Sexual Health JSNA | Boltons Health Matters
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Sexual Health JSNA


This is the JSNA chapter on sexual health. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 


Sexual health affects our physical and psychological wellbeing and is central to some of our most important and lasting relationships during our lives.  The World Health Organisation (WHO) define sexual health as “a state of physical, emotional, mental, and social wellbeing related to sexuality; not merely the absence of disease, dysfunction, or infirmity.  Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.  For sexual health to be attained and maintained, the sexual rights of all persons must be protected, respected, and fulfilled” .  As such, sexual health is a term covering all issues around intercourse, contraception, and childbearing.
At the heart of good sexual health are equitable relationships and sexual fulfilment backed with access to information and services to help avoid unwanted pregnancy or disease.  However, many people with sexually transmitted infections (STIs) are unaware that they have a disease and may remain undiagnosed for many years, with much greater consequences for their overall health and wellbeing.  Many sexual infections can have long-term effects on health; for instance, some strains of the HPV virus that cause genital warts are also linked to cervical cancer.  Also, untreated chlamydia can result in pelvic inflammatory disease which, in turn, may lead to ectopic pregnancy and infertility.
There have been increases in STIs in the UK over the last couple of decades with subtle changes in the characteristics of those at risk.  For instance, there has been an unexpected rate of increase in the numbers of heterosexuals diagnosed with HIV which has been acquired from overseas.  Despite significant strides in the treatment and care of HIV/AIDS and advancement in drugs, people are still being diagnosed too late to avoid long-term illness or premature death.
It is recognised that investing in sexual health services delivers cost savings by reducing the prevalence of STIs as well as preventing unintended conceptions.  Nationally, contraception services save the NHS at least £2.5 billion per annum.  It is estimated that for every £1 invested in contraception services, the NHS saves £11. 

Implications for Commissioning

Bolton should be working towards achieving a chlamydia diagnosis rate of at least 2,400 per 100,000 (Public Health Outcomes Framework indicator).  Bolton is predicted to achieve 2,460 by the end of the year which slightly exceeds the target.
There needs to be a continuation of the focus on embedding chlamydia screening in primary care and sexual health services, emphasising the need for repeat screening annually and on change of sexual partner, and ensuring treatment and partner notification standards are met.  Targeting those young people at the greatest risk will also support the services to continue to meet the target on an ongoing basis.
Prevention efforts, such as greater general STI screening coverage and easier access to sexual health services, should be sustained and continue to focus on groups at highest risk.  Many STIs do not have symptoms and raising awareness of the risks of infection amongst the targeted groups may be the only way to ensure people understand the risks and how these can be reduced.  Encouraging more routine testing for asymptomatic people is also valuable.
In Bolton the new cases of HIV infection are largely from two population groups, men who have sex with men (MSM) and heterosexual residents.  In the North West new cases represented 11% of all cases of HIV.  The two dominant modes of infection are the same as for Bolton, MSM and heterosexual sex.  The largest proportion of HIV positive individuals presenting for care were categorized as asymptomatic at 62%.  Just over a third (34%) of all HIV cases were exposed to HIV abroad with the majority (70%) contracted in sub Saharan Africa.  Therefore, in order to reach these highest risk groups prevention measures and awareness campaigns need to be developed targeting these populations.  This should help address the Public Health Outcomes Framework measure of reducing late diagnosis of HIV.  For example MSM having unprotected sex with casual or new partners should have an HIV-STI screen at least annually, and every three months if changing partners regularly.  New arrivals to the UK should be tested and then provided with supporting advice and information on safer sex.
HIV testing therefore needs to be made more accessible and include increased availability in primary care.  There may need to be training for staff in primary care to support the increased testing.
During 2011 in the North West, of the 2,405 HIV positive patients accessing community and voluntary sector services many did not always attend a statutory service.  For example, 27% had not attended a statutory service in the last twelve months and 19% had not attended one ever.  Therefore some community sector providers are the sole providers of care for a significant number of patients.  This has implications for service commissioning.
Health promotion and education are important interventions for the prevention of STIs and HIV through improving public awareness and encouraging safer sexual behaviour.  Consistent condom use, reducing the number of sexual partners and the avoidance of overlapping sexual relationships all reduce the risk of being infected with an STI.

Who's at Risk and Why?

