Uneasy Bedfellows?

1. Uneasy Bedfellows?STI Services and Primary Care Dr Nicola Steedman Consultant in Sexual Health Countess of Chester Hospital NHS Foundation Trust BAHSHE Annual Conference 7th July 2008

2. Objectives Where have we been? To explore the historical relationship between GUM clinics and Primary Care Where are we now? To assess the current situation relating to the provision of sexual health services Where are we going? To try to predict the future of the relationship between our specialities

3. Venereal Diseases have always been common Sir James Paget 1879, 50% of outpatient attendances in his hospital were due to syphilis During WW I alarming increase in VD

5. A royal report on the prevalence of venereal diseases in the UK was commissioned and reported in 1916 �� the ablest physicians and military, hospital and pubic health authorities�� Venereal Diseases Regulation Act

7. Venereal Diseases Regulations 1916 Local authorities should provide services which Could be accessed directly (without physician referral) Enabled voluntary attendance Assured confidentiality Provided free treatment 113 national clinics were established in 1917

8. Venereal Diseases Regulations 1916 Services taken over by the NHS in 1948 Their aim? ��to provide confidential, free, open access services for the diagnosis and treatment of sexually transmitted infections��

9. Development of the speciality The origins of the speciality Sir William Osler promoted the term �genitourinary medicine� in his evidence to the Royal Commission on Veneral Diseases in 1914 Venereology as a speciality began being practised after the report by the commission in 1916

10. Development of the speciality The MSSVD was established in 1922 An independent forum where the new speciality�s many and varied problems could be discussed, recorded and reported Caseload figures 1921

11. From then�. To now�

12. How far have we come? In the UK More than 260 clinics Led by consultants in genitourinary medicine Covering a wide range of STI including HIV The total number of patients attending clinics in England during a one-week period in August 2007 was 20,701 (more than 1 million patients per year) And the name? VD Clinic Special Clinic STD Clinic GUM Clinic Sexual Health Clinic!

13. STI Service Objectives and Principles of STI Management The ultimate goal for STI services To reduce the incidence of STI in the community How do we attempt to achieve it? Provision of accessible, confidential, non-judgmental services Free and immediate diagnosis and treatment for all with/at risk of STI Epidemiological treatment/partner notification Comprehensive national surveillance programmes and data collection

14. The Current SituationGU Medicine � Core and Specialised Services Core Functions Provision of surveillance, screening, diagnosis, treatment and contact tracing for STI and HIV Sexual health promotion, teaching, training and research

15. The Current SituationGU Medicine � Core and Specialised Services Specialised services provided at some clinics HIV ongoing care (including pregnancy) Genital dermatology/vulval conditions Sexual assault services Sexual dysfunction services �One-stop shops� including contraception Clinics for special groups � young people, MSM, CSW, ethnic minorities, prisoners

16. Advantages and Disadvantages of the Status Quo

17. Specialised GU Medicine Clinics May be perceived as� More anonymous More gay-friendly Having better testing facilities (direct microscopy, faster specimen transit time, close microbiology links) But also as� More stigmatising Less accessible

18. STI Services in Primary Care� May be perceived as Less able to maintain confidentiality/anonymity Non-specialist But also as� More comfortable to speak to/approachable More aware of the patient�s background More accessible

19. So who is doing what? We continue to do what we have always done, just more of it!

20. Trends in diagnoses made in GUM clinics in the UK: 1997 � 2006 Slide 1: Trends over the 10 year period from 1997 to 2006 show a gradual rise in both the number of new STI diagnoses and other STI diagnoses (e.g. recurrent infections). Other diagnoses made in GUM clinics (e.g. candidosis & vaginosis) have remained relatively stable.Slide 1: Trends over the 10 year period from 1997 to 2006 show a gradual rise in both the number of new STI diagnoses and other STI diagnoses (e.g. recurrent infections). Other diagnoses made in GUM clinics (e.g. candidosis & vaginosis) have remained relatively stable.

