Joint strategic needs assessment

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Sexual Health and HIV (2014)

Topic titleSexual Health and HIV
Topic ownerStrategic Sexual Health Commissioning Group
Topic author(s)Ellyn Dryden, Carl Neal
Topic quality reviewed26/08/2014
Topic endorsed byStrategic Sexual Health Commissioning Group 24th September 2014
Topic approved byStrategic Sexual Health Commissioning Group 24th September 2014
Current versionSeptember 2014
Replaces version2010
Linked JSNA topicsTeenage Pregnancy, Safeguarding, Domestic Violence, Prostitution, Offenders
Insight Document ID64966

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Executive summary

Introduction

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Sexual health covers the provision of advice and services around contraception, relationships, sexually transmitted infections (STIs) (including HIV) and abortion (Department of Health 2013a).

There is a clear relationship between sexual ill health, poverty and social exclusion: the highest burden of sexually related ill-health is borne by groups who often experience other inequalities in health, including gay men, teenagers, young adults, black and minority ethnic groups, and more deprived communities (Department of Health, 2013a).

Sexually transmitted infections (STIs), including HIV, remain one of the most important causes of illness due to infectious disease among young people (aged between 16 and 24 years old). If STIs, including HIV, are not diagnosed and treated early, there is a greater risk of onward transmission to uninfected partners, and a greater risk that complications might occur. Many STIs have long-term effects on health, for example chlamydia can lead to infertility and some infections are associated with cervical cancer (Department of Health 2013a). 

The impact of STIs remains greatest in young heterosexuals under the age of 25 years and in men who have sex with men (MSM). The most commonly diagnosed STI in 2013 was chlamydia. The number of gonorrhoea diagnoses increased by 15% between 2012 and 2013. Reducing gonorrhoea transmission, and ensuring treatment resistant strains of gonorrhoea do not persist and spread remains a public health priority (PHE, 2014b). Large increases in STI diagnoses were seen in MSM, including a 26% increase in gonorrhoea diagnoses. Although partly due to increased testing in this population, ongoing high levels of unsafe sexual behaviour probably contributed to this rise (PHE, 2014b).

Current figures show that some sexually transmitted infection rates are increasing in Nottingham City in line with the trend nationally. In 2012, Nottingham was ranked 22 (out of 326 local authorities, number one has the highest rates) in England for rates of acute STIs.

In the UK the overall prevalence of HIV is 1.5 per 1,000 population (1.0 in women and 2.1 in men) and the proportion of people unaware of their HIV infection is approximately 22%. Nottingham City has a ‘high’ HIV prevalence (2.78 per 1,000 population), higher than both the regional (East Midlands) and national (England) averages. Whilst anyone can contract HIV, certain population groups have higher exposure risk including men who have sex with men (MSM), certain ethnic groups including Black Africans, and migrants from high HIV prevalence e.g. counties in Sub-Saharan Africa (Public Health England, 2013).  Nearly one in two heterosexuals born abroad acquired their infection in the UK; highlighting the need for further prevention.  In 2013, 48% of people diagnosed with HIV were diagnosed at a late stage of infection.  Evidence shows that early treatment helps prevent onward transmission, and for People living with HIV can expect a near normal life expectancy and better clinical outcomes if they are diagnosed early

Whilst there has been a decline in the rate of teenage pregnancies in Nottingham City since 2007, the City still ranks as one of the highest teenage pregnancy rates in England. In 2012, the under 18 teenage conception rate for Nottingham City per 1,000 women was 37.7, compared to 27.7 in England.

Provision of sexual health services is complex and there are a wide range of providers, including general practice, community services, acute hospitals, pharmacies and the voluntary, charitable and independent sector.

Domestic Violence, Prostitution and Teenage Pregnancy are considered elsewhere.

Unmet needs and gaps

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Key issues concerning unmet needs and gaps are summarised in this section, please see section 8 for full detail.

  1. HIV testing and diagnosis:
  • Efforts need to focus on addressing the City’s high HIV prevalence (2.78 per 1,000 population), and late diagnosis (65.8% of new cases)
  • HIV testing needs to be increased within general practice and sexual health services
  • There is currently a limited amount of provision around HIV awareness, prevention and campaigns, including work to reduce stigma associated with HIV in those most at risk
  • More training and education is required to reduce stigma, promote the prevention of HIV and encourage earlier presentation
  1. Chlamydia screening:
  • In order to meet the Public health Outcomes Framework indicator, a good level of coverage for Chlamydia testing is required, ensuring that services are accessible and provided across a range of venues
  1. Primary care services:
  • There are potential gaps in provision of STI screening and LARC services in some localities of Nottingham City
  • There is potential to increase the uptake of STI screening, particularly within general practice, especially in areas of highest need
  • There is a low rate of GP prescribed LARC, compared to the England average (2012/13)
  • Reporting requires improvement in relation to all primary care provision of STI screening (and for Chlamydia treatment) and LARC provision
  1. Secondary care services:
  • Whilst the current GUM and CASH services cover most of the areas of highest need in the city, there are some potential gaps in provision in the high need areas of Aspley and Basford.
  • The sexual health services delivered by NUH are not yet integrated in line with the model proposed during 2012. The services should continue to be integrated in line with best practice to ensure that the model agreed is delivered effectively and according to need.
  • The delivery of clinic in a box by School Nurses and Health Visitors is currently inconsistent. In addition, restrictions on delivery in schools and workload are an issue and will need exploring.

Sexual health promotion and sex and relationship education (SRE):

  • Sex and Relationship Education (SRE) provision across schools is inconsistent.
  • Current websites which provide sexual health information on clinic locations are uncoordinated and out of date. There is no social networking in place for promotion of sexual health clinics and young people’s outreach clinics, this requires development.
  • It is important to continue work on increasing awareness around the signs and symptoms of child sexual exploitation.
  1. Vulnerable groups:
  • There is potential to increase engagement with refugees and asylum seekers in terms of early identification of HIV
  • Appropriate screening methods should be considered for testing in line with the needs of vulnerable groups
  1. Local termination of pregnancy services:
  • The local authority will need to work closely with the CCG around future commissioning arrangements to ensure services are fully linked into sexual health services in the area
  1. Local Sexual Health strategy
  • There is currently no sexual health strategy for the City

Nottingham City is developing an HIV Strategy and Action Plan.

Recommendations for consideration by commissioners

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HIV testing and diagnosis:

  • Increase access to HIV testing by targeting vulnerable populations to reduce late diagnosis. Whilst recognising that whilst anybody can become infected with HIV, local trends suggest that some groups have a higher proportion living with HIV such as Black African men and women (many of whom are migrants) and gay and bisexual men.
  • Ensure commissioning arrangements support effective HIV prevention and screening services.
  • Local Authority Commissioners will need to work with NHS England local Area Teams to ensure effective and coordinated HIV treatment and care and ensure clear pathways exists to facilitate effective HIV treatment and care.
  • Ensure systems are in place to deliver effective monitoring of HIV resources and available data within Nottingham City.
  • Increase the role of Primary Care including general practice in HIV Testing, therefore increasing both the skills training and the role of GPs and nurses particularly in high prevalence areas.
  • Increase Point of Care Testing (POCT); also known as rapid antibody tests, defined as medical testing at or near the site of patient care and allows screening to be taken outside the hospital environment.
  • Explore and quantify the health needs for HIV counselling services and clarify the level of support required.
  • Ensure data is available to inform service development and commissioning

Chlamydia Screening:

  • Continue to reinforce good practice in line with Chlamydia screening, ensuring that testing remains accessible to young people through a range of commissioned services
  • Ensure outreach provision is targeted at young people who have limited access to sexual health services (homeless young people, looked after young people and those leaving care, youth offenders and BME young people)
  • Ensure internet testing services are not duplicated. Internet testing kit return rates should be high (approximately 75%) and positivity percentage should match the city average
  • Consider expanding internet testing services, which prove to be effective in Nottingham City
  • Consider the offer of home testing kits to be sent 3 months following a positive Chlamydia diagnosis, this will aim to reduce reinfection rates
  • Ensure the message of annual screening and additional testing on each change of partner is promoted to young people
  • Continue to promote adherence to treatment and partner notification professional guidelines