Sexually active individuals are at risk of sexually transmitted infections (STIs), but sexual ill health is not equally distributed amongst the population with certain groups being at greater risk.  These include:
• Young people;
• Women;
• Men who have sex with men;
• People from African communities;
• People living with HIV;
• Victims of sexual and domestic violence;
• Other marginalised or vulnerable groups including prisoners.
The Sexual Health Strategy  outlined the clear link between poor sexual health and deprivation and social exclusion.  Groups (outside of those above) that are commonly identified as being at increased risk of sexual ill health include: young people not in education, training, or employment (NEETs), asylum seekers and refugees, sex workers, drug users who inject, people with learning difficulties, and homeless people.
Of all these at risk groups, young people (aged 16-24) are at the greatest risk; though making up approximately just 12% of the population young people account for 65% of all chlamydia, 50% of all genital warts, and 50% of all gonorrhoea infections diagnosed in genitourinary medicine (GUM) clinics.

The Level of Need in Population

Bolton is currently ranked 87 (out of 326 local authorities, where first in the rank has highest rates) in England for rates of STIs.  The management of sexual health in healthcare involves the identification and treatment of STIs and prescribing/advice around contraception.  Although other diseases are spread through sexual contact (hepatitis B, herpes simplex, thrush, scabies, pubic lice, and a range of bacterial infections) the group of infections conventionally considered as the STIs are: chlamydia, gonorrhoea, genital herpes, HIV/AIDS, genital warts, and syphilis. 

Chlamydia is the most commonly diagnosed STI in the UK.  Prevalence is highest in the 16-24 age group, with particularly high rates in women aged 16-19.
In 2011 there were 978 diagnoses of chlamydia in people aged 15-24 years in Bolton.  This gives a rate of 2833.9 (per 100,000 population) which is higher than the national average (2124.6 per 100,000).  This is not necessarily a negative finding however, as a higher prevalence is judged to be a product of ‘better’ testing with a recommended rate by the Health Protection Agency (HPA) of greater than 2400.0 per 100,000, of which Bolton scores higher.  The rate of diagnosed chlamydia has effectively doubled in 15-24 year olds over the past decade which is partly explained by the introduction of the National Screening Programme for Chlamydia in 2003.
In Bolton over 2010/11 7.1% of the 15-24 population tested positive for chlamydia, which is higher than average for England (5.2%) and for the North West region (6.6%).  The proportion testing positive is also higher than most of our statistical peers (Calderdale (7.7%) and Leeds (7.9%) being the exceptions).  Achieving a high diagnosis rate through screening reflects success at identifying infections which, as chlamydia is often asymptomatic, may have otherwise gone untreated and led to further health consequences.

After chlamydia, gonorrhoea is the second most common bacterial STI.  The highest rates are seen in women aged 16-19 and men aged 20-24.  However, the true number of cases may be significantly higher than those diagnosed in GUM clinics and other settings as gonorrhoea is frequently without symptoms in women, who may therefore not attend a clinic.
Nationally, increases in all age prevalence are evident up to 2003 but since then a reduction has been seen.  This is also the pattern in Bolton where we had a peak in 2004 with a general decrease since; however rates of both gonorrhoea and chlamydia in 15-24 year olds have begun to increase again in Bolton primarily as the result of the recent Greater Manchester R U Clear chlamydia and gonorrhoea screening programme.
During 2011 in Bolton, 130 diagnoses of gonorrhoea were made in GUM clinics for people of all ages, which gives a rate of 48.8 (per 100,000 population) and is higher than the national average (39.1 per 100,000).
Evidence demonstrates higher prevalence in particular groups: black and minority ethnic (BME) groups, men who have sex with men, men aged 20-24, and women aged 16-19.

Genital Herpes
The numbers of people suffering a first attack of genital herpes has been steadily increasing nationally over the past decade.
In 2011 in Bolton there were 160 diagnoses of herpes, which is a small but consistent increase on previous years (2010, 151; 2009 145).  This gives a rate of 60.0 per 100,000 population which is similar to the national average (59.6).
In the North West, 63.9% of all herpes diagnoses are female and occur in the younger age groups.

The number of people living with HIV and AIDS in the North West has continued to increase over the past twenty years.  This is partly explained by improvements in treatment and improved life expectancy.
The true prevalence of HIV/AIDS in Bolton as in England as a whole is unknown, as an estimated third of people with the disease are unaware of it.  There has been a 7% increase in new cases of HIV in the North West from 2010 to 2011.
HIV diagnoses in the UK have consistently been majority-male (unlike many parts of the world such as sub-Saharan Africa), are predominantly White or Black African ethnicity, and after a peak in 2005 for heterosexual sex, the transmission route in 2011 is fairly equal between heterosexual sex and men who have sex with men.  Those aged 30-34 years account for the largest share (17.5%) of new HIV diagnoses in 2011, closely followed by the 35-39 and 25-29 age groups; however, during the 2000-2010 decade new HIV diagnoses among the over 50s tripled in the UK.
Prevalence of diagnosed HIV in Bolton is 1.54 per 1,000 population aged 15-59 years; around 240 Bolton residents access HIV related care each year.  Of Bolton’s fifteen statistical peers, only four (Salford 4.00, Coventry 2.72, Sandwell 2.11, Bury 1.63) have a higher prevalence of diagnosed HIV.
Uptake of HIV testing in 2011 among men who have sex with men in Bolton is 93.6%; this is the proportion of all individuals who are offered an HIV test in GUM clinics.  Among Bolton’s women this proportion falls to 85.6% with uptake slightly higher at 88.4% among Bolton’s heterosexual men.