21. Trends in services provided at GUM clinics in the UK: 2003 - 2006 Slide 2: New service codes were introduced at GUM clinics in 2003 in England, Wales and Northern Ireland and in 2005 in Scotland. Between 2003 and 2006, sexual health screens rose from 659,752 to 960,868. The number of HIV tests undertaken increased from 426,155 to 705,502 during the same period. The number of patients who were offered an HIV test and who refused decreased between 2005 and 2006 by 2% (from 272,346 to 266,605). There was a 20% increase in women attending GUM clinics for contraceptive services from 33,102 to 39,826 between 2003 and 2006. Slide 2: New service codes were introduced at GUM clinics in 2003 in England, Wales and Northern Ireland and in 2005 in Scotland. Between 2003 and 2006, sexual health screens rose from 659,752 to 960,868. The number of HIV tests undertaken increased from 426,155 to 705,502 during the same period. The number of patients who were offered an HIV test and who refused decreased between 2005 and 2006 by 2% (from 272,346 to 266,605). There was a 20% increase in women attending GUM clinics for contraceptive services from 33,102 to 39,826 between 2003 and 2006.

22. Number of new diagnoses of selected STIs, GUM clinics, United Kingdom: 2006 Slide 3: Number of new diagnoses of selected STIs, GUM clinics, United Kingdom: 2006 Since 1997, diagnoses of uncomplicated chlamydia infections have increased from 42,668 to 113,585 in 2006. This was followed by an increase in the viral infections genital warts (first attack) and genital herpes (first attack) of 3% and 9% respectively. There has been a percentage decrease in gonorrhoea diagnoses since 2003. Between 2005 and 2006 a decrease of 1% was also observed for infectious (primary & secondary) syphilis. Slide 3: Number of new diagnoses of selected STIs, GUM clinics, United Kingdom: 2006 Since 1997, diagnoses of uncomplicated chlamydia infections have increased from 42,668 to 113,585 in 2006. This was followed by an increase in the viral infections genital warts (first attack) and genital herpes (first attack) of 3% and 9% respectively. There has been a percentage decrease in gonorrhoea diagnoses since 2003. Between 2005 and 2006 a decrease of 1% was also observed for infectious (primary & secondary) syphilis.

23. And in Primary Care? National Chlamydia Screening Programme Pilot sites 1999-2001 Roll out for national cover 2003-2007 Opportunistic screening in non-GUM settings for all sexually active men and women <25yrs

24. Where is the NCSP screening happening?

25. Are we reaching the right people?

28. And are we winning?

29. Trends in diagnoses made in GUM clinics in the UK: 1997 � 2006 Slide 1: Trends over the 10 year period from 1997 to 2006 show a gradual rise in both the number of new STI diagnoses and other STI diagnoses (e.g. recurrent infections). Other diagnoses made in GUM clinics (e.g. candidosis & vaginosis) have remained relatively stable.Slide 1: Trends over the 10 year period from 1997 to 2006 show a gradual rise in both the number of new STI diagnoses and other STI diagnoses (e.g. recurrent infections). Other diagnoses made in GUM clinics (e.g. candidosis & vaginosis) have remained relatively stable.

30. Rates of diagnoses of uncomplicated genital chlamydial infection by sex and country, GUM clinics, United Kingdom: 1997 - 2006 Slide 4: Rates of diagnoses of uncomplicated genital chlamydial infection by sex and country, GUM clinics, United Kingdom: 1997 - 2006 Rates of diagnoses of uncomplicated genital chlamydial infection have been increasing in all countries in the UK since 1997. In 2006, England had the highest rates of infection for both men (198/100,000 population) and women (196/100,000 population). Between 2005 and 2006, rates of chlamydia increased among men in all UK countries except Wales. Among women, an increase in rates was seen in Scotland and Northern Ireland. Slide 4: Rates of diagnoses of uncomplicated genital chlamydial infection by sex and country, GUM clinics, United Kingdom: 1997 - 2006 Rates of diagnoses of uncomplicated genital chlamydial infection have been increasing in all countries in the UK since 1997. In 2006, England had the highest rates of infection for both men (198/100,000 population) and women (196/100,000 population). Between 2005 and 2006, rates of chlamydia increased among men in all UK countries except Wales. Among women, an increase in rates was seen in Scotland and Northern Ireland.