Primary care sexual health services:

  • Review overall provision of STI screening and treatment, and LARC provision as part of the re-procurement of LCPHS.
  • Commission STI screening and LARC provision in localities where there are some potential gaps in provision
  • Ensure a review of primary care provision of existing sexual health ‘Locally Commissioned Public Health Services’ (LCPHS)
  • Develop commissioning plans for the reprocurement of sexual health ‘Locally Commissioned Public Health Services’ post April 2015
  • Identify geographical areas of need, and work with providers to increase activity levels of STI (sexually transmitted infections) testing including HIV testing, and increase take-up of LARCs (long-acting reversible contraception)
  • Continue to work with community pharmacies to provide treatment for Chlamydia

Secondary care sexual health services:

  • Ensure the delivery of an integrated sexual health service is implemented and that services are in line with best practice and need
  • Ensure prevention efforts are maintained, with a focus on groups at highest risk such as young people, persons of black ethnicity and MSM. This is vital to control STI transmission
  • Ensure all sexual health clinical venues are You’re Welcome accredited by March 2015
  • Shadow the Integrated Sexual Health Tariff to inform the development a cost effective model for commissioning and providing sexual health services in Nottingham City
  • Ensure sexual health clinics are in line with areas of high need by mapping access to sexual health clinics and primary care services, including the uptake of LARC
  • Following the integration of sexual health services, undertake a health equity audit of all sexual health services to ensure they are accessible to the whole population
  • Develop the link between Public Health Nurses for Children and Young People and community sexual health services through the new school health model
  • Develop the provision of clinic in a box through Public Health Nurses, linking with the Sexual Health Promotion facilitator in the new school health service model
  • Ensure that all mainstream youth services and the Youth Offending Team offer C-Card and proactively promote information about the full range of contraception and NUH Sexual Health services

Sexual health promotion and sex and relationships education (SRE):

  • Review the provision of sex and relationships education in schools to inform and develop consistent provision
  • Fully evaluate the Awaredressers project
  • Carry out engagement activity to establish how, when and where people would like to receive information about local services
  • Improve access to up-to-date sexual health service provision information through the development of a co-ordinated sexual health website for Nottingham City and Nottinghamshire County

Vulnerable groups:

  • Continue the provision of specialist services for prostitutes/ sex workers to meet relevant needs. Ensure services provide screening and treatment, contraception, vaccinations, health promotion and access to other support all in one site
  • Review the sexual health service access pathway for young offenders and develop accordingly
  • Continue to ensure sexual health services are accessible and meet the needs of MSM and LGBT communities, including appropriate testing

Termination of Pregnancy Pathway Development:

NHS Nottingham City CCG in conjunction with the Local Authority and TOP providers has committed to supporting a review of the TOP pathway in order to establish that accessibility, quality and value for money is being achieved. Initial scoping meetings and planning has commenced and the following actions have been identified as required in 2013/14:

  • Review of the pathway and commissioned services working closely with commissioners, clinicians, service users, service providers, public health and the local authority to include:
    • Needs assessment and capacity planning/gap analysis
    • Service/pathway design, redesign and transformation with a strengthened governance and supervision structure
    • Best practice review and service specification development including the development of a TOP provider network
    • To analyse and use information (health needs assessment, activity levels, benchmarking data etc.) to develop service improvement / development plans taking into consideration funding, workforce implications and information technology requirements.
    • To develop a robust performance management framework to monitor progress against implementation of the pathway.

Joint working:

  • The local authority will need to work with the CCG and NHS England to ensure that the care and treatment people receive is of a high quality and is not fragmented, this should include:
  • Offering comprehensive and seamless HIV testing and treatment services
  • Ensuring future commissioning arrangements for termination of pregnancy services continue to embed the improvement of sexual health and reduce the risk of repeat unwanted pregnancy

Agree pathways and commissioning arrangements for services associated with and taking place in sexual health services (e.g. menorrhagia and cervical screening) with appropriate commissioners, taking a whole system approach and using the ‘making it work’ commissioning guide for sexual health, reproductive health and HIV.

What do we know?

1. Who is at risk and why?

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Sexual health needs vary according to factors such as age, gender, sexuality and ethnicity, and some groups are particularly at risk of poor sexual health. It is crucial that individuals are able to live their lives free from prejudice and discrimination (Department of Health, 2013a). Groups who are most at risk of poor sexual health and may experience barriers to accessing services include: women, young people; asylum seekers and refugees; black and minority ethnic groups; single homeless people; men who have sex with men (MSM) and those who identify as gay and bisexual men; sex workers and young people who are being sexually exploited or at risk of becoming involved in selling sex; looked after young people and care leavers; intravenous drug users; (IDUs) people with learning disabilities and learning difficulties, as well as young people with low educational achievement; people in prisons and youth offending institutions; young offenders; young people not in education, training or employment.

Young People

Most people become sexually active and first start forming relationships between the ages of 16 and 24. Young people in these age groups have significantly higher rates of poor sexual health, including STIs and termination of pregnancies, than older people (Department of Health 2013a).  In 2013, among heterosexuals diagnosed in GUM clinics, 63% with chlamydia, 56% with gonorrhoea, 54% with genital warts, and 42% with genital herpes were aged 15 to 24 years (Public Health England, 2014b). The latest (2011) mid year estimates show that the City has a very high proportion (28%) of people aged 18 to 29 (ONS Census 2011).

Disability

It is estimated that there are more than one million people living in England with a learning disability, but research has found that young people with learning disabilities do not have good access to sex and relationship education or information (CHANGE, 2010).There is little data available on the sexual health of people with disabilities as this is not yet included in any of the national sexual health datasets. 

Gender

The sexual health needs of people will vary according to their gender (Department of Health, 2013a), particularly in respect of the provision of contraception and termination of pregnancy services.  However people of all genders, including transgender people, can be affected by STIs and the health needs of other groups such as sex workers is likely to differ according to their gender.

Ethnicity

In 2013, the highest rates of STI diagnoses were found among persons of black ethnicity, and the majority of these cases were among persons living in areas of high deprivation, especially in urban area. This high rate of STI diagnoses among black ethnic communities is most likely the consequence of a complex interplay of cultural, economic and behavioural factors. Additionally, risk behaviours and STI epidemiology vary between black African and Caribbean ethnic groups (Public Health England, 2014b).

While anyone can contract HIV, black African men and women were the second largest group affected by HIV, with 38 per 1,000 living with the infection (26 per 1,000 men and 51 per 1,000 women).  Of the 31,800 black African men and women newly diagnosed with HIV, 23% remained unaware of their infection.

Over the past five years, an estimated 1,000 black African men and women probably acquired HIV in the UK annually.  It is estimated that approximately 48% of heterosexuals born abroad acquired their infection in the UK, and this highlights the need for further prevention efforts particularly those born aboard particularly in sub-Saharan countries and highlights the need for further prevention efforts, particularly among black African communities (PHE, 2013a). 

Late diagnosis is the most important predictor of morbidity and short-term mortality among those with HIV infection.   In 2011, the proportions of HIV diagnosed late among black African and black Caribbean heterosexual men was 66%, compared to 47% in white heterosexual men. Among women, the proportion diagnosed late was highest among black African (61%) and black Caribbean (47%), compared to 44% in white women (PHE, 2013a).

Sexual Orientation

In England in 2013, among male GUM clinic attendees, 81% of syphilis diagnoses, 63% of gonorrhoea diagnoses, 17% of chlamydia diagnoses, 11% of genital herpes diagnoses and 8% of genital warts diagnoses were among MSM. The number of diagnoses of STIs reported in MSM has risen sharply in recent years and accounts for the majority of increased diagnoses seen among men. Gonorrhoea diagnoses increased by 26% in the past year, syphilis diagnoses by 12%, chlamydia diagnoses (from GUM) by 11%, and genital herpes diagnoses by 7% (Public Health England, 2014b).

