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Implementation of the National Sexual Health and HIV Strategy- Implications for Health advisers. George Kinghorn. Overview. Current Sexual Health in UK The national strategy for sexual health & HIV Headlines Implementation plan Health advisers - a view of the future.

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implementation of the national sexual health and hiv strategy implications for health advisers

Implementation of the National Sexual Health and HIV Strategy-Implications for Health advisers

George Kinghorn

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

overview
Overview
  • Current Sexual Health in UK
  • The national strategy for sexual health & HIV
    • Headlines
    • Implementation plan
  • Health advisers - a view of the future

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

national survey of sexual attitudes and lifestyles 11 changes between 1990 2000
National Survey of Sexual Attitudes and Lifestyles 11Changes between 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

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

determinants of hiv transmission efficiency
Determinants of HIV transmission efficiency
  • The presence of STIs increases individual susceptibility and HIV transmission.
    • M-F transmission
        • GUD x3; NUD x2
        • BV flora increases risk x4
    • F-M transmission
        • GUD x4; NUD x3

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

slide5

Mental Health

Anogenital Cancers

Unwanted pregnancies

STIs/HIV

Neonatal Infections

Subfertility

Linked Sexual Health Pathologies

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

stis in 2003
STIs in 2003
  • Worsening sexual health and increasing STI
  • Re-emergence of infectious syphilis
  • Antimicrobial resistance in gonorrhoea
  • Uncontrolled chlamydia epidemic in young
  • Long term sequelae of viral STIs
  • Acceleration in newly diagnosed HIV
  • HIV treatable but at enormous expense

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

slide7

Annual New Cases

GUM,Sheffield 1972-2001

Thousands

25

+

20

+

+

15

+

+

Male

+

+

+

+

+

+

+

+

Female

+

+

+

+

+

+

+

+

Total

+

+

+

10

+

+

+

+

+

+

5

+

+

0

75

80

85

90

95

00

Year

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

numbers of new episodes seen in gum clinics united kingdom 1990 to 2001
Numbers of new episodes seen in GUM clinicsUnited Kingdom, 1990 to 2001

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

new diagnoses of selected stis in gum clinics england wales northern ireland 2001
New diagnoses of selected STIs in GUM clinics, England, Wales & Northern Ireland: 2001

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

slide10
Diagnoses of uncomplicated genital chlamydial infection in GUM clinics by sex and age group, UK: 1995-2001*

Males

Females

*Data are currently unavailable from Scotland for 2000 and 2001

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

diagnoses of uncomplicated gonorrhoea in gum clinics by sex and age group uk 1995 2001
Diagnoses of uncomplicated gonorrhoea in GUM clinics by sex and age group, UK: 1995-2001*

Males

Females

*Data are currently unavailable from Scotland for 2000 and 2001

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

projected prevalence of hiv in uk 2000 10
Projected prevalence of HIV in UK 2000-10

Number of individuals in care

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

lifetime treatment costs of hiv in uk 2000 2010
Lifetime treatment costs of HIV in UK2000-2010

£ Billions

Assumes 10 years of treatment

70% eligible

Average £15,000 p.a.

3% inflation

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

background to national strategy
Background to National Strategy

Good sexual health is an important part of physical and mental health.

Sexual health problems in England have grown in recent years.

There are more new HIV infections and sexually transmitted infections are rising.

England has the highest teenage birth rates in Western Europe

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

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

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

headline recommendations prevention
Headline RecommendationsPrevention

New public education campaign

Targeted local prevention campaigns

More responsive national helplines

Development of evidence-base for sexual health promotion

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

headline recommendations services
Headline RecommendationsServices
  • Widened role for primary care
  • Closer working between primary and secondary care
  • Increased community role for sexual health advisers
  • Targeted chlamydia screening to begin 2002
  • Improved access to GUM services
  • Managed clinical networks for HIV and other services

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

local sexual health networks
Local Sexual Health Networks
  • Three levels of service with increasing specialisation
  • Increased patient choice to improve access and uptake
  • Information about and advertisement of local services
  • Identification of local sexual health profile of communities
  • Agreed roles, responsibilities, and referral criteria
  • Education and training of staff

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

features of level one services
Features of Level One services

Sexual history and risk assessment

Contraceptive information and services

STI testing for women

Assessment and referral of men with STI symptoms

HIV testing and counselling

Cervical cytology screening and referral

Pregnancy testing and referral

Hepatitis B immunisation.

