1. 3Cs & HIV Programme Chlamydia, Contraception, Condoms & HIV
A programme to support basic sexual health provision in general practice
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

2. 3Cs & HIV programme Supporting sexual health provision in general practice
The 3Cs & HIV programme is designed to support general practices deliver:
A basic sexual health offer (‘3Cs’) during any routine consultation with young adults (15 – 24 year olds):
A chlamydia screen
Signposting or provision of contraception advice
Free condoms
HIV testing in adults (≥ 16 years) in line with current clinical guidelines:
Awareness of indicator conditions where HIV testing should be considered
In high prevalence areas, routine offer of HIV test to all new practice registrants
The 3Cs & HIV programme is specifically designed meet the needs of, and to fit alongside work already being undertaken by, GP teams.
3Cs (&HIV) programme designed to fit with current GP activity and meet needs of practice GP teams, to deliver this:
South West RCT GP feedback
Design informed by further qualitative GP, practice nurse and patient interviews undertaken for 3Cs development
GP and practice nurse advisory panel to guide ongoing development and delivery
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

3. General practice An important role in sexual health promotion
At least 60% of young adults visit their GP every year - and want the option of accessing sexual health services1,2
Most people become sexually active between years old:3,4,5
Sexual activity can be opportunistic, unplanned and linked with alcohol and drugs
STI rates and under 18 conceptions are indicators of ongoing health inequality
70% of young adults who have had a chlamydia test are more likely to test again in future, and 68% are more likely to recommend testing to friends
The 3Cs & HIV programme will help young adults access sexual health advice and services to avoid negative health outcomes that may impact their future life chances
Most people become sexually active between years old:
Sexual activity can be opportunistic, unplanned and linked with alcohol and drugs3,4
STI rates and under 18 conceptions are indicators of health inequality3,4
Young men in particular are less likely to use community contraception services3
STIs disproportionately affect young adults5
5. HPA 2011 STI annual report.
NCSP web survey of 1,500 young adults (2012):
45% of respondents had tested at least once
68% of those believed testing is a normal part of young adults’ lives
Of those who had not tested, 41% were not sexually active
Testing has a positive impact on future health-seeking behaviour:
70% of those who have tested were more likely to test again in future
68% were more likely to recommend testing to friends
56% were more likely to discuss contraception with a new partner
53% were more likely to ask their GP/ practice nurse for a test
Salisbury et al. British Journal of General Practice. 2006; 56:99-103; 2. Hogan et al. BMC. Public Health 2010, 10:616; 3. DH. Improving Access to Sexual Health Services for Young People.2007 ; 4. DfES. Teenage Pregnancy Next Steps. 2006; 5. HPA Web Survey of Young Adults (2012)
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

4. 3Cs & HIV programme Why include HIV testing?
HIV in the UK, 2011:1
Estimated 96,000 people living with HIV – 24% (22,600) are unaware of their infection
Estimated prevalence of 1.5 per 1,000 population – higher among MSM and black Africans
47% of HIV cases diagnosed late (CD4<350) in 2011
Why focus on reducing late HIV diagnoses?
Public health impact – treatment can prevent onward transmission2 - indicator within Public Health Outcome Framework
Individual prognosis - early diagnosis can lead to near-normal life expectancy3
Cost - expanded HIV testing shown to be cost effective4-5 and increased costs of a late versus early diagnosis (x2-3 times) which persist longer term7,8
The proportion of late HIV diagnoses remained high (47%) in 2011
Public health impact
Late HIV diagnoses indicator within Public Health Outcome Framework
Approximately 25% of those with HIV unaware of infection, responsible for 50-75% of transmission
Transmission risk reduced if aware of status and if on treatment
Individual prognosis
Late HIV diagnosis a major predictor of morbidity and short-term mortality. Early diagnosis can lead to near-normal life expectancy1
Cost
The costs of a late HIV diagnosis are x3 those of an early HIV diagnosis (CD4 >500)
Expanded HIV testing shown to be cost effective in studies
1. HPA HIV in the UK 2012 report; 2. Cohen et al NEJM Nakagawa et al AIDS 2012; 4. Paltiel et al N Engl J Med 2006; 5. Yazadanpanah et al Plos One 2011; 6. MMWR 2006; 7. Krentz et al HIV Med 2008; 8. Beck et al Plos One 2011
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 4