New diagnoses of HIV among MSM have been increasing since 2007.  During the first decade of the 21st Century, acquisition of HIV in heterosexuals surpassed the number of new diagnosis in MSM, however, MSM once again remain the group most affected by HIV.  In 2012, it was estimated that with 47 per 1,000 MSM were living with the infection.  This is equivalent to an estimated 41,000 MSM, of whom 7,300 (18%) were unaware of their infection (Public Health England, 2013a).

Direct and indirect measures of incidence show that the rate of HIV transmission in this population remains high. The overall prevalence of HIV in 2012 was 1.5 per 1,000 population (Public Health England, 2013a), with the highest rates reported among men who have sex with men (MSM) (47 per 1,000) and the black African community (37 per 1,000). Almost two-thirds of MSM newly diagnosed as HIV infected at an STI clinic had not attended that clinic for testing in the previous three years, which strongly suggests there is room for improvement in the frequency of testing by those at highest risk (HPA, 2012a).

Evidence suggests that gay and bisexual men who use particular illegal drugs (as well as alcohol) are more likely to engage in risky sex (Stonewall, 2011).Lesbians and bisexual women are often believed to be the healthiest adult population group. Many assume they cannot contract STIs and that they are at low (or no) risk in comparison with heterosexual women. There is also a widespread assumption that lesbians have never had sex with men; however, one UK study showed that 85% of lesbians had previously had sex with men (Department of Health, 2007). In addition, 40% of women attending GUM clinics who had exclusively female partners received an STI or other diagnosis, compared to 18.5% of women who had sex with men (The Lesbian and Gay Foundation, 2013).

Nearly 60% of lesbian and bisexual women say that it’s hard to find information about sexual health that is relevant to them and 45% say that being lesbian or bisexual means that they have less access to sexual health services. 25% report having bad experiences in sexual health services because of their sexual orientation (The Lesbian and Gay Foundation, 2013).

People Who Inject Drugs (PWID)

An estimated 2,200 people who inject drugs were living with HIV in the UK in 2012, of whom 300 were unaware of their infection.  The prevalence of HIV amongst this population was 13 per 1,000 (95% C.I. 9.4 – 17 per 1,000) in England, Wales and Northern Ireland.  Amongst people who injected drugs for the first time in the preceding three years, HIV was 10 per 1,000 (95% C.I. 2.9. – 27 per 1,000) in 2012.  This is similar to prevalence found in 2011, indicating transmission is on-going albeit at a low level (PHE, 2013a).

PWID are vulnerable to infection, not only through their injecting practices but also through their sexual behaviour (USAID, 2007; Strathdee and Sherman, 2003). PWID have been found to be more likely to report a recent STI than non-injecting drug users (Cheng et al., 2010), to have low rates of consistent condom use; to frequently report multiple sexual partners and to face barriers to accessing HIV/STI testing and treatment services (USAID, 2007). Infections, such as HIV and hepatitis B and C virus infections, acquired through unsafe injecting, can then be spread into the wider population through risky sexual behaviour (Strathdee and Sherman, 2003).

Homeless People

Homeless people are at an increased risk of STIs and unwanted pregnancies and can come under pressure to exchange sex for food, shelter, drugs and money. This makes it vital to address the health needs of this group (Department of Health, 2013a). There is little data available on the sexual health of homeless people in Nottingham City.  This is an area that will need further work in the future.

Offenders and Prisoners

People convicted of a crime who are accommodated in prison are included in the Nottingham City JSNA chapters on Offenders, this also includes the health needs of youth offenders.  However, the sexual health needs of youth offenders are within this remit. A health needs assessment for youth offenders in Nottingham City was completed in February 2012, which systematically assessed the health needs of Young Offenders who are in contact with the Youth Offending Team (YOT) in Nottingham City, primarily with regards to emotional well-being, substance misuse, sexual health and physical health.

Sex workers / Prostitutes

Some prostitutes are at higher risk of poor sexual health outcomes. Prostitutes also experience vulnerabilities such as violence, rape and sexual assault, homelessness, and drug and alcohol problems that may impact on their sexual health needs. There is a strong need for specialist services to be available because of the barriers prostitutes face in accessing mainstream services:

  • The legal framework around prostitution makes some wary of disclosure to health professionals.
  • They might fear stigma and judgemental attitudes.
  • For some leading chaotic lives, particularly those affected by drug and alcohol abuse, accessing services with standard opening hours is challenging.
  • Access to services, particularly for those who are being trafficked, coerced or ‘pimped’, might be controlled by others.

(Department of Health, 2013a)

Safeguarding is considered elsewhere.

Wider determinants of sexual health; social class

There is evidence that those groups for social class five (manual unskilled) are more at risk of poor sexual health and that for younger people they experience higher rates of sexually transmitted infections. (Department of Health 2013a).

Research using the Office for National Statistics Longitudinal study has shown that the risk of unintentionally becoming a teenage mother is ten times higher among girls in social class five (manual unskilled) than in social class one (professional). Children in care and children of teenage mothers are also more likely to become teenage mothers, as are girls of Bangladeshi, Pakistani and Afro-Caribbean origin. Data also suggests that those young women who have higher educational aspirations are more likely to opt for a termination of pregnancy (Health Development Agency, 2004).

2. Size of the issue locally

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Sexually transmitted Infections

In 2012, Nottingham was ranked 22 (out of 326 local authorities, first in the rank has highest rates) in England for rates of acute STIs. 4,247 acute STIs were diagnosed in residents of Nottingham, a rate of 1397.5 per 100,000 residents. 67% of diagnoses of acute STIs were in young people aged 15-24 years. The rate of chlamydia diagnoses per 100,000 young people aged 15-24 years in Nottingham was 2813.2 in 2012 (PHE, 2012, LASER).

Between 2012 and 2013, all new STIs (all ages) increased by 16.2%, compared to an increase by 6% in the East Midlands and a decrease by 1% in England. The rate of genital warts decreased between 2012 and 2013 by 3.7% (185.6 to 178.8 per 100,000 population), compared to a decrease by 2% in the East Midlands and a decrease by 1% in England. The gonorrhoea diagnosis rate increased between 2012 and 2013 by 61.7% (82.3 to 133.1 per 100,000 population), compared to 15% in England (47.8 to 54.8).

Figure 1: Diagnosis rate of all acute STI’s in Nottingham City diagnosed by GUM services in 2012

Fig1.png

 

Figure 1 shows STI’s diagnosed in GUM on a map of Nottingham City. The map suggests areas with some of the highest rates of STI’s are: Bilborough, Aspley, Basford, Bulwell, Bestwood, Sherwood, Mapperley, St Ann’s, Berridge and Arboretum. This suggests that the Central and North of Nottingham City has higher rates of STI’s than the South.

Benchmarking STI rates

Benchmarking Nottingham against similar Local Authorities (ONS centres with industry B) for rates of acute STIs is shown in figure 2. The rate per 100,000 population for all acute STI’s in Nottingham is higher than all similar local authorities and the England average.

Figure 2. All acute STI rates per 100,000 total population, 2013

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Source: Number and rates of acute STI diagnoses in England, 2009-2013, Public Health England

Figure 3 indicates that Nottingham City has higher rates of Chlamydia, Gonorrhoea and Herpes than all similar local authorities.

Figure 3. Acute STI rates per 100,000 total population (all ages), 2013

Area of residence

Chlamydia

Gonorrhoea

Herpes

Syphilis

Genital warts

England

390.2

54.8

60.3

6.1

137.2

Nottingham

914.4

133.1

88.4

2.9

178.8

Barking and Dagenham

391.5

80.8

76.6

6.8

144.8

Birmingham

530.6

89.5

60.7

4.2

133.5

Leicester

479.5

54.0

69.4

2.7

115.8

Manchester

619.8

123.9

81.6

16.1

207.1

Sandwell

372.9

61.0

54.3

1.3

110.2

Wolverhampton

403.6

60.2

56.6

2.0

125.9

 

Source: Number and rates of acute STI diagnoses in England, 2009-2013, Public Health England

Reinfection with STI’s

Reinfection with an STI is a marker of persistent risky behaviour. In Nottingham, an estimated 10.5% of women and 15.7% of men presenting with an acute STI at a GUM clinic during the four year period from 2009 to 2012 became reinfected with an acute STI within twelve months. Nationally, during the same period of time, an estimated 9.6% of women and 12% of men presenting with an acute STI at a GUM clinic became reinfected with an acute STI within twelve months (PHE, LASER, 2012).

