reprocurement of sexual health ‘Locally Commissioned Public Health Services’ post April 2015
- Identify geographical areas of need, and work with providers to increase activity levels of STI (sexually transmitted infections) testing including HIV testing, and increase take-up of LARCs (long-acting reversible contraception)
- Continue to work with community pharmacies to provide treatment for Chlamydia
Secondary care sexual health services:
- Ensure the delivery of an integrated sexual health service is implemented and that services are in line with best practice and need
- Ensure prevention efforts are maintained, with a focus on groups at highest risk such as young people, persons of black ethnicity and MSM. This is vital to control STI transmission
- Ensure all sexual health clinical venues are You’re Welcome accredited by March 2015
- Shadow the Integrated Sexual Health Tariff to inform the development a cost effective model for commissioning and providing sexual health services in Nottingham City
- Ensure sexual health clinics are in line with areas of high need by mapping access to sexual health clinics and primary care services, including the uptake of LARC
- Following the integration of sexual health services, undertake a health equity audit of all sexual health services to ensure they are accessible to the whole population
- Develop the link between Public Health Nurses for Children and Young People and community sexual health services through the new school health model
- Develop the provision of clinic in a box through Public Health Nurses, linking with the Sexual Health Promotion facilitator in the new school health service model
- Ensure that all mainstream youth services and the Youth Offending Team offer C-Card and proactively promote information about the full range of contraception and NUH Sexual Health services
Sexual health promotion and sex and relationships education (SRE):
- Review the provision of sex and relationships education in schools to inform and develop consistent provision
- Fully evaluate the Awaredressers project
- Carry out engagement activity to establish how, when and where people would like to receive information about local services
- Improve access to up-to-date sexual health service provision information through the development of a co-ordinated sexual health website for Nottingham City and Nottinghamshire County
- Continue the provision of specialist services for prostitutes/ sex workers to meet relevant needs. Ensure services provide screening and treatment, contraception, vaccinations, health promotion and access to other support all in one site
- Review the sexual health service access pathway for young offenders and develop accordingly
- Continue to ensure sexual health services are accessible and meet the needs of MSM and LGBT communities, including appropriate testing
Termination of Pregnancy Pathway Development:
NHS Nottingham City CCG in conjunction with the Local Authority and TOP providers has committed to supporting a review of the TOP pathway in order to establish that accessibility, quality and value for money is being achieved. Initial scoping meetings and planning has commenced and the following actions have been identified as required in 2013/14:
- Review of the pathway and commissioned services working closely with commissioners, clinicians, service users, service providers, public health and the local authority to include:
- Needs assessment and capacity planning/gap analysis
- Service/pathway design, redesign and transformation with a strengthened governance and supervision structure
- Best practice review and service specification development including the development of a TOP provider network
- To analyse and use information (health needs assessment, activity levels, benchmarking data etc.) to develop service improvement / development plans taking into consideration funding, workforce implications and information technology requirements.
- To develop a robust performance management framework to monitor progress against implementation of the pathway.
- The local authority will need to work with the CCG and NHS England to ensure that the care and treatment people receive is of a high quality and is not fragmented, this should include:
- Offering comprehensive and seamless HIV testing and treatment services
- Ensuring future commissioning arrangements for termination of pregnancy services continue to embed the improvement of sexual health and reduce the risk of repeat unwanted pregnancy
Agree pathways and commissioning arrangements for services associated with and taking place in sexual health services (e.g. menorrhagia and cervical screening) with appropriate commissioners, taking a whole system approach and using the ‘making it work’ commissioning guide for sexual health, reproductive health and HIV.