5. HIV testing: an opportunity in general practice
76% of people diagnosed with HIV had been seen in health services in previous year – of which, 76% in general practice1
Department of Health pilot projects investigated expanded HIV testing in general medical services:2
Feasible
Cost-effective
Acceptable to patients
Unlinked anonymous HIV testing of glandular fever samples from primary care - 0.9% (6/694) positivity (Hsu et al HIV Medicine 2013 )
Burns et al AIDS 2008
HPA Time to Test for HIV Report 2011
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 5

6. 3Cs &HIV programme Anticipated results
The 3Cs & HIV programme adapts an intervention trialled by the HPA to increase chlamydia testing in general practice
In this randomised controlled trial, surgeries that fully engaged with the intervention significantly improved screening rates and chlamydia detection1
These results provide a realistic measure of the take up and efficacy of the 3Cs & HIV intervention if commissioned in General Practice
The 3Cs & HIV programme is designed to strengthen sexual health work already funded and underway in your area, and support delivery of Public Health Outcomes Framework indicators
3Cs (& HIV) is designed to strengthen sexual health work already funded and underway in your area, and support delivery of Public Health Outcomes Framework indicators:
Identifying chlamydia infections to achieve 2,400 diagnosis rate (15-24 yr olds)
Reducing under-18 conceptions
Expanding HIV testing to reduce late HIV diagnoses
3Cs (& HIV) adapts an intervention trialled by the HPA to support general practices increase chlamydia testing, based on the Theory of Planned Behaviour
In a randomised controlled trial, surgeries that fully engaged with the intervention:
Increased screening rates 2.33 times (CI , p<0.001) vs. controls
Increased chlamydia detection by 76% (CI 25% to 148%, p=0.005)
These results provide a realistic measure of the take up and efficacy of this intervention if commissioned in general practice
McNulty C. In press
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

7. 3Cs & HIV programme Outline of delivery
The 3Cs & HIV programme is designed to fit into current general practice activity, and support surgeries engage young adults in an evidence-based sexual health intervention
The NCSP will offer 1,500 surgeries across England the opportunity to participate in 2013/14:
Local areas sign up to participate and identify a local 3Cs & HIV trainer
NCSP ‘train the trainers’ and provide all 3Cs & HIV programme materials
3Cs trainers engage local practices in participating
Local 3Cs & HIV practices deliver offer to young adults on ongoing basis
3Cs & HIV practice data collected and evaluated across 2013/14

8. An evidence-based programme8
An evidence-based programme
Employing the Theory of Planned Behaviour

9. The Theory of Planned Behaviour
Personal Attitudes
Subjective Norms
Intention to Screen
Behaviour: sexual health offer for all young adults
Perceived Barriers
Evidence base showed us that complex interventions have had varied success. If only few staff participate, not likely to succeed.
If using Behavioural Change Theory, more likely to be successful, as designing intervention to address particular psychological barriers.
If you aren’t familiar with it, this is a model that proposes that human behaviour is driven by 3 considerations and these are able to predict whether a person intends to do something. The 3 considerations are 1) whether the person is in favour of doing it – Personal Attitude, 2) how much the person feels social pressure to do it Subjective Norm) and 3) perceived Behavioural Controls – their own abilities and external factors which they may have less control of.
Define outcome or goal of the intervention-
Define the likely causes/ antecedents of the target behaviour
Identify what may influence or cause the behaviour, and how an intervention may act on these determinants
External Barriers
Chlamydia screen offer forgotten,
surgery premises’ barriers etc.
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

10. INTERVENTION SOLUTION
Theory of Planned Behaviour: supporting general practice engage young adults in chlamydia screening
IDENTIFIED BARRIERS
INTERVENTION SOLUTION
Personal Attitudes
“Low numbers of young adults visit my practice”
Show surgery annual footfall for yr olds
Discuss the evidence base showing young adults’ preference for sexual health services via their GP
“Young adults don’t want to talk about sexual health”
Subjective Norms
“My colleagues do not offer sexual health care to young adults”
Normalise the sexual health offer through:
Appointing a sexual health champion per surgery
Surgery posters promoting the initiative
Invite cards given to young adults at Reception
Perceived Barriers
“I lack knowledge about STIs, HIV and pregnancy rates”
Practice staff offered training sessions and provided with information resources
“I lack experience / confidence engaging young adults in sexual health matters”
Training videos show the offer being delivered