In Nottingham, an estimated 4.9% of women and 3.9% of men presenting with gonorrhoea became reinfected with gonorrhoea within twelve months. Nationally, an estimated 3.8% of women and 7.3% of men presenting with gonorrhoea became reinfected with gonorrhoea within twelve months (PHE, LASER, 2012).

Chlamydia

Since chlamydia is most often asymptomatic, a high diagnosis rate reflects success at identifying infections that, if left untreated, may lead to serious reproductive health consequences. Public Health England recommends that local areas achieve a rate of at least 2,300 per 100,000 resident 15-24 year olds, a level which is expected to produce a decrease in chlamydia prevalence.

In 2013, the chlamydia diagnosis rate in 15-24 year olds in Nottingham was 2,893 per 100,000. 31.8% of 15-24 year olds were tested for chlamydia with a 9.1% positivity rate. Nationally, 24.9% of 15-24 year olds were tested for chlamydia with a 8.1% positivity rate. The number of tests, annual coverage and positivity for Nottingham are shown in figure 4.

Figure 4. Chlamydia testing data in 15-24 year olds in Nottingham, 2013

 

Number of chlamydia tests in GUM

Number of Chlamydia tests in other settings

Total number of tests

Number of positives (all settings)

Percentage of population tested (all settings)*

4,244   

18,485

22,729

2,071

31.8

*Repeat tests are not excluded

Source: Chlamydia testing data for 15-24 year olds in England 2013, Public Health England

Source: Chlamydia testing data for 15-24 year olds in England 2013, Public Health England

Figure 4 indicates that approximately 19% of all Chlamydia tests in Nottingham City were carried out at GUM.

Figure 5 indicates that Nottingham City has higher rates of Chlamydia diagnoses than all other similar local authorities (ONS centres with industry B).


Figure 5: Chlamydia diagnosis rate per 100,00 population of 15-24 year olds, 2012

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Source: Chlamydia testing data for 15-24 year olds in England 2013, Public Health England

STI Prevention groups

Young people

Figure 6. Age group and gender of cases of acute STIs in Nottingham, 2012

6.PNG

Source: PHE LASER Report, 2012

Young people between 15 and 24 years old experience the highest rates of acute STIs. In Nottingham, 67% of diagnoses of acute STIs were in young people aged 15-24 years. The age profile is shown in figure 6.

Young people are also more likely to become reinfected with STIs, contributing to infection persistence and health service workload. In Nottingham, an estimated 8% of 15-19 year old women and 11.2% of 15-19 year old men presenting with an acute STI at a GUM clinic during the four year period from 2009 to 2012 became reinfected with an STI within twelve months. Teenagers may be at risk of reinfection because they lack the skills and confidence to negotiate safer sex.

Men who have sex with men (MSM)

In Nottingham in 2009 to 2012, for cases in men where sexual orientation was recorded, 6.1% of acute STIs were among MSM (PHE LASER Report, 2012).

Ethnic group and country of birth

The proportion of acute STIs diagnosed in GUM clinics by ethnic group is shown in figure 7. Where recorded, 14.7% of acute STIs diagnosed in Nottingham were in people born overseas (PHE LASER Report, 2012).

Figure 7. Number and proportion of acute STIs diagnosed in GUM clinics by ethnic group, 2012

 

Ethnic Group

Percentage %

Not specified

0.7

Other ethnic groups

1.5

White

63.8

Mixed

6.1

Black or Black British

25.2

Asian or Asian British

2.7

Source: PHE LASER Report, 2012

Figure 8. The rate per 100,000 of acute STIs by ethnic group in Nottingham and England, 2012

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Source: PHE LASER Report, 2012

Figure 8 indicates that Nottingham City has higher rates of STI’s diagnosed in White and Black ethnic groups compared to England.

Sex workers/prostitutes

There are an estimated 130-150 female street sex workers currently working in the Nottingham City area, with a further 100-200 off street sex workers working in saunas, brothels, massage parlours or from their own homes.  There are also a number of male street prostitutes, working largely from public toilets around the city. Prostitution is continuously reducing visibility due to advances in technology, especially through social networking.

Young Offenders

In 2010/11 the youth offending population in contact with the Youth Offending Team (YOT) was 469. Data from contraception and sexual health services (CASH) (outreach clinic at the YOT) for 2010 to 2011 shows that there were 189 new Nottingham City YOT clients and 227 returning clients. As 40% of all young offenders in 2010/11 accessed the clinic, it can be assumed that this is a significant health need.

Figure 9: Percentage of young offenders and the general population accessing CASH outreach at the YOT by age (2010/11)

9.PNG

Source: Health needs assessment of young offenders in Nottingham City (2012)

Amongst the young offender population, the proportion accessing CASH appears to be highest in the 12 -13 year age group. Those aged 18-19 years accessed CASH significantly less than the younger age groups. A different pattern of access is found in the general population which has the lowest proportion accessing CASH amongst the youngest age groups and access increases with age. This indicates that young offenders may have increased sexual health needs at a younger age than the general population and that sexual health needs becomes more similar to the general population as the young offenders get older.

HIV

The number of HIV diagnosed persons in Nottingham City has been steadily increasing since 2006. Between 2008- 2012, there was a 32.6% increase in the number of HIV diagnosed persons in Nottingham City.  (SOPHID data 2012). In 2012 there were a total of 606 persons with diagnosed HIV living locally. This compares to 563 persons in 20111 and equates roughly to a rise of between 30-40 new cases diagnoses each year.

Within Nottingham City, 70% of new HIV diagnoses in 2013 were in males. The highest new infection rates were amongst adults aged between 25-44 years representing 57% of all overall diagnoses in Nottingham City. 19% were in people aged less than 25 years; 19% of all new diagnosis was in people aged between 45-54 years; and just over 5% were in people aged 55 years and over.

Of all the new HIV diagnoses in Nottingham City in 2013, 59% were in the ‘Black- African’ and ‘Black Caribbean’ and ‘Black other unspecified’ community.  (PHE, SOPHID, 2013).  Within these three ethnic groups 64% of new diagnoses were in males and 36% in females.

In 2013, heterosexual transmission of HIV remains the main route of transmission for residents of Nottingham City, with 59% of diagnoses in this exposure category.  This is higher than the national figures recording 47% acquisition via heterosexual contact. HPA/PHE data identifies that throughout the last 13 years of data, heterosexual transmission of HIV remains significantly higher than acquisition amongst any other group including MSM.  30% of all new transmission of HIV was by MSM. 

In 2012, Nottingham City’s HIV prevalence was 2.78 per 1000 of the population (Public Health England, 2013), exceeding the national threshold recommended for universal screening in GP practices and acute hospital admissions, which is set at 2.0 per 1000 of the population.

In Nottingham City, between 2010 and 2012, 66% of new diagnoses were made late (CD4 <350) and 42% made very late (CD4 <200). This is an increase when compared to the period 2006-10, when 62% of new diagnoses were made late and 35% very late.  This is considerably poorer than other high prevalence areas in England.

Figure 10: Local comparisons of proportions of individuals diagnosed ‘Late’ and Very Late within 91 days of HIV diagnosis, resident in England, all Risk Groups: 2012

 

 

Prevalence of HIV (per 1,000 among persons aged 15-59)

Proportion late diagnosis (CD4>350mm3)

Proportion very late diagnosis

(CD4>200mm3)

 

 

England

2.05

47%

28%

 

 

Nottingham

2.78

66%

42%

 

 

Barking and Dagenham

5.73

56%

34%

 

 

Birmingham

2.31

51%

28%

 

 

Leicester

3.55

62%

28%

 

 

Manchester

5.7

54%

29%

 

 

Sandwell

2.03

58%

36%

 

 

Wolverhampton

2.46

58%

35%

 

 

Source:  Public Health England (SOPHID data 2012).

