1. 2003/4 Sexually Transmitted Infections Foundation Course 2013 / 20141

2. 2003/4 2013 / 20142 Note to Course Organisers: The Epidemiology slides are provided for use in conjunction with your local data. Local data could be obtained from your Local Authority or PCO or from your clinic returns and SOPHID data. The Sexual Health Balanced Scorecard provides a snapshot of sexual health at local level. Interactive maps and charts are found at http://www.apho.org.uk/sexualhealthbalancedscorecard This slide set is designed to be edited according to your own local audience and it is not expected that you show all the slides.

3. 2003/4 32013 / 2014 Epidemiology of STIs and HIV & Sexual Health Services in 2013

4. 2003/4 4 2013 / 2014 Learning Outcomes At the end of this session you should be able to: Describe national and regional rates of common STIs Demonstrate understanding of trends in STI and HIV infection rates in your local area Identify sub-populations at greater risk of STIs/HIV

5. 5 % change 20112002-20112010-2011 Chlamydia186,196135%-2% Genital warts76,07121%1% Genital herpes31,15481%5% Gonorrhoea20,965-13%25% Syphilis2,91587%10% Number of new diagnoses of selected STIs, GUM clinics, England: 2002, 2010 and 2011 Routine GUM clinic returns http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1215589015024

19. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System HIV tests among STI clinic attendees: England, 2009-2011

21. 21 STIs & HIV HIV is an STI – many of the risk factors for acquiring infection are the same Some STIs increase risk of acquiring HIV Some STIs increase shedding of HIV in infected individuals and therefore increase risk of transmitting HIV

22. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Annual new HIV and AIDS diagnoses and deaths: United Kingdom, 1981-2011

23. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System New HIV diagnoses by exposure group: United Kingdom, 2002 – 2011 1

24. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Number of people newly diagnosed and people living with diagnosed HIV infection: United Kingdom, 1980-2011

25. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Estimated number of people living with (both diagnosed and undiagnosed) HIV infection in the United Kingdom: 2011

26. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System Prevalence rates of HIV: United Kingdom, 2010 People with diagnosed or undiagnosed HIV infection/1000 population All1.5 Men2.0 Women0.9 MSM47 Black African47

27. HIV and STI Department, Health Protection Agency - Colindale HIV and AIDS Reporting System London Prevalence of diagnosed HIV infection by region of residence among population aged 15-59 years: United Kingdom, 2011 Less than 1 1-2 >2

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30. 2003/4 30 Summary Variety of risk factors for STI acquisition HIV /other STIs interact HIV and STI rates are increasing in UK National and regional rates of STIs vary Data from Health Protection Agency (Centre for Infections)

31. 2003/4 31 Sources of Data www.hpa.org.uk/HPAwebHome/ www.statistics.gov.uk www.isdscotland.org www.apho.org.uk/sexualhealthbalancedscorecard www.ons.gov.uk/ons/index.html

32. 2003/4 322013 / 2014 Section 2 Sexual Health: Service Provision and Primary Care

33. 2003/4 33 Learning Outcomes At the end of this session you should be able to: Describe recent changes in policy and specialist practice List linked sexual health disorders Describe clinical pathways and the potential for shared care Recall the particular issues of confidentiality in the context of sexual health

34. 2003/4 34 STI - Service Objectives Control of communicable diseases which have potentially serious effects upon Physical well-being Psychological well-being STI control is essential to reduce HIV acquisition and transmission

35. 2003/4 35 Linked Sexual Health Pathologies Neonatal Infections Anogenital Cancers Unintended pregnancies Mental Health Subfertility STIs HIV

36. 2003/4 Establishment of “VD” Clinics 1916 : Specialist clinics set up around the country : 113 by 1917 36 Public Health (VD) Regulations 1916 Voluntary attendance, no doctors referral needed Confidentiality assured Free treatment

37. 2003/4 37 Confidentiality The 1916 Regulation has been updated over the years: NHS (Venereal Diseases) Regulations 1974  Officers of all Health Authorities NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000  members or employees of Trusts After 2012 H&SC Legislation ???? NB: Applicable only to England

38. 2003/4 38 GUM Clinics today National network of clinics –Most major cities, towns –Consultant-led service Providers: Acute trust Integration with HIV/AIDS inpatient services May be linked to other acute services e.g. ID medicine, urology, dermatology, gynae Community care trust Co-location / integration with other sexual health services Private/third sector

39. 2003/4 39 Principles of STI Management Test before treatment Screen for accompanying STIs Simple treatment regimens Follow-up after treatment Partner notification Non-judgemental patient support, counselling, education

40. 2003/4 Range of GUM Services Core services Surveillance Screening Diagnosis & treatment Prevention of STI/HIV Partner notification Sexual health promotion Teaching and training Research Outreach services Vulval/genital dermatology Management of CIN Contraception Adolescent health care Sexual abuse services Erectile dysfunction Psychosexual services 40

41. 2003/4 41 National Survey of Sexual Attitudes and Lifestyles Changes: 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

42. BEST PRACTICE GUIDANCE YOUNG PEOPLE UNDER 16 ON CONTRACEPTION, SEXUAL AND REPRODUCTIVE HEALTH 20002001200220032004200520062007200820092010201120122013 NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000 Better prevention, better services, better sexual health - The national strategy for sexual health and HIV a sexual health and HIV commissioning toolkit for Primary Care Trusts and local authorities Recommended standards for NHS HIV services Effective Commissioning of Sexual Health and HIV Services Recommended standards for sexual health services Competencies for specialised STI services within primary care Standards for the management of sexually transmitted infections (STIs) Primary Care Service Framework: Management of Sexual Health in Primary Care GUM 48-hour Access: Getting to target and staying there National Chlamydia Screening Programme Azithromycin becomes OTC medicine A Framework for Sexual Health Improvement in England Health and Social Care Act 2012