11. External barriers The use of computer pop ups & templates encouraged
Forgetting to make the offer during a routine consultation
GP practice receives three contacts, including at least one visit
Risk that practice momentum declines over time
GP practice receives regular newsletter and information on the practice’s results
Intervention can be tailored to suit each surgery’s set up
Practice environment not conducive to making the offer

12. South West of England Trial Results1
Analysed 76 intervention and 81 control surgeries. Of the 76 surgeries offered the intervention:
47 (63%) fully engaged (received three contacts with support worker)
16 (21%) partially engaged (received one or two contacts)
13 (17%) did not engage (refused all contacts)
During the trial period:
2,907 vs. 2,379 screens in intervention and control surgeries, respectively
76% screening increase in intervention surgeries vs. controls (p<0.001)
40% increase in infections detected per surgery population (p=0.04)
‘Fully engaged’ intervention surgeries:
Increased screening rates 2.33 times vs. controls (p<0.001)
Increased chlamydia detection by 76% (p=0.005)
Increased screening significantly for at least 9 months following the intervention
McNulty C. In press
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 12

13. South West of England Trial Results1
Start of intervention
Intervention period
Support ends
Increase in screening is sustained nine months after support ended in intervention practices
Once trained, 3Cs & HIV surgeries can use programme to strengthen their sexual health offer on long-term basis
Impact sustained
Post intervention effect
The effect was much greater in those 47 practices that were fully engaged with a 16% increase in positive screens and the intervention the screening rate increased by 1.97 times that seen in the control practices. In both the no engagement and partially engaged practices there were non-significant increases in the screening rates above the control practices. You will only be engaging with practices who are interested and therefore we expect that this sort of effect. These figures also show you that you should be able to attain X% acceptance if approach and engage practices positivity with the full intervention package.
Chlamydia screening rate per year olds in study surgeries January 2009 to January 2012, by month
McNulty C. In press
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 13

14. South West of England Trial: Qualitative Results
Feedback from qualitative interviews:
Intervention was detailed and thorough
Easy access to the support available
Chlamydia support team went to the surgery to implement the intervention
Chlamydia support team stayed in contact over a year
Reward and recognition
“I think probably coming and actually explaining what it was and giving us the support and phone support after and coming back to the practice and checking how we were doing was helpful” Practice Nurse
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 14

15. 3Cs & HIV programme development: Preliminary GP interviews
“I think GU services and contraception go hand in hand”
“I think doing all ‘three Cs’ would be reasonable”
“It’s a good idea to make the link between chlamydia, condoms and contraception. It makes sense to look at prevention at the same time as cure”
“We should be giving sexual health advice alongside the chlamydia testing, otherwise we’re just testing not educating”
Post intervention effect
The effect was much greater in those 47 practices that were fully engaged with a 16% increase in positive screens and the intervention the screening rate increased by 1.97 times that seen in the control practices. In both the no engagement and partially engaged practices there were non-significant increases in the screening rates above the control practices. You will only be engaging with practices who are interested and therefore we expect that this sort of effect. These figures also show you that you should be able to attain X% acceptance if approach and engage practices positivity with the full intervention package.
“Really, I think it’s vital that chlamydia testing is offered with these other things as well”
“It’s a population that needs a bit of lateral thinking on how to engage them”
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 15

16. 3Cs & HIV programme delivery16
3Cs & HIV programme delivery

17. 3Cs & HIV programme: Local area participation
NCSP currently inviting expressions of interest from areas
To participate, areas must identify someone currently working in sexual health to become their 3Cs & HIV trainer
The 3Cs & HIV trainer will deliver the programme locally: engaging local practices, providing ongoing support and evaluating achievements
The time required by 3Cs & HIV trainers will vary per area, depending on the number of practices engaged, but estimated at 0.5 WTE if 30 practices
NCSP currently inviting expressions of interest from Areas
To participate, Areas must identify someone currently working in sexual health to become their 3Cs (& HIV) trainer:
Can be split between two or more staff
Participation will not require additional capacity if already working in general practice role
The 3Cs (& HIV) trainer will deliver the programme locally:
Commit for one year minimum
Attend an initial training course
Engage and train around 30 local general practices
Provide ongoing practice support
Collect data to evaluate programme
Report into NCSP sexual health facilitator
The time required by trainers will vary per Area, depending on the number of practices engaged, but is estimated at 0.5 WTE if 30 practices engaged (including travel time)
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