Late diagnoses of HIV are those made at a point after which treatment should have been initiated, and is a significant factor that affects the prognosis. Individuals diagnosed late carry a tenfold increased risk of dying within a year of diagnosis due to an impaired response to Antiretroviral (ARV) therapy, poorer clinical outcomes and increased healthcare costs. Knowledge of a person’s HIV status is also associated with a reduction in risky behaviours. An earlier diagnosis can prolong life, reduce transmission, and has been demonstrated to be cost-effective.  In Nottingham City, in 2012, 64% of persons living with HIV were of Black African or Black Caribbean ethnicity.

Within Nottingham City, there are wide geographical variations in where cases of HIV are diagnosed, with low rates in areas such as Wollaton East and Lenton Abbey, Clifton South, to significantly higher rates in areas such as Aspley, St Ann’s and Bestwood. NB. For Bridge and north Bestwood data indicated either no recorded or low recorded HIV prevalence.

Figure 11 illustrates this variation in prevalence of HIV by Medium Super Output Area (MSOA) of residence in 2012, whilst Figure 6 shows the regional variation of prevalence rates.

Figure 11: Prevalence of HIV by Nottingham City MSOA (Medium Super Output Area), 2012.

11.PNG

 

Source:  Public Health England (East Midlands) SOPHID data, 2012

The highest rates of HIV diagnoses in Nottingham were found among persons classified as deprived by the Index of Multiple Deprivation (IMD).  In 2012, 72% of persons with an HIV diagnosis are classified as being in the highest deprivation quintile. (SOPHID 2012)

Figure 12. HIV testing and coverage. 2013

 

Indicator

Period

Nottingham

East Midlands

 England

Compared with England

HIV testing uptake, MSM (%)

2013

93.9%

96.3%

94.8%

 

HIV testing uptake, women (%)

2013

83.7%

83.2%

75.8%

 

HIV testing uptake, men (%)

2013

85.1%

86.7%

84.9%

 

HIV testing coverage, MSM (%)

2013

83.0%

87.1%

86.1%

 

HIV testing coverage, women (%)

2013

79.1%

74.0%

65.6%

 

HIV testing coverage, men (%)

2013

79.7%

79.3%

77.5%

 

Contraception

Figure 13. Contacts with women at community contraceptive clinics by age group 2012/13

 

 

Total first contacts with women
(all reasons)

Total first contacts with Women
(Contraception reasons only)1

Percentage of first contacts with women under 20
(all reasons)

Percentage of first contacts with women aged 20-34
(all reasons)

Percentage of first contacts with women aged 35 & over (all reasons)

 

 

 

 

 

 

England

1,199.1

897.6

27

52

20

Nottingham University Hospitals NHS Trust

15.3

11.3

32

54

15

 

Source: Health and Social Care Information Centre, NHS Contraceptive Services: England, 2012/13

During 2012/13 NUH community contraceptive clinics had a higher percentage of women under 20 and aged 20-34 accessing services compared to the England average. The percentage of first contact with women aged 35 and over was lower than the England average. However, this reflects NUH as a provider and not residents of Nottingham City, NUH also provide community contraceptive clinics for the south of Nottinghamshire County.

Figure 14. Percentage of total first contacts with women at community contraceptive clinics by method of contraception 2012/13

14.PNG                                               

During 2012/13 the percentage of total first contacts at NUH community contraceptive clinics was higher than the England average for LARC methods and lower than the England average for user dependant methods. However, this reflects NUH as a provider and not residents of Nottingham City, NUH also provide community contraceptive clinics for the south of Nottinghamshire County.

The rate of GP prescribed LARC during 2012/13 per 1,000 female population aged 15-44 in Nottingham City (46.0) was lower than the England average (49.0) (PHE, sexual and reproductive health profiles).

Overall, contraception data suggests that uptake may need to increase within primary care.

Teenage conceptions and termination of pregnancy

Whilst there has been a decline in the rate of teenage pregnancies in Nottingham since 2007, the City still ranks as one of the highest teenage pregnancy rates in England.

In 2012, the under 18 teenage conception rate for Nottingham City per 1,000 women was 37.7, compared to 27.7 in England and compared to Nottingham City rates of 54.4 in 2010 and 61.5 in 2009 (ONS, 2011). There are areas of the City with rates that are over twice times the national average rate conceptions per 1000 women age 15-17. In 2012 the termination of pregnancy rate for Nottingham City (10 per 1,00 in under 18 years and 19 per 1,000 in 18-19 years) was lower than the national average (13 per 1,00 in under 18 years and 26 per 1,000 in 18-19 years).

At lower geographical level, annualised 2010 teenage conception rates per 1000 women aged 15-17 were highest in Arboretum (81/1000), Aspley (77/1000), Bulwell (71/1000), Basford (67/1000), St Ann’s (67/1000) and Bestwood (56.3/1000). The percent of pregnancies that end in termination is low for Arboretum (17%), Radford and Park (21%) and is highest for Basford at 50% and Wollaton East at 57%.  A high percentage of pregnancies ending in termination may indicate higher need for access to contraceptive and health promotion services. Teenage pregnancy and termination of pregnancy is also considered elsewhere in the Teenage Pregnancy JSNA chapter.

3. Targets and performance

Back up to the contents

The importance of sexual health is acknowledged by the inclusion of three indicators in the national Public Health Outcomes Framework 2013-2016 (Department of Health, 2012):

  • Under 18 conceptions
  • Chlamydia diagnosis
  • People presenting with HIV at a late stage of infection

Delivering improvement against these three sexual health indicators will remain a key focus for the local authority to make significant improvements in services until 2016.

Figure 1 shows mixed results for local acute STI rates in 2013.  Whilst Nottingham City has a lower Syphilis rate when compared to the England average, Gonorrhoea rates were significantly higher.   It is not clear from this data alone why the rate of Gonorrhoea rates is higher than other areas and why over the last year it has increased significantly. It is recommended that the reasons for this recorded increase are looked at further and the Nottingham University Hospital NHS Trust is undertaking an audit to investigate.  Genital warts and genital herpes diagnosis rate diagnosis rate are also higher than the national average.  The proportion of young people aged 15-24 screened for Chlamydia is higher than the regional and national average and the diagnosis rate of 28.9 per 1,000 is higher than the national target of 2.3 per 1,000.

Figure 1. Acute STI rates per 100,000 population, 2013

 

Indicator

Nottingham

East Midlands

 England

Compared with England

Total acute STIs

1596.2

745.8

834.2

 

Syphilis diagnosis rate

2.9

2.1

5.9

 

Gonorrhoea diagnosis rate

133.1

37.4

52.9

 

Chlamydia diagnosis rate / 100,000 aged 15-24 (PHOF indicator 3.02)

2,893

2,171

2,016

 

Chlamydia proportion aged 15-24 screened

31.8%

27.6%

24.9%

 

Genital warts diagnosis rate

178.8

117.1

133.4

 

Genital herpes diagnosis rate

88.4

53.9

58.8

 

 

4. Current activity, service provision and assets

Back up to the contents

Since 1st April 2013, most sexual health services are now commissioned by local authorities, but Clinical Commissioning Groups (CCGs) and the NHS England also have a role.

Services commissioned by the local authority:

Nottingham University Hospitals (NUH) Sexual Health Services

An integrated sexual health service model is currently being implemented by Nottingham University Hospitals (NUH) Trust. This aims to improve sexual health by providing easy access to services through open access ‘one stop shops’, where the majority of sexual health and contraceptive needs can be met at one site, usually by one health professional, in services with extended opening hours and accessible locations. In addition, services will be delivered that are acceptable and accessible to people disproportionately affected by unwanted pregnancy and sexual ill health. The current model operates as detailed below:

Genito-Urinary Medicine (GUM):

Nottingham City Hospital site is the central referral centre for sexual health screening. Patients can either self refer to the service or be referred by their General Practitioner. It operates both an appointment and walk in service, an appointment can be offered within 2 working days at a variety of community clinics sited in the City areas of highest need. Services provided include tests, treatment and advice for sexually transmitted infections, full sexual health screening, HIV tests, same day HIV testing by appointment, pre- and post-HIV counselling, psycho sexual counselling, free

Condoms, interpreters available by arrangement in advance. A LARC contraception clinic is now being provided at the GUM site alongside STI testing (bookings only).