31. Number of diagnoses of genital warts (first, recurrent & re-registered episodes) by gender, GUM clinics, England and Wales: 1972 - 2006 Slide 9: Number of diagnoses of genital warts (first, recurrent and re-registered episodes) by sex, GUM clinics, England and Wales*: 1971 - 2006 Between 1971 and 2006, the number of all genital warts diagnoses (first, recurrent and registered episodes) increased by 8 and 12 times in men and women respectively. These rises may reflect increased incidence of infection, greater public awareness and/or improved diagnostic sensitivity. Although the number of genital warts diagnosed almost trebled (2.9-fold increase) in GUM clinics between 1977 and 1986, the following years saw a more gradual increase in this diagnoses. This may be due to changes in sexual behaviour that coincided with the emergence of the HIV epidemic during the mid-eighties. Since 1994 numbers have continued to rise reaching 75,569 cases among men and 57,757 among women in 2006.Slide 9: Number of diagnoses of genital warts (first, recurrent and re-registered episodes) by sex, GUM clinics, England and Wales*: 1971 - 2006 Between 1971 and 2006, the number of all genital warts diagnoses (first, recurrent and registered episodes) increased by 8 and 12 times in men and women respectively. These rises may reflect increased incidence of infection, greater public awareness and/or improved diagnostic sensitivity. Although the number of genital warts diagnosed almost trebled (2.9-fold increase) in GUM clinics between 1977 and 1986, the following years saw a more gradual increase in this diagnoses. This may be due to changes in sexual behaviour that coincided with the emergence of the HIV epidemic during the mid-eighties. Since 1994 numbers have continued to rise reaching 75,569 cases among men and 57,757 among women in 2006.

32. Number of diagnoses of genital herpes (first and recurrent episodes), by gender, GUM clinics, England and Wales: 1971 - 2006 Slide 20: Number of diagnoses of genital herpes (first and recurrent episodes) by sex, GUM clinics, England and Wales*: 1971 - 2006 Between 1971 and 2006, the number of genital HSV diagnoses made at GUM clinics increased by 5 and 22 times in men and women respectively. This is reflected in the changing women to men ratio, from 0.3:1 in 1971 to 1.4:1 in 2006. This cross over occurred in the early 1990s and women appear to be on a continuing increasing trajectory. The number of diagnoses stabilised and fell briefly in the mid-eighties possibly due to changes in sexual behaviour following extensive media coverage of HIV and AIDS.Slide 20: Number of diagnoses of genital herpes (first and recurrent episodes) by sex, GUM clinics, England and Wales*: 1971 - 2006 Between 1971 and 2006, the number of genital HSV diagnoses made at GUM clinics increased by 5 and 22 times in men and women respectively. This is reflected in the changing women to men ratio, from 0.3:1 in 1971 to 1.4:1 in 2006. This cross over occurred in the early 1990s and women appear to be on a continuing increasing trajectory. The number of diagnoses stabilised and fell briefly in the mid-eighties possibly due to changes in sexual behaviour following extensive media coverage of HIV and AIDS.

33. Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales, Scotland: 1931 - 2006 Slide 24: Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*: 1931 - 2006 Diagnoses of infectious syphilis made at GUM clinics in England, Scotland and Wales peaked towards the end of World War II, and then fell sharply in the late 1940s. Men in England and Wales experienced increases in diagnoses throughout the 1960s and 70s, while female cases remained constant. During this period Scotland saw fluctuating figures which peaked in 1968 and 1978 in both men and women. The male to female ratio in diagnoses peaked at 8:1 in 1983 in England and Wales and was similarly high at this time in Scotland, reaching 10:1 in 1984. This suggests that sex between men was the most common route of acquisition. Diagnoses in men declined in the early to mid-1980s, coinciding with emerging awareness of HIV, adoption of safer sex practices, and a parallel fall in HIV transmission among homosexual men. Since the late 1990s there has been a 15 fold increase in syphilis diagnoses among men in England and Wales. Slide 24: Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*: 1931 - 2006 Diagnoses of infectious syphilis made at GUM clinics in England, Scotland and Wales peaked towards the end of World War II, and then fell sharply in the late 1940s. Men in England and Wales experienced increases in diagnoses throughout the 1960s and 70s, while female cases remained constant. During this period Scotland saw fluctuating figures which peaked in 1968 and 1978 in both men and women. The male to female ratio in diagnoses peaked at 8:1 in 1983 in England and Wales and was similarly high at this time in Scotland, reaching 10:1 in 1984. This suggests that sex between men was the most common route of acquisition. Diagnoses in men declined in the early to mid-1980s, coinciding with emerging awareness of HIV, adoption of safer sex practices, and a parallel fall in HIV transmission among homosexual men. Since the late 1990s there has been a 15 fold increase in syphilis diagnoses among men in England and Wales.