43. 2003/4 43 National Strategy for Sexual Health and HIV (2001 ) Widened role for primary care Closer working between Primary and Secondary care Increased community role for sexual health advisers Targeted chlamydia screening Improved access to GUM services Managed clinical networks for HIV and other services

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45. Access, Patient Choice, Location, Range of Services, Confidentiality Treatment, Partner Notification, Surveillance Data, Principles of STI care Competence, Assessment Maintaining competence, Clinical Leadership, Training Appropriately trained staff Appropriate risk assessment and history and examination Service responsible for ensuring users get results and awareness of what tested for Clinical Assessment Gold standard tests, GUM need on site microscopy Lab reports <7working days, 24h access to HIV tests Encourage electronic requesting and reporting Diagnostics Avoid syndromic management (Rx no tests), empirical Rx (test, treat before results) ok All should get results, Rx according to BASHH, PN measured, MI Clinical Management Info about pts held securely and in compliance with NHS requirements All registered with ICO, comply with data reporting requirements Info to all pts about how their data used and safeguards in place Information Governance Clear pathways: explicit agreed and used by all providers Networks; GUM leading role in Mx STIs in network Links to other services Led by GUM but all services need CG lead IT used to support CG, all to do annual audits, quality markers Clinical Governance Need frameworks to engage with patients, incl non-users of STI services Patient reported outcome measures should be developed Patient and Public Engagement 45

46. Sexual History-taking and risk assessment (Incl need for PEP/EC) Signposting to appropriate SH services Chlamydia screening Asymptomatic STI screening and Rx of asymptomatic infections (except Rx for syphilis) in men (excluding MSM) and women PN of STIs or onward referral for PN HIV testing POCT HIV testing Screening/vax hepB Condoms Psychosexual problems- assessment and referral Level 1 STI testing and treatment of symptomatic but uncomplicated infections in men (except MSM) and women excluding: men with dysuria &/or discharge Symptoms at extra-genital sites eg rectal or pharyngeal Pregnant women Genital ulceration other than uncomplicated genital herpes Level 2 STI testing and treatment of MSM STI testing and treatment of men with dysuria and genital discharge Testing and treatment of STIs at extra genital sites STIs with complications, with or without symptoms STIs in pregnant women Recurrent conditions Management of Syphilis and BBV Tropical STIs HIV care and PEP Level 3 46

47. 2003/4 Standard 7: Links to other services All services managing STIs should ensure that they have formal links with the local specialist GUM service for advice, support and referral Clear clinical care pathways should focus on ensuring appropriate clinical management for people accessing services and supporting professionals in the delivery of high quality care 47

48. 2003/4 Clinical Links Primary Care Specialist GUM service Other providers: Eg. CASH Third Sector 48 Agreed clinical guidelines, joint teaching and training, shared management of long term conditions Agreed rapid track pathways for patients with unexpected complicated disease Clinical Governance Leadership role

49. 2003/4 49 A Framework for Sexual Health Improvement in England (2013 ) Ambitions reduce inequalities and improve sexual health outcomes informed and responsible choices about sex and relationships recognise that sexual ill-health affects all parts of our society Need to address: stigma, discrimination and prejudice reducing STI rates using evidence-based interventions/initiatives reducing unwanted pregnancies / access to full range of contraception options support women with unwanted pregnancies to make informed decisions on options tackle HIV through prevention and increased access to testing promote integration, quality, value for money and innovation Joined-up provision to enable seamless patient journeys Best Practice in Commissioning prioritising the prevention of poor sexual health strong leadership and joined-up working focusing on outcomes

50. 2003/4 50 Planning an Enhanced Service ? These essential documents are on the BASHH website…

51. 2003/4 51 RCGP / BASHH www.bashh.org/documents/Sexually%20Transmitted%20 Infections%20in%20Primary%20Care%202013.pdf

52. 2003/4 52 BMA and ABI guidelines 2002 A standard GPR report (see www.abi.org.uk) Insurance companies should only ask for relevant information Doctors should: –only provide relevant information –not answer questions which require opinion or speculation on risk or that are inappropriate http://www.bma.org.uk/ap.nsf/content/MedicalInfoInsurance STIs and Insurance

53. 2003/4 53 STI Testing and Life Insurance BMA / ABI Guidance Dec 2002 Sexually transmitted infections Single episodes of STI and even multiple episodes of “non-serious” STI are not relevant Blood-borne viruses: HIV / hepatitis B / hepatitis C Insurers should not ask whether applicant has had a test… Doctors should not reveal whether applicant has had test… Insurance companies may only ask whether the applicant has had a positive test result

54. 2003/4 54 Summary: STIs in 2013 Changing sexual attitudes and lifestyles Worsening sexual health and increasing STI esp. in MSM Re-emergence of infectious syphilis and LGV Antimicrobial resistance in gonorrhoea Chlamydia epidemic in young Long term sequelae of viral STIs HIV treatable but drugs costly HIV Testing – new guidelines to reduce late diagnoses Widening range of providers of STI/GUM services Challenge of new commissioning arrangements in England