Patient attendance figures during 2013/14 were in excess of 17,000.

Victoria Health Centre:

The Victoria Health Centre site is the specialist central site, with patients accessing from across Nottingham City and Nottinghamshire. The service provides a fully comprehensive contraceptive service offering all methods of contraception alongside asymptomatic sexually transmitted infection screening for Chlamydia, Gonorrhoea, Syphilis and HIV and treatment for Chlamydia. It manages the unplanned pregnancy advisory clinic with onward referral for termination of pregnancy to a variety of providers. The centre leads on the training and education of a variety of professionals including a regular intake of medical students on placements.

Five community contraception clinics are currently being provided across Nottingham City located in the areas of highest need. One community clinic is a fully integrated sexual health clinic, providing CaSH and community GUM services (Clifton Cornerstone), with three more clinics to still be integrated. One community hub will provide a GUM service specifically for men including the offer of point of care HIV testing and one community hub will be specialised in delivering services to young people.

Spoke Clinics and GP Partnerships will be located in Nottingham City. These will provide contraceptive services in primary care settings, including investigations and treatment of problems with oral contraceptives and IUCD insertion.

Patient attendance figures during 2013/14 were in excess of 18,500

NUH Sexual Health Outreach Service:

Young people’s outreach clinics are provided in a number of community and primary care locations throughout Nottingham City in a variety of accessible settings (colleges, LIFTS, health centres). Further outreach clinics are also provided to target those most at risk of poor sexual health, these include: Prostitute Outreach Workers, Women’s refuge, and Men’s Saunas.

A counselling/emotional well-being service is provided for those identified as most at risk of poor sexual health by providing sexual health information and interventions to enable individuals to exercise healthier choices in their sexual relationships and minimise risk taking behaviour.

The sexual health outreach service also provide specialist health promotion sessions within the local community to those most at risk of poor sexual health, in order to increase knowledge and skills to support positive sexual health behaviours and increase appropriate access to sexual health services, information, support and advice.

Specific health promotion is provided for gay and bisexual men, men who have sex with men, focusing on HIV prevention and STI’s and homophobic bullying.

National Chlamydia Screening Programme

A national service hosted locally, coordinated by NUH. The coordination of the Chlamydia screening providers includes: training, data collection, contact tracing and treatment, ensuring that an accessible community based programme is provided for young people in Nottingham City. The service offers free test and treatment to under-25s via many venues including community contraceptive services, GPs, youth clinics and pharmacies. For more information visit www.chlamydiascreening.nhs.uk

Total number of Chlamydia screens across all providers January to December 2013 were in excess of 22,000

C-Card Condom Service:

Sexual health advice, support and condom distribution services for young people to increase the availability, accessibility and acceptability of condoms to young people aged 13-24 years, to risk assess young people into mainstream sexual health services and increase the number of workers within the community who have sexual health knowledge, skills and understanding. There are multiple ‘registration’ and ‘pick up’ sites across Nottingham City linked to wards with high rates of teenage pregnancy which are accessible to young people. This also provides a safeguarding opportunity for young people aged between 13 and 18 when they register, as they have to re-register every year until 18.

The Health Shop

Provides information and support about sex, relationships and drugs including HIV and syphilis testing, Chlamydia and Gonorrhoea screening, Hepatitis screening and vaccination, needle exchange, pregnancy testing, emergency contraception and free condoms. A clinical psychologist provides specific support around sexuality and gender identity and support for individuals who have experienced sexual or domestic abuse.

Patient attendance figures March 2013 to March 2014 were in excess of 1,700.

Awaredressers

The Awaredressers project provides free condoms in 20 venues around the city. Venues are predominantly barbers but include studios and community organizations, the project targets the African and Caribbean communities in Nottingham.

General Practice

63 practices in the City provide a wealth of sexual health service provision to the community. Services vary within each practice but may include a full range of contraception including Long Acting Reversible Contraception (LARC’s), screening, diagnosis and treatment for STIs, pregnancy information and care, support and referrals to termination of pregnancy services, emergency hormonal contraception and pregnancy testing, cervical cytology, advice on medical gynaecological issues such as menopause, counselling and onward referral for specialist sexual health care such as vasectomy and sterilisation.

Community Pharmacies

a. Emergency Hormonal Contraception

The Emergency Hormonal Contraception (EHC) Scheme for community pharmacies in Nottingham City was established in August 2007 and has been developed and rolled out to more sites since then.  Approximately 58 pharmacies in Nottingham City now offer free EHC to women aged between 14 and 24 years who are registered with a Nottingham City GP practice.

b. C-Card Scheme

Approximately 57 pharmacies in Nottingham City are registered as a Pick Up Point for the C-Card Scheme. This enables young people between the ages of 13 and 25 years, who are registered on the C-Card Scheme, to pick up their free condoms from the pharmacy giving wider access throughout Nottingham city to the scheme. Four Pharmacies offer C-card registration onto the scheme.

c. Pregnancy Testing

Approximately 45 pharmacies in Nottingham City offer pregnancy testing to young women aged between 14 and 24 years, who are registered with a Nottingham City GP practice.

d. Chlamydia Screening and Treatment

Six Pharmacies offer Chlamydia screening, whereas approximately 53 pharmacies offer Chlamydia treatment. These services are offered to young people between the ages of 15 and 24 years, who are registered with a Nottingham City GP practice. Patients who are found to be positive after screening are given a choice of options for treatment, community pharmacy being one option.

Sexual health and relationships within the public health nurse model for children and young people

A new model of delivery for school health is currently being implemented across the city. This model will ensure that the most experience/qualified nurses support children and families with the greatest need, irrespective of age.

Within this model there are three health promotion facilitators, one of these facilitators has a particular focus on sexual health and relationships. This will ensure consistent and equitable provision of sexual health services, including clinic in a box provision by public health nurses.

This post also includes training for those who work with young people aged 5-25. The training aims to provide workers with the awareness, skills and knowledge to work with young people around sex and relationships. In addition, workshop sessions are provided on:

  • Increasing the understanding of young people from diverse BME communities in Nottingham and how their sexual health issues vary
  • Young people, pornography and the internet  

Clinic in a Box

School nurses, Health Visitors, Midwives and Family Nurse Partnership (FNP) aim to offer contraception, pregnancy testing and sexual health information to Nottingham City residents aged 15-24 years old by providing Clinic in a Box. This includes all relevant material: emergency contraception, Chlamydia screens, pregnancy testing, c-card, condoms and information.

Healthy Schools

The Healthy Schools team support all state maintained schools in the City develop a PSHE curriculum that promotes social and emotional skills and forms the bedrock for effective SRE.

An SRE consultant works with schools on policy and programme development focusing on knowledge and skills to enable pupils to make informed decisions about sexual health issues. The work includes sessions for parents, staff training and resource development.

Preventx Chlamydia Screening

An online service (www.freetest.me) which provides free Chlamydia screening kits by post to residents of Nottingham City, including free return postage. Results are received through a chosen method and also offer a tracking service to track and collect results.

Services commissioned by CCGs and the NHS England

NHS Walk-In Centre

The Nottingham WIC offers open access 7 days a week, 365 days per year to a number of sexual health services including free condoms, emergency hormonal contraception, pregnancy testing and Chlamydia screening. It offers advice, information and onward referral to a number of specialist services in respect of sexual health care.

NGY (previously Base 51 Nurse)

Provides sexual health and health promotion to young people to improve their health outcomes for vulnerable people aged 12-25 years.  Encourages uptake of contraception and sexually transmitted infection screening and partner notification by providing information on the full range of contraception methods; including emergency contraception, hormonal contraception, pregnancy testing and condoms via the c-card scheme, signposting clients to appropriate services for other integrated sexual health services as appropriate, including referral for termination of pregnancy services.