34. New HIV and AIDS diagnoses and deaths among HIV-infected persons, UK

35. National Survey of Sexual Attitudes and Lifestyles (NATSAL) 2000 Second such survey Data collection 1999-2001 Collects information on sexual practices, hence potential STI risk Compared with NATSAL 1990 all increasing Mean no. heterosexual partners last 5 years No. partners in last year Homosexual partnerships Payment for sex Concurrent/simultaneous partnerships

36. Overall� �� The NHS provides a comprehensive range of sexual health services � including GUM clinics, community family planning clinics and services in primary care � but too often they are fragmented, poorly advertised and too narrowly focused. Access is a problem in some parts of the country. In rural areas especially, long journeys and patchy provision often restrict access to services. Information on sexual health is often out of date or simply not available��

38. The National Strategy for Sexual Health and HIV (2001) The first of its kind! A strategy to Modernise UK sexual health and HIV services Address the rising prevalence of STI/HIV Called for A broader role for those working in primary care settings, with providers collaborating to plan services jointly so that they deliver a more comprehensive service to patients more integrated sexual health services, including pilots of one-stop clinics, primary care youth services and primary care teams with a special interest in sexual health Long term plan (10 years) with substantial financial investment

39. The National Strategy for Sexual Health and HIV (2001) � A new model of working� Three levels of service provision for developing a comprehensive local service Commissioners and providers in primary care and acute Trusts need to work together to set up a network that provides all three levels of services and meets the needs of their local population

40. Levels of Sexual Health Service Provision Level 1 Sexual history taking and risk assessment STI testing in women HIV testing Pregnancy testing/referral Contraception information and services Assessment and referral of men with STI symptoms Cervical cytology screening and referral Hepatitis B immunisation

41. Levels of Sexual Health Service Provision Level 2 IUD/contraceptive implant insertion Testing for and treating STI Vasectomy services Partner notification STI screening in men (invasive/non-invasive)

42. Levels of Sexual Health Service Provision Level 3 Support provider quality Clinical governance at all levels Specialist services: Outreach for STI prevention Outreach for contraception services Specialised infections management Co-ordination of partner notification Highly specialised contraception Specialised HIV treatment and care

43. The GP Contract and Sexual Health Accepted 2003, came into effect 2004 A significant proportion of the new money tied to the contract was available to reward practices for providing higher quality services The clinical areas targeted were Stroke/ TIA/ Hypertension/ Diabetes/ COPD/ Epilepsy Hypothyroidism/ Cancer/ Mental health/ Asthma i.e. Not sexual health! � Health and Social Services Boards may also commission a range of National Enhanced Services to provide more specialised sexual health services�� All enhanced services may be commissioned from GP practices or from elsewhere and a practice will not have to provide any of the enhanced services unless it wishes to do so No incentive for primary care to provide sexual health services (or even NCSP!) and effectively ignored the National Strategy for Sexual Health and HIV tier system http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/252/25205.htm

44. Are there any incentives for primary care to provide sexual health services? Financial The cost of PBR �142 for first attendance and �79 for every follow up appointment 2006/7 National Enhanced Services in primary care may be more cost-effective � even taking into account annual retainers Holistic What do patients want? To access care locally The �one-stop shop�! Public Health As medical practitioners we all have a responsibility to do what we can to reduce the onward transmission of infections in the population