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

slide20

Features of Level Two Services

Intrauterine device (IUD) insertion

Contraceptive implant insertion

Testing and treating sexually transmitted infections

Invasive sexual transmitted infection testing for men

(until non-invasive tests are available)

Partner notification

Management of psychosexual problems

Vasectomy

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

features of level three services
Features of Level Three services

Responsibility for sexual health services needs assessment

Supporting provider quality and clinical governance requirements at all levels

Providing specialist services, specialised infections management, including

  • specialised HIV treatment and care.
  • outreach for sexually transmitted infection prevention
  • co-ordination of partner notification, in a variety of settings

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

sti foundation stif courses
STI Foundation (STIF) Courses
  • MSSVD sponsored
  • Attitudes, knowledge and skills based
  • 2-day course regional and local
  • Multidisciplinary audience
    • Primary care doctors and nurses
    • GUM physicians
  • Sheffield course July 2003

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

headline recommendations standards and targets
Headline RecommendationsStandards and Targets
  • National standards for sexual health services
  • Development of care pathways
  • HIV testing to be encouraged
  • Targets to reduce incidence of HIV and gonorrhoea by 2007

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

hiv and sti testing targets in gum
HIV and STI testing targets in GUM

HIV testing

Offer to all at first STI screening

Uptake target 70%

Hepatitis B immunisation

Offer to all HS/BS men at first attendance

Uptake target 70%

Reduction in newly acquired GC and HIV

25% by 2007

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

headline recommendations research and training
Headline Recommendations:Research and Training

Supporting education, training and research agenda

MRC Sexual Health and HIV Research Committee

To develop evidence-base for implementing strategy

STIs to have equal importance to HIV

Evaluation of“one-stop” youth clinics and specialist primary care provision

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

sexual health and hiv strategy for england financial support
Sexual Health and HIV Strategy for EnglandFinancial Support
  • £47.5 million 2000-3
    • Half to introduce chlamydia screening
    • Public Education campaign
  • £5 million to pump-prime GUM services in 2002-3

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

current unmet need in gum
Current unmet need in GUM
  • Few non-appointment clinics remaining
  • Waiting times for routine appointments
    • Increased from 5-6 days in 2000, to 14 days in 2002
  • Numbers waiting longer than 48 hrs calculated to be in excess of 30,000
  • Inevitable adverse public health consequences
    • Increased complications
    • Increased STI and HIV transmission

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

deterioration in gum access median times days to first appointment
Deterioration in GUM AccessMedian times (days) to first appointment

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

additional gum funding required
Additional GUM Funding required
  • Average cost of GUM clinic episode = £150
  • Number of additional episodes
    • Current waiting lists 80,000
    • New demand from education campaign 50,000
    • Total additional capacity required 130,000
  • Funding required p.a. c. £20 million

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

pump priming for gum 2002 3
Pump-priming for GUM 2002/3

Support to expand service access

Current unmet need

Increased demand from education campaign

Clinic allocations

According to caseload in 2000/01

DH requirements

Support for health advisers

New consultant posts to be shared across districts

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

implementation plan immediate priorities 1
Implementation PlanImmediate Priorities (1)
  • Publication of
    • Commissioning and Health Promotion toolkits
    • Training mapping and strategy report
    • African HIV frameworks for prevention and care services, health promotion
  • Disseminate evidence of effectiveness of HIV and STI prevention
  • Improve
    • quality of national helplines
    • Public information and advice on sexual health

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

implementation plan immediate priorities 2
Implementation PlanImmediate Priorities (2)
  • Roll out of chlamydia screening in 10 areas
  • Appoint to Independent Advisory Group
  • Publish standards for HIV care
  • Commission further standards for broader sexual health

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

roll out of chlamydia screening
Roll out of Chlamydia screening

National screening campaign to start in 10 sites

opportunistic

women aged 20-24

Reinfection study in Portsmouth, Wirral

to inform re-screening interval

Development of real-time PCR

near patient-testing (40 minutes to result)