Termination of Pregnancy

Women in Nottingham City have access to a comprehensive TOP service via the Unplanned Pregnancy Advisory Service hosted within the Contraception and Sexual Health Service. The service is implemented to Royal College of Obstetricians and Gynaecologists guidelines (2004). This includes access to a full pre-assessment (including scan), onward referral to a choice of provider for either a medical or surgical TOP and follow up counselling sessions.

If the gestation of pregnancy exceeds 13 weeks, or local capacity has been fully utilised or through personal choice the woman may be referred to a provider outside the local area to undergo the TOP. It is recognised that an onward referral can cause further distress to some women, however work is on-going to continually improve an accessible pathway to ease this. Third party provider standards are rigorously monitored to ensure women are treated with respect and care at this vulnerable time.

SARC-Sexual Assault Referral Centre

The SARC in Nottinghamshire (The Topaz Centre) is centrally located to provide a Nottinghamshire wide (including Bassetlaw) specialist medical and forensic examination resource for victims of alleged rape and sexual assault/abuse, accessible twenty four hours a day either in person or by phone. The services are available to all, regardless of whether the victim chooses to engage with the Criminal Justice Process.

SARCS provide a safe and secure place where victims can receive an integrated service of medical care and forensic examinations quickly and sympathetically from specially trained and experienced health professionals, and also access to practical and emotional support such as crisis support, counselling, advocacy services and safeguarding from trained crisis and support workers. This includes referral to other acute, mental health or sexual health services and follow-up as required.

The Topaz Centre also provides a dedicated holistic paediatric forensic medical service to child victims aged over 13 years and provides a thorough assessment of the child’s health and well-being and contributes to ensuring the child’s welfare.

Victims can also have immediate access to emergency hormonal contraception, prophylaxis treatment for bacterial infections, HIV PEP starter packs, and referral to GUM services for further treatment/assessment.

Attendance figures in 2012-2013 were approximately 500 with around 90% of those being female. There was a similar spilt between police and self referrals.

Assets

LGBT Forum: This Forum is made up of representatives from the Lesbian, Gay, Bisexual and Transgender (LGBT) community and voluntary and community organisations, and provides advice and consultancy on City Council policies and services.

5. Evidence of what works (what we should be doing)

Back up to the contents

Components of chlamydia screening and the impact of screening on behaviour: 2014 NCSP web survey report.

This report presents results of the 2014 National Chlamydia Screening Programme (NCSP) web survey, which examined how chlamydia screening affects young adults’ subsequent knowledge and/or healthcare-seeking or sexual behaviour.  The results suggest that chlamydia screening has wider impact on young adults’ sexual health beyond diagnosis and treatment alone.

Full report can be found at: http://www.chlamydiascreening.nhs.uk/ps/resources/web-survey/2014%20NCSP%20web%20survey%20report.pdf

PHE & Brook: C-card guidance

Brook and PHE have published an updated Condom-Card Scheme guide called C-card condom distribution schemes. Why, what and how. Local schemes have proved a successful element of strategies to reduce unprotected sex, rates of STIs and unplanned pregnancies. The update guide showcases practitioners’ experiences of commissioning, developing and providing these schemes. The guide can be found at:

http://www.brook.org.uk/images/brook/professionals/documents/page_content/ccard/C-Card_condom_distribution_schemes_July2014.pdf

Halving late diagnosis of HIV: a toolkit for local action

This document is a report of the work carried out by MEDFASH with the Greater Manchester Sexual Health Network to pilot a process for engagement of stakeholders to ensure the local delivery of the national Halve It goals. It combines a commentary on the process undertaken within Greater Manchester with a checklist of suggested key actions and reflections on how the Greater Manchester experience can inform other local areas.

http://www.medfash.org.uk/publications

In March 2013 the Department of Health Published ’A Framework for Sexual Health Improvement in England’. The Framework looks at the life course from young people into old age, as well as its aim to look at the wider determinants of poor sexual health. It sets out the following ambitions to improve the sexual health and wellbeing of the whole population:

  • Sexual health up to 16 ambition: build knowledge and resilience among young people.
  • Young people aged 16-24 ambition: improve sexual health outcomes for young adults
  • People aged 25-49 ambition: all adults have access to high quality services and information
  • Older people aged over 50 ambition: people remain healthy as they age

The Framework recognises that some elements of sexual health have already improved in recent years, but there are important issues that still need to be addressed. The main aims are to:

  • Continue to tackle the stigma, discrimination and prejudice often associated with sexual health matters.
  • Continue to work to reduce the rate of sexually transmitted infections (STIs) using evidence-based preventative interventions and treatment initiatives.
  • Reduce unwanted pregnancies by ensuring that people have access to the full range of contraception, can obtain their chosen method quickly and easily and can take control to plan the number of and spacing between their children.
  • Support women with unwanted pregnancies to make informed decisions about their options as early as possible.
  • Continue to tackle HIV through prevention and increased access to testing to enable early diagnosis and treatment.
  • Promote integration, quality, value for money and innovation in the development of sexual health interventions and services.

Following the ‘Framework for Sexual Health Improvement’, the Department of Health published ‘Commissioning Sexual Health services and interventions best practice guidance for local authorities’ to help local authorities commission high quality sexual health services for their local area.

Evidence and data

Chlamydia Testing Activity Dataset (CTAD) and Sexually Transmitted Infection (STI) dataset

http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1201094610372

http://www.chlamydiascreening.nhs.uk/ps/data.asp

Public Health England: data on HIV http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIV/

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIV/HIVData/  

http://www.hpa.org.uk/sexualhealthprofiles

http://fingertips.phe.org.uk/profile/sexualhealth/data

http://www.phoutcomes.info/public-health-outcomes-framework#gid/1000043/pat/6/ati/102/page/3/par/E12000004/are/E06000018

http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/1311HIVintheUk2013report/

Office for National Statistics : under 18 conceptions

http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-wales/2011/2011-conceptions-statistical-bulletin.html

2014 Local Health Profiles: Sexual and Reproductive Health Profiles
http://fingertips.phe.org.uk/profile/sexualhealth/data#gid/8000057/pat/6/ati/102/page/0/par/E12000004/are/E06000018

Health and Social Care Information Centre : Contraception Statistics http://data.gov.uk/dataset/nhs_contraceptive_services_england

Bayer Healthcare Contraception Atlas 2011 http://www.swagnet.nhs.uk/Contraception%20Atlas%202011%20v5%20-%20Bayer%20Healthcare.pdf

Department of Health: Abortion Statistics https://www.gov.uk/government/collections/abortion-statistics-for-england-and-wales

Clinical and Service Standards

BASHH: [British Association of Sexual Health] Sexually Transmitted Infections in Primary Care (2013)

http://www.bashh.org/documents/Sexually%20Transmitted%20Infections%20in%20Primary%20Care%202013.pdf

British Association of Sexual Health and HIV : Standards for the Management of Sexually Transmitted Infections (2014) http://www.bashh.org/documents/Standards%20for%20the%20management%20of%20STIs%202014%20FINAL%20WEB.pdf

Faculty of Sexual and Reproductive Healthcare Service Standards (2013) http://www.fsrh.org/pdfs/All_Service_standards_January_2013.pdf

MEDFASH : Recommended standards for sexual health services (2005) http://www.medfash.org.uk/uploads/files/p17abl5efr149kqsu10811h21i3tt.pdf

British HIV Association (BHIVA) Standards of Care for people living with HIV in 2013 http://www.bhiva.org/standards-of-care-2013.aspx

British HIV Association (BHIVA) Management of HIV infection in pregnant women 2012 (updated May 2014)

http://www.bhiva.org/PregnantWomen2012.aspx

Competency Framework for Sexual Health Advisors (2013)

http://www.ssha.info/wp-content/uploads/SSHA_National_Competency_Framework_Final_Jan13.pdf

Society of Sexual Health Advisers Manual (2004) http://www.ssha.info/resources/manual-for-sexual-health-advisers/

You’re Welcome: Quality criteria for young people’s health services (2011) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127632.pdf