45. What about HIV? National Strategy for Sexual Health and HIV �GPs can also make a significant contribution to reducing the number of people with undiagnosed HIV especially for people who are reluctant to use GUM services. HIV testing has always been possible in primary care, although in practice its availability is variable�� In the past people have been put off by concerns about GP�s providing medical reports to insurance companies Updated advice from the Association of British Insurers and the BMA makes it clear that only positive HIV tests will affect insurance

46. HIV Testing Now everyone's responsibility

49. What about long-term HIV care? National Strategy for Sexual Health and HIV All HIV practitioners will be expected to work within a managed service network, which means that all HIV treatment and care should be given within the networks The networks will support non-specialist HIV services in primary care and provide a focus for local training and professional development

50. Predicting the Future�

51. Is there a role for shared care for sexual health between GUM and Primary Care?

52. I think there has to be� More cohesion needed between national strategy and contract incentives Patients want a local service NHS Operating Framework 2007 places renewed emphasis on local priorities and services The majority of tests are not difficult to do Asymptomatic screening is at least providable Increased HIV testing

53. Or shall never the twain meet?

54. Disturbing Symptoms 6 (April 2008) Collaboration between BASHH, BHIVA and THT Annual survey of England�s sexual health and HIV services � specialists and PCTs 68% of those surveyed reported an increase in community/primary care based sexual health services in the last year http://www.tht.org.uk/informationresources/publications

55. What can anyone and everyone do? NCSP

56. What can anyone and everyone do? NCSP More HIV testing

57. What can anyone and everyone do? NCSP More HIV testing Basic STI screen for asymptomatic patients Most at risk are <25 years old New sexual partner last 12 months

59. Are there advances on the horizon to make all our jobs easier? Postal testing Kits for Chlamydia Virtual Clinics? The HPV vaccination programme

60. What can anyone and everyone do? NCSP More HIV testing Basic STI screen for asymptomatic patients ? Warts/HSV treatment Warts: Warticon or Aldara creams at home HSV: Aciclovir 200mg 5xday for 5 days

61. And what should be referred on� MSM At risk of a broader range of STI including gonorrhoea, syphilis, hepatitis B and HIV Potential sites of infection for gonorrhoea include the throat and rectum Rectal Chlamydia is also common. Recent cases of LGV and hepatitis C Therefore a more extensive range of tests are offered to an asymptomatic gay men who has had unprotected anal intercourse Individuals high risk for HIV Men with purulent urethral discharge STI in pregnancy Complicated partner notification issues Unusual genital ulceration Anyone diagnosed with HIV Syphilis Neisseria Gonorrhoeae

62. What about asymptomatic patients who say �my partner has an STI� ? Genital warts No test or treatment for asymptomatic HPV infection Therefore, reassure and offer a chlamydia test Genital herpes Same as for warts Chlamydia Either refer to GUM Or send off urine test, treat and contact trace yourself GUM can offer guidance and support Gonorrhoea and syphilis � refer GUM

63. You cannot do everything� National Strategy for Sexual Health and HIV ��Not all the elements of general sexual health services can be provided easily or economically by every primary care team. Primary care teams with a special interest in sexual health can provide these services to a high standard��

64. What to do if you want to become more involved in STI service provision BASHH www.bashh.org/

66. What to do if you want to become more involved in STI service provision BASHH http://www.bashh.org/ RCGP http://www.rcgp.org.uk/ Toolkit �Confidentiality for Young People� Document �STI in Primary Care�

68. What to do if you want to become more involved in STI service provision BASHH http://www.bashh.org/ RCGP http://www.rcgp.org.uk/ You local GUM clinic www.chestersexualhealth.co.uk

70. What to do if you want to become more involved in STI service provision BASHH http://www.bashh.org/ RCGP http://www.rcgp.org.uk/ You local GUM clinic Attend a local Sexually Transmitted Infections Foundation (STIF) course http://www.bashh.org/education_training_and_careers/stif

72. Conclusion Current service provision is inadequate to meet rising prevalence of STI The National Strategy for Sexual Health and HIV calls for all interested parties to extend their involvement Reducing prevalence requires widespread opportunistic testing, as well as behaviour change Technological advances should allow more self-testing in the future