Transcript A National Sexual Health Strategy

Implementation of the
National Sexual Health and HIV StrategyImplications for Health advisers
George Kinghorn
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
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
National Survey of
Sexual Attitudes and Lifestyles 11
Changes 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
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
Linked Sexual Health Pathologies
Mental
Health
Unwanted
pregnancies
Anogenital
Cancers
STIs/HIV
Neonatal
Infections
Subfertility
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
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
Annual New Cases
GUM,Sheffield 1972-2001
25
Thousands
+
20
+
15
10
5
+
++
+
+
+
+++
+
+++++
++
++
++
++
+
+
+
++
+
0
75
80
85
90
95
Year
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
00
Male
Female
+Total
Numbers of new episodes seen in GUM clinics
United Kingdom, 1990 to 2001
1400000
1200000
1000000
Annual 800000
Number 600000
400000
200000
0
1990
1992
1994
1996
Year
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
1998
2000
New diagnoses of selected STIs in GUM clinics,
England, Wales & Northern Ireland: 2001
Syphilis
Chlamydia
Gonorrhoea
Genital warts
Genital herpes
2001
715
71,225
22,697
67,672
17,850
% change
2000-2001 1996-2001
119%
486%
10%
108%
7%
87%
2%
14%
5%
12%
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
Rate per 100,000 population
Diagnoses of uncomplicated genital chlamydial infection in
GUM clinics by sex and age group, UK: 1995-2001*
1100
1000
900
800
700
600
500
400
300
200
100
0
Males
<16
16-19
20-24
25-34
35-44
45+
1100
Females
1000
900
800
700
600
500
400
300
200
100
0
1995 1996 1997 1998 1999 2000 2001
1995 1996 1997 1998 1999 2000 2001
*Data are currently unavailable from Scotland for 2000 and 2001
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
Diagnoses of uncomplicated gonorrhoea in GUM clinics
by sex and age group, UK: 1995-2001*
250
Rate per 100,000 population
Males
200
150
<16
16-19
20-24
25-34
35-44
45+
250
Females
200
150
100
100
50
50
0
0
1995 1996 1997 1998 1999 2000 2001
1995 1996 1997 1998 1999 2000 2001
*Data are currently unavailable from Scotland for 2000 and 2001
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
Projected prevalence of HIV in UK 2000-10
Number of individuals in10%
care growth
15% growth
90000
80000
70000
60000
50000
HIV
prevalence 40000
30000
20000
10000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
Lifetime treatment costs of HIV in UK
2000-2010
£ Billions
Year
2010
2008
Assumes 10 years of
treatment
2006
70% eligible
Average £15,000 p.a.
2004
3% inflation
2002
2000
0
2
4
6
10% growth
8
10
12
15% growth
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
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
Headline Recommendations
Prevention
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
Headline Recommendations
Services
• 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
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
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
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
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,
management, including
specialised
infections
 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
STI Foundation (STIF) Courses
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•
•
•
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
Headline Recommendations
Standards 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
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
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
Sexual Health and HIV Strategy for England
Financial 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
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
Deterioration in GUM Access
Median times (days) to first appointment
2000
2001
2002
Male
5
7
12
Female
6
8
14
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
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
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
Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust
Implementation Plan
Immediate 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
Implementation Plan
Immediate Priorities (2)
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•
•
•
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
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
Implementation Plan
Immediate 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
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
Health promotion and prevention for
GUM / HIV services (1)
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•
•
•
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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
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
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
DH Health Advisers Working
Group
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•
•
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
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
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
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
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
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
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