Time to test for HIV: Expanded healthcare and community HIV testing in England (2011) http://www.hpa.org.uk/timetotesthiv2011

NICE guidance

NICE advice [LGB21] on HIV testing http://www.nice.org.uk/advice/lgb21/chapter/Introduction

NICE guidance on long acting reversible contraception, 2005

http://www.nice.org.uk/CG30

One to one interventions to reduce the transmission of sexually transmitted infections and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups (PH3) (2007)

http://guidance.nice.org.uk/PH3

NICE guidance on HIV testing for men who have sex with men (2011) http://www.nice.org.uk/guidance/PH34

NICE guidance on HIV testing among black Africans (2011) http://www.nice.org.uk/guidance/PH33

National Chlamydia Screening Programme

The National Chlamydia Screening Programme http://www.chlamydiascreening.nhs.uk/ps/index.asp

National Chlamydia Screening Programme Standards - 7th edition
http://www.chlamydiascreening.nhs.uk/ps/resources/core-requirements/NCSP%20Standards%207th%20edition%20FINAL.pdf

Information on the Public Health transition

Sexual Health Commissioning - Frequently Asked Questions http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10171/3880628/PUBLICATION-TEMPLATE

 

 

6. What is on the horizon?

Back up to the contents

Nottingham City has relatively young population and demands placed upon sexual health, which are expected to increase.  Nationally, the annual (medical) costs of treating newly diagnosed STIs are expected to rise from £660 million to £867 million by 2020.  Chlamydia treatment accounts for 38% of this spend (Lucas, 2013).

The latest (2011) mid year estimates show that the City has a very high proportion (28%) of people aged 18 to 29 (ONS Census Statistics, 2011). This is due largely, but not entirely, to the presence of the two universities; full-time university students account for approximately 1 in 8 of the population. The total population of the City is very likely to continue to rise, the City Council estimates indicate a rise of 5,100 (1.7%) from 2011 to 2016 and a further 12,300 (4.0%) from 2016 to 2021. The wards showing the greatest population increase in the next few years are likely to be those with the most house-building, including purpose-built student accommodation. This may result in an increased demand for sexual health services in the student population, who are also the age group most at risk of poor sexual health.

According to the 2011 Census, 34.6% of the City’s population are from Black and Minority Ethnic (BME) groups, which are defined as everyone who is not White British. This is an increase from 19.0% in 2001. The groups showing the biggest increases were Other White (2.5% to 5.1%), Mixed - White and Black Caribbean (2% to 4%), Black African (0.5% to 3.2%), and Pakistani (3.6% to 5.5%). The largest groups other than White British are now Other White (5.1%) – which will include large numbers of people from Poland. This indicates an increase in the Black African population group, who have some of the highest rates of HIV (HPA, 2012). BME groups generally have a considerably younger age-structure than the overall population, this may result in an increased need for sexual health services among this population.

Nationally, teenage pregnancy rates have fallen to their lowest levels since records began. Rates in Nottingham City have also been decreasing and it is expected that this will continue in order to meet the Nottingham Plan 2020 target of reducing teenage pregnancy by 50% from the 1998 baseline. Nottingham City has a high termination of pregnancy rate; there were slightly fewer live births in 2011 (4,462) than in 2010 (4,477) but both years were much higher than 3,275 at the low-point in the year  2000 (ONS births data). In 2011, 30.3% of births were to mothers born outside of the UK, a slight increase from 2010 (29.3%), and more than double the percentage in 2001 (14.5%) (ONS, 2011 and 2001 to 2009).

The use of more effective long active reversible methods of contraception (LARC’s) has increased nationally: 28% of community contraception- service users in 2011/12, up from 18% in 2003/04 (NHS information for Health and Social Care, 2012). It is expected that the use of long active reversible methods of contraception will continue to increase in Nottingham City, as these will be made more easily available due to the integration of sexual health services.

There are an increasing number of secondary schools in Nottingham City which are moving to academy status. Whilst it is not mandatory for Academies to teach sex education, they are required through their funding agreements to provide a broad and balanced curriculum and this may require more work to be done locally to engage academies in providing sex and relationship education.

7. Local views

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Nottingham University Hospitals (NUH) engagement

In order to develop the integrated service model for sexual health services provided by NUH, a comprehensive engagement exercise took place in 2012 to ascertain local views including non-service users as well as current service users. The key points which emerged from the questionnaire can be found in the document: A review of sexual health service provision 2011/12 and a proposed integrated service model.

Nottingham University Hospitals have also carried out the following engagement during 2013/14:

  • Men’s sexual health service use questionnaire
  • Consultations on the delivery of an integrated sexual health clinics at Clifton Cornerstone and Victoria Health Centre
  • Public and service user engagement on the sexual health service name

These consultations were in addition to the annual patient satisfaction survey.

SHOT Questionnaire for LGBT Individuals Attending Nottingham Gay Pride, 2011

Key findings:

  • More men than women had regular sexual health check ups but significant numbers of both men and women did not have regular check ups.
  • There was some lack of knowledge around where sexual health screening can be obtained.
  • High proportions of both men and women favoured a city centre base for screening services.
  • Only 35% of men had been vaccinated against Hepatitis B.
  • There was a degree of ignorance around HIV which would encourage unsafe sexual intercourse.

High Pavement College Young People’s Consultation

A consultation took place in December 2011/ January 2012 with an aim to ascertain:

  • Knowledge levels in regard to contraceptive sexual health services,
  • Knowledge levels in relation to sexually transmitted infections and related services and
  • What (if any) student led College sexual health service would be acceptable to students at High Pavement.

132 students took part in answering a questionnaire, 82 were female and 43 were male.

Overall, the consultation resulted in the following key points:

  • A need to raise awareness of CASH services in colleges, the services which are offered and consider the location within colleges: It was found that young women stated they would predominately use GP services and men would use the Walk-in Centre to access contraceptives/condoms, only 10 young women and 9 young men said they would access the CASH service. The main response for young women and men said they would go to their GP if they thought they had an STI, only 6 women and 3 men said they would access the CASH service. When asked if students use the CASH service in college it was reported that very few students used the service. There was also a clear lack of understanding of what the service provided. A key issue was the location of the service – it was considered too public and too embarrassing to use.
  • Up to date information on local services and internet information: The majority of young people cited the internet as the main means of finding out where to go if they had an STI. CASH clinic in college scored a little higher on this than other questions. Furthermore, little specific information was given on description of symptoms and therefore suggests little knowledge. Therefore, this concludes students need to be able to access clear relevant information on STIs.
  • Increased awareness of CASH services in SRE at school: Virtually all the students reported that they had received SRE at secondary school. Even though the majority believed they had been informed about local services, their responses to other questions suggest this was only partly the case.

Nottingham City Council

In order to develop future social care services for HIV, a ‘Working Together’ event took place on 4th June 2013 which invited providers of health and social care services as well as HIV service users.  Findings highlighted the need for closer integration of services, including clear referral pathways between providers of services, as well as more outreach work within the MSM and Black African community.

What does this tell us?

8. Unmet needs and service gaps

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  1. HIV testing and diagnosis:

Within Nottingham City, there is a need to ensure we address both the high prevalence of HIV, as well as the high proportion of ‘late’ diagnosis (late is nationally defined as a prevalence of 2 per 1,000 population). 

Nottingham City has a ‘high’ HIV prevalence (2.78 per 1,000 population), higher than both the regional (East Midlands) and national (England) averages.  Nationally, there is guidance recommending universal HIV testing in high prevalence areas.  Such recommendations for universal HIV testing in high prevalence also places expectation on additional capacity and testing to be developed locally.  However, Nottingham University Hospital serves neighboring authorities including Nottinghamshire and Derbyshire where the prevalence of disease is very low. Further work is therefore required to consider and develop plans for local HIV testing services.

The recommendations for universal testing in high prevalence areas also include testing for all new GP registrations, however, not all practices carry out HIV tests, and of those who do test there is considerable variability.  The re-commissioning of locally commissioned public health services (similar to the previous Locally Enhanced Services) offers an opportunity to engