Sexual Health Matters

The national strategy for sexual health and HIV: what does it mean for HIV services?

Dr Deborah Beere. Consultant in Contraception and Reproductive Health and Sexual Health Lead for Middlesbrough Primary Care Trust. Contraception and Reproductive Health Service. South Bank Health Shop, 23-27 Middlesbrough Road, South Bank , Middlesbrough. TS6 6NW.

Key words: Sexual health, HIV, national strategy, service development

Introduction
In July 2001 the first National Strategy for Sexual Health and HIV ⁽¹⁾ was published for consultation. The strategy recognises the relationship between sexual health, poverty and social exclusion including the unequal impact of HIV on gay men and certain ethnic minority groups. Unplanned pregnancies and sexually transmitted infections (STIs) can have a long lasting effect on people. There is a rising prevalence of STIs and HIV. Visits to genito-urinary medicine (GUM) clinics have doubled over the last decade and now stand at over one million per year. Although there is an improved life-span for people infected with HIV, there is still no cure. This brings new challenges for those who provide treatment, support and care. For many years there have been significant variations in the quality of and pressures on sexual health services across the country. The strategy addresses the need to raise standards of service in line with the principles set out in the NHS Plan and the complex issues associated with HIV.

Where are we now?
The consultation on the strategy ended in December 2001 and the Department of Health received over 400 written responses. Following the consultation, a twenty- seven point action plan has been produced. ⁽²⁾ There has also been a Health Authority led base line assessment of Sexual Health Services. This has been submitted to the Department of Health and the analysis is due to be published shortly.

All Primary Care Trusts (PCTs) have been asked to identify a Sexual Health Lead and to establish a multi-agency steering group. The multi-agency group has to produce a local strategy that reflects the requirements of the national strategy and the needs of the local population. In South Tees we have a multi-agency group that has members from Middlesbrough and Langbaurgh PCTs, Social Services, Education, South Tees Acute Hospitals Trust, and the voluntary sector. We are in the process of drawing up our local strategy. The Department of Health is going to publish a Commissioning Toolkit to support the implementation and development of local plans from April 2003. There will also be a Health Promotion Toolkit.

Aims of the strategy
The five main aims of the strategy are

Reduce the transmission of HIV and STIs
Reduce the prevalence of undiagnosed HIV and STIs
Reduce unintended pregnancy rates
Improve health and social care for people living with HIV
Reduce the stigma associated with HIV and STIs

Sexual Health and HIV services will continue to be funded largely from mainstream allocations. However there will be an additional Ł47.5 million investment over the next two years to help implement specific initiatives and pump prime changes of service delivery.

Targets
The strategy sets several targets

To reduce by 25% the number of newly acquired HIV infections and gonorrhoea infections by 2007
To offer all GUM clinic attenders an HIV test on their first screening for STIs by the end of 2004 with a view
- To increasing the uptake of the test by those offered it to 40% by the end of 2004 and to 60% by the end of 2007
- To reduce by 50% the number of previously undiagnosed HIV infected people attending GUM clinics who remain unaware of their infection after their first visit by the end of 2007
By the end of 2003, all homosexual and bisexual men attending GUM clinics should be offered Hepatitis B immunisation at their first visit.
Expected uptake of all three doses in those not previously immunised to reach 50% by the need of 2004 and 70% by the end of 2006
To ensure that women have access to an abortion within three weeks of the first appointment with the referring doctor
To halve the rate of conceptions in under 18's by 2010 - cross-links to the Teenage Pregnancy Strategy. ⁽³⁾

Actions - Services
The Department of Health will work with professional bodies and service users to produce models of service guidance and standards. The strategy discusses three levels of service provision (Table 1). Further guidance on these levels will be provided in the Commissioning Toolkit. Inevitably there will be some overlap depending on who is providing the service. Targeted sexual health services will be continued and developed further, including an action plan for African Communities and the Community HIV and AIDS Prevention Strategy (CHAPS) for Gay men. The national chlamydia screening programme has been rolled out to ten further pilot sites. The Department of Health has requested expressions of interest in piloting three different models of "One Stop Shop" sexual health services. These will be piloted and evaluated up to 2006.There will be a review of GUM skill mix and working practices, aiming to develop the role of health advisers, reduce waiting times and improve open access GUM services. Guidance will be produced on provision of and good practice for Contraceptive Services, including a NICE (national institute for clinical excellence) review of long acting contraceptive methods by 2006. There will also be new guidance on the commissioning of Abortion Services in order to tackle inequalities of access to abortion.

HIV Services - Treatment and Care
The strategy will ensure equality of access to HIV services, regardless of where a person lives. This will be achieved through the development of managed clinical networks, clinical partnerships and collaborative working. National guidelines on HIV treatment and care are being developed, based on updating existing guidelines such as the BMA Foundation for AIDS Guidelines (1999). ⁽⁴⁾ The strategy recognises that Social Care has an important part to play in the care of people with HIV. Social Care will address social exclusion issues and help with access to education, employment and leisure facilities. It will ensure that people have their needs assessed with regard to welfare, benefits, housing and advocacy. It will provide support to carers and families of those with HIV. The AIDS support grant is being reviewed and two reports are to be commissioned on the support needs of adults living with HIV and children living with HIV.

Tackling stigma and discrimination
The strategy aims to tackle the stigma and discrimination that can be associated with STIs and HIV. The commissioning toolkit will contain guidance on this. There is also continued support for the National AIDS Trust's prejudice campaign. An action plan will be developed to tackle stigma and discrimination across government.

Conclusion
The national strategy for Sexual Health and HIV is ambitious and raises several issues and challenges. It has been launched at a time when there are limited resources available and the NHS has just undergone another reorganisation nationally and locally.

There are many other priorities in the NHS Plan and National Service Frameworks (NSFs) that will compete with the Strategy for resources. All services providing Sexual Health Care are already under pressure and there is a shortage of skilled staff. This must be addressed through the Workforce Development Confederation in order to support the implementation of the strategy. A national sexual health training strategy needs to be developed to ensure that all those involved in the delivery of Sexual Health Care have the necessary skills to provide high quality easily accessible services.

This strategy is long overdue but now it is here, all of us working in any aspect of Sexual Health Care have a responsibility to ensure its implementation to improve the sexual health of the nation.

Table 1 - Levels of service provision

Level One	Level Two	Level Three
Sexual History and risk assessment	Testing and treating STIs	Outreach for STI prevention
STI testing for women	Partner notification	Outreach contraception services
HIV testing and counselling	Invasive STI testing for men	Specialised infections management including co-ordination of partner notification
Pregnancy testing and referral	Intrauterine contraceptive device insertion	Highly specialised contraception
Contraceptive information	Contraceptive implant and services	Specialised HIV treatment insertion and care
Assessment and referral of men with STI symptoms	Vasectomy	Psychosexual counselling
Cervical cytology screening and referral		Termination of Pregnancy
Hepatitis B immunisation

References

The National Strategy for Sexual Health and HIV - Department of Health July 2001.
The National Strategy for Sexual Health and HIV Implementation Action Plan - Department of Health June 2002.
Teenage Pregnancy - report by the Social Exclusion Unit June 1999.
BMA Foundation for AIDS guidelines 1999.

(This article is based on a lecture given at the 4th Annual Cleveland HIV Update on 8th November 2002.)

©2002 Sexual Health Matters. Published Quarterly by Express Print Works, Middlesbrough, UK
ISSN 1469-7556
http://www.sexualhealthmatters.com.