A sexual health and HIV strategy for England

The Department of Health last month produced a comprehensive framework for England for preventing the sexual causes of premature death and ill health.¹ The key objectives of the strategy are to ensure that all individuals have access to the knowledge and skills necessary to achieve positive sexual health and that services should be readily available to all who require them. The specific aims are to reduce the undiagnosed prevalence and transmission of sexually transmitted infections and HIV, to reduce unintended pregnancies, and to improve social and health care for people with HIV. The proposals will increase the role of primary care and strengthen links between specialist services and other local agencies. The strategy is comprehensive—but it looks overambitious for the resources allocated to it.

Main recommendations

• Prevention New public education campaign from 2002Targeted local prevention campaignsMore responsive national helplinesDevelopment of evidence base for sexual health promotion

• Standards and targets National standards for sexual health servicesDevelopment of care pathwaysHIV testing to be encouragedTargets to reduce incidence of HIV and gonorrhoea by 2007

• Services Widened role for primary careCloser working between primary and secondary careImproved access to genitourinary medicine servicesIncreased community role for sexual health advisersManaged clinical networks for HIV and other servicesTargeted chlamydia screening to begin 2002Improved access to NHS terminations of pregnancy

• Research and training Supporting education, training, and research agendaEvaluation of “one stop” youth clinics and specialist primary care  provision

Sexual ill health affects all age groups and sections of society but harms disproportionately vulnerable groups such as young people, minority ethnic groups, and those affected by poverty and social exclusion.²,³ Serious complications particularly affect women and gay men. There are unacceptable geographical inequities in the levels of sexual ill health and service provision.

The consequences of poor sexual health have important implications for both individuals and society. Unintended pregnancies may have a long lasting impact on quality of life for both mother and child, and their prevention saves the NHS over £2.5bn a year.¹ Sexually transmitted infections are also associated with serious maternal and neonatal morbidity, preventable infertility, anogenital cancers, and transmission of HIV. The average lifetime treatment cost for each HIV positive individual is estimated to be £135 000-181 000 (EJ Beck et al, International AIDS Conference, Durban 2000). Current trends suggest that the lifetime costs for the known HIV positive population could rise to £4.5bn by 2003.⁴ Preventing a single HIV transmission saves £500 000-£1m in individual health benefits and treatment costs.

Earlier and more vigorous prevention interventions contributed to the UK having a lower prevalence of HIV than many other European countries.⁵ AIDS self help awareness and campaigns among gay men had a major impact in reducing HIV transmission during the early 1980s, and later general population campaigns in 1986-7 reduced the transmission of other sexually transmitted infections among heterosexuals. But these trends have not been sustained. During the past decade the annual number of new attenders at genitourinary medicince clinics has escalated to over one million, and cases of gonorrhoea have doubled since 1995.⁶ Even greater increases are reported in chlamydial infections, the commonest cause of preventable infertility. Recently acute outbreaks of syphilis have emerged in Brighton, Manchester, and London, mainly affecting men who have sex with men.⁷ A parallel increase in HIV transmission is likely.

Specialist genitourinary medicine clinics, the major providers of control of sexually transmitted infections and HIV care, have not been resourced to accommodate this accelerating demand. Although the public health need is for urgent treatment of suspected sexually transmitted infections,⁸ a survey in 2000 showed that emergency access for acute cases was possible in only 51% of clinics.⁹,¹⁰ The situation had worsened by June 2001, when over 80% clinics reported longer times to appointment, extending to over a week in two thirds of clinics.

The national strategy seeks to improve access to services by increasing primary care involvement and widening the role of nurses. Local networks of providers will be based on three proposed service levels. All primary care teams will be required to provide a general service level. An intermediate level of community based primary care teams with specialist skills will be introduced, and both will be supported by specialist services. Chlamydia screening will be introduced for targeted risk groups in 2002, facilitated by use of molecular diagnostic tests that provide reliable results on non-invasive samples such as urine.

HIV testing will be promoted, especially in pregnant women and attenders at genitourinary medicine clinics. Challenging targets have been set to reduce the incidence of new transmissions of gonorrhoea and HIV by 2007. While prevention efforts will be principally targeted at those living with HIV and groups at high risk, there will also be new general information campaigns from 2002.

The strategy also proposes that specialist services for genitourinary medicine, contraception, and sexual health promotion should be commissioned together, while HIV services will be part of regional specialised commissioning. Improving access to care will depend on ensuring that all providers work to national standards within local networks with clear referral pathways. Local multiagency steering groups will be established to inform, implement, and monitor sexual health. The increasingly complex medical management of HIV will necessitate the development of managed clinical service networks in which there are partnerships between different groups of providers, the voluntary sector, and user groups.

Specialist providers will generally welcome the additional impetus that this ambitious strategy gives to sexual health, despite some concerns over commissioning. Nevertheless, increasing awareness and wider screening will detect more infections, which will inevitably exacerbate pressures on genitourinary medicine services; these will also need resources to support the education and research effort. Primary care already feels overburdened and may be less enthusiastic.

This strategy—which is out for consultation until December—deserves support from both healthcare providers and the government. The initial £47.5m investment for 2002-4 is manifestly insufficient. Successful implementation will require substantial investment for both infrastructure and staff. Nevertheless, these additional costs will be far smaller than those of managing the complications of sexually transmitted infections (including HIV) associated with deteriorating sexual health in England. Meeting the 25% target reduction in the incidence of HIV is potentially worth £450m in savings alone, and an investment of this size will be required to ensure that the other laudable strategy aims are also achieved.

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