18. 3Cs & HIV programme: NCSP role
The NCSP will provide the following to support local delivery of the 3Cs & HIV programme:
‘Train the 3Cs & HIV trainer’ course
Two follow up contacts with each 3Cs & HIV trainer
3Cs & HIV resource pack for practices
Free condoms
Performance data, per practice
Project coordination and monitoring
The NCSP will provide the following to support local delivery of the 3Cs (& HIV) programme:
Two-day ‘train the 3Cs trainer’ course (held regionally/locally)
Two follow up contacts with 3Cs trainers, following initial course
3Cs resource pack for practices (e.g. posters, reception cards)
Condoms (linking with local C-card schemes)
HIV tests
Performance data, analysed per participating practice
Project coordination and monitoring
Newsletters for Trainers
All training, resources and support provided at no charge by the NCSP.
Travel costs are not included.
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

19. 3Cs & HIV programme: Support and resources for practices
The programme is designed by GPs to fit general practice – and can be tailored to each practice, building on their current skills and services.
Each practice receives:
An interactive training session
Ongoing supportive follow up from their area trainer
3Cs & HIV practice resources to promote the programme
3Cs & HIV website – further information and resources
The programme is designed by GPs to fit general practice, and Trainers can tailor it to each practice to build on current skills and services:
Per practice, the Trainer will tailor an interactive training session:
Advice on offering chlamydia testing, contraception and condoms (& HIV testing)
Discussing practical barriers to delivery and identifying solutions
Running through the training videos and resources
3Cs practice resources to keep sexual health ‘front of mind’:
Surgery posters, Reception invitation cards, Computer prompts
Supportive follow up :
3Cs (& HIV) website - educational literature, latest data etc.
Performance data
3Cs Newsletter for GP practices (locally adapted)
Each practice will receive three Trainer contacts, including at least one visit
3Cs (& HIV) website – further information and resources
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

20. 3Cs & HIV data collection
The NCSP will evaluate the impact of the 3Cs & HIV programme
Using local systems to collect data by practice on:
Chlamydia testing and diagnoses
Contraceptive prescribing data for year olds
HIV testing
Registration / use of C-card and local condom programmes
Aim: data available ~6 months after the end of each quarter
The NCSP will monitor and evaluate all aspects of the 3Cs (& HIV) programme to track the impact of the intervention
It is especially important to evaluate sections of the 3Cs (& HIV) that were not part of the South West RCT, these being signposting information on contraception, distribution of condoms and HIV testing
We will work with local data collection systems to collect data by practice on:
Contraceptive prescribing data for year olds
HIV testing in new practice registrants
Registration and usage of C-card or other local condom distribution programmes
Chlamydia testing and diagnoses data will be analysed using the Chlamydia Testing Activity Dataset (CTAD), which is a national mandatory surveillance system
Aim: package of data to be available ~6 months after the end of each quarter
This data will only be used to inform the progress of the 3Cs(& HIV) programme and will not be used to monitor practices against other indicators such as the Quality and Outcomes Framework (QOF)
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx

21. Timeline
Jan – May 2013: expressions of interest & participant selection
May – Jun 2013: NCSP training of 3Cs local area trainers
End of May – Jul 2013: 3Cs & HIV trainers recruiting GP surgeries
Jul 2013 onwards: 3Cs & HIV programme delivery roll out
3Cs HIV Slide Pitch Presentation_full deck_May 2013.pptx 21

22. What next?
If you are interested in participating, please discuss with your NCSP sexual health facilitator:
London
South East & Central
East of England
West Midlands
North West
Yorkshire, Humber & North East
East Midlands
South West
We look forward to working with you.

23. 3Cs & HIV Programme
Chlamydia, Contraception, Condoms & HIV