Genital Warts
Genital warts are the most common viral STI diagnosed in the UK.  The highest rates are seen in women aged 16-19 and men aged 20-24.
The number of new diagnoses of genital warts in GUM clinics in the UK has increased by 30% since 1999.  The introduction of the Human Papillomavirus vaccination programme for all girls born after 1990 offers hope in reversing this trend.
In 2011 there were 339 acute diagnoses of genital warts in Bolton, which is a reduction from 392 in 2010 and 417 in 2009, and equates to a rate of 127.2 per 100,000 population.

The number of diagnoses of syphilis has risen significantly in recent years in the UK.  This increase has been attributed to a number of outbreaks throughout the UK with the largest occurring in London.  However, syphilis remains one of the least common STIs in the UK.
Nationally, the largest numbers are seen in men who have sex with men.
In 2011 there were 5 diagnosed cases of syphilis in Bolton, preceded by 9 in 2010 and 13 in 2009.  The trend is Bolton is erratic due to these small numbers.

Nationally, 57% of 16-19 year olds say they use contraception.  Among these, 65% use condoms and 54% the pill (though some will use both).  In addition, 86% had heard of emergency hormonal contraception (EHC), and 17% had used EHC at least once in the last 12 months.
In 2010/11 there were approximately 11,700 clinic attendances for NHS contraception services in Bolton.  Of these 3,900 were first contacts by women (of which 2,400 were for contraceptive reasons only) and 1,000 first contacts were made by men.  During the same period in Bolton there were 700 attendances for emergency contraceptives.
As a total percentage for all attendances for contraception reasons only, 21% were for long acting reversible contraceptives (LARCs), while 79% were for user dependent methods.

Current Services in Relation to Need

The sexual and reproductive health service, based at Royal Bolton Hospital, is well staffed and delivered from good quality premises.  However, there is no weekend provision and out-of-hours provision is also limited.  However, 88.9% of all attendances by Bolton residents to GUM clinics are made at the Royal Bolton site.  In 2011 an HIV test was offered to 55% of attendances and an HIV test was done in 48% of attendances at GUM clinics by residents of Bolton.  This is against a national figure of 77% of attendances offered an HIV test and an HIV test being done in 62% of attendances.
In the community contraceptive and sexual health services are currently offered on an appointment and drop-in basis.  This has been a recent development in response to the fact that many young people in particular prefer drop-in clinics to set appointment times.  Whilst some contraceptive clinics are currently provided during the evenings, there is no weekend provision in the all-age service.
Tier 2 sexual health and contraceptive services are provided for young people at The Parallel.  The service is provided each weekday and on a Saturday morning and offers a mixture of drop-in and appointment only clinics.
Virtually all individuals requesting a GUM appointment within 48 hours are offered an appointment within this timescale, meaning that the current target is consistently achieved.
There are enhanced school nurse drop-in services provided from seven sites and these include the provision of some contraceptive and broader sexual health services.
Nurse drop-in clinics to increase access to contraception and sexual health services are now held in two further education providers covering four sites across the borough by Brook.
Free condom schemes (C-Card) are provided in Bolton and are targeted towards young people, LGB communities, and people accessing Primary Care.
Generic contraceptive and sexual health services are provided by a number of GP practices across Bolton and seven Bolton GPs have been identified as GPs with a special interest in sexual health.  Eleven practices also provide an enhanced service for long acting reversible contraception ( LARC).
Abortion services from non-NHS providers currently provide chlamydia and gonorrhea testing and contraception.  NHS providers undertake chlamydia screening but contraception provision is inconsistent.
Currently the majority of Bolton GP practices offer chlamydia and gonorrhoea screening as well as generic testing for other STIs.
There is a Specialist HIV Social Worker based at the Centre for Sexual Health (Royal Bolton Hospital).  A range of grants are also given to voluntary sector organisations to provide additional support including Barnardo’s Health through Action, George House Trust, and The Lesbian and Gay Foundation.  These provide both prevention of sexual ill health measures and support for those living with HIV.

NICE affirms that interventions to prevent sexually transmitted infections can be cost effective, particularly when targeted at high risk groups .
Screening strategies targeting high risk populations that lead to early identification and treatment are cost-saving as they avert future costs of dealing with complications and onward transmission.  Screening for chlamydia in young women is directly cost-saving, while screening young men is cost effective.  In addition, antenatal screening for HIV in high risk women is cost-saving, as well as being cost effective even if done on all women. 
The overall cost of sexual health promotion is minor compared to the costs of treating STIs and unintended pregnancies.  Interventions that are evidence-based and lead to behaviour change are the most cost effective (for example, free condom provision for at risk groups, assertive outreach health promotion for at risk groups, needle exchanges, sex and relationship education in schools).
As untreated infections lead to onward transmission and increase demand on GUM clinics, early treatment of STIs and partner notification are cost effective interventions.
The cost of treating STIs nationally (excluding HIV) is estimated at £170million.  HIV is responsible for a significant burden on NHS resources.  The average lifetime treatment costs for an individual who is HIV positive is around £135,000-£185,000, and due to recent increases in drug costs and longer life expectancy this figure is more likely to be around £276,000.  Nationally, preventing each onward transmission of HIV could save £1million in health benefits and treatment costs.

Projected Service Use and Outcomes

The National Chlamydia Screening Programme originally had a Government target of testing 35% of the 15-24 year old population.  In 2011 Bolton has achieved 30% of this population group screened (10,421 diagnoses), the second highest percentage in Greater Manchester.  However the new target is to diagnose 2,400 per 100,000 of this population which Bolton looks set to achieve for 2012.
Whilst there have been significant improvements in the health and quality of life for people living with HIV, there is still an uncertainty of how a person’s life will be in reality.  As more people are living longer with HIV and face the real possibility of living into old age, there is a possibility of a rise in the number of people infected and seeking support and care.  In turn, the number of people affected by HIV also increases the numbers that require support as partners, families, and carers.  Late diagnosis of HIV adds to the cost burden on services as treatment is not as successful and co morbidities are more likely to occur.  This can then lead to further or extra requirement for both health and social care.
The population profile of Bolton is getting older with the baby boom generation moving into their 50s and 60s.  Little is known about the sexual behaviour of this group, but there have been recent increases nationally in GUM attendance in these older populations with higher than previous rates of infection.  This is likely to lead to greater projected service use in the coming decades as this population grows.

Evidence of What Works

Bolton’s Health Matters has created a collection of evidence and intelligence to ensure best practice in decision within this area. To view this collection, please click here

Community Views and Priorities

A recent sexual health needs assessment for Black African communities, asylum seekers and refugees living in Bolton has been completed and an action plan to address the needs has been developed.  This document is available on Bolton’s Health Matters by clicking here

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

Unmet Service Needs and Gaps

There is a need to make improvements in the following areas of sexual health services in Bolton:
1. Increase access to community and primary based HIV/STI testing, treatment and care, in particular to address the late diagnosis of HIV and to ensure early treatment and contact tracing for other STIs;
2. Better support for Bolton’s LGB groups, in particular younger people who are coming to terms with their sexuality and improve accessibility to all services by developing ‘LGB friendly services’;
3. More prevention work targeted at Black African communities, asylum seekers, and refugees;
4. Collaboration to deliver holistic and integrated harm reduction interventions that specifically target the most vulnerable communities;
5. Increase interventions designed 

Recommendations for Further Needs Assessment Work

• Assessment and regular monitoring/analysis of the Public Health Outcomes Framework indicators linked to sexual health are necessary.  These are:  1.1 Children in poverty; 1.4 First-time entrants to the youth justice system; 1.5 16-18 year olds not in education, employment or training; 2.4 Under 18 conceptions; 2.21 Access to non-cancer screening programmes; 3.2 Chlamydia diagnoses (15-24 year olds); 3.3 Population vaccination coverage; 3.4 People presenting with HIV at a late stage of infection.
• A greater understanding is needed of the profile of people who experience STIs in Bolton.
• Health equity audits should be performed in relation to the National Chlamydia Screening Programme in Bolton.
• Implementation of the action plan addressing the needs of LGB groups in relation to wider services including social care to promote wellbeing.
• A greater understanding of the needs of older adults in relation to sexual health is needed to better inform service planning for this group.

Key Contacts

Jayne Littler - Strategic Commissioning and Development Manager, Public Health

HIV Social Care Needs Assessment221.12 KB

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