Grant from Capital Modernisation Fund

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

implementation plan immediate priorities 3
Implementation PlanImmediate Priorities (3)
  • Launch new sexual health information and awareness campaign
  • Roll out HIV prejudice and discrimination campaign
  • Monitor investment and progress on strategic implementation nationally

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

best practice in gum
Best Practice in GUM
  • Open access services
  • Same day or next working day attendance following suspicion of an STI
  • Booked appointment within 7 working days
  • Diagnosis and management according to national / regional guidelines
  • Access to female doctor where possible
  • Provision of data according to local, national requirements

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

health promotion and prevention for gum hiv services 1
Health promotion and prevention for GUM / HIV services (1)
  • Routine offer of HIV testing at sexual health screen
  • Pre-test discussion with doctor / nurse / health adviser
  • Ethical HIV testing guidelines with informed consent
  • Offer of condoms and lubricant in absence of infection
  • Safer sex advice and risk reduction education at all stages of consultation
  • Post exposure prophylaxis
  • Partner notification of any potential risk of infection

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

health promotion and prevention for gum hiv services 2
Health promotion and prevention for GUM / HIV services (2)
  • Support for partners and other family members
  • Referral to
    • other agencies in voluntary and statutory sector for support / counselling/ support
    • Other NHS specialties such as drug services, psychology, health promotion, where relevant
  • Regular clinic information and clinical updates
    • Local gay press
    • Publications for African communities

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

best practice in hiv services 1
Best Practice in HIV services (1)
  • Initial appointment with specialist within 2 weeks of initial diagnosis
  • Provision of monitoring and therapy according to national guidelines
  • Referral to specialist in-patient unit
  • Provision of emergency walk-in facilities
  • Encouragement of patient registration and good communication with GPs

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

dh health advisers working group
DH Health Advisers Working Group
  • Set standards for Health adviser practice
  • Update Health advisers manual
  • Advise upon future training requirements
  • Recommendations about future numbers
    • No less than 1 health adviser for each consultant
    • Avoid isolated practitioners
    • Increase to meet outreach community activities

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

changes to health adviser role
Changes to Health Adviser role
  • Partner notification in outreach community settings
    • Level 2 general practice, contraception clinics
    • Focus on high prevalence PCTs
    • Preferably linked to GUM-based team
  • Closer liaison with sexual health promotion
  • Performance assessed against national and local standards

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

modernisation of working practises in gu medicine
Modernisation of Working Practises in GU Medicine
  • Extended role of nurses
    • nurse practitioners
    • follow-up examinations
    • HIV treatment adherence support
  • Reduced follow-ups
    • telephone results line
    • home-based treatments
  • Triage
    • by qualified nurses and health advisers
  • HIV testing
    • use of written pre-test information

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

triage protocols
Triage protocols
  • Triage should only be performed by

trained clinical staff

  • Written protocols essential
    • Symptoms / conditions for urgent access
    • Advice if no suitable clinic session

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

suggested triage protocol
Suggested triage protocol
  • Immediate
    • PEP for HIV infection
    • Underage attenders
  • Urgent (within 24 hrs)
    • Acutely painful conditions
    • Acute psychological distress related to STI
  • Within 48 hrs
    • Known contacts of STI
  • Routine
    • All other conditions
    • Anyone perceiving themselves at risk of STI

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

parliamentary health committee report on sexual health
Parliamentary Health Committee Report on Sexual Health
  • To be published within next month
  • Likely to
    • Comment upon crisis in GUM
    • Emphasize need to growth in consultants and supporting staff
    • Criticise
      • PCT Funding mechanisms
      • Chlamydia screening proposals

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust

summary
Summary
  • Sexual health is firmly on the agenda and is currently being reviewed by Health Select Committee
  • The government views sexual health as “a priority”
  • Primary care ill-prepared and currently unwilling to provide additional sexual health services
  • GUM service overload but new opportunities to expand workforce, modernise facilities and practise
  • Extension of health adviser role and numbers crucial
  • Major challenge to secure increased recurrent funding

Department of GU Medicine, Sheffield Teaching Hospitals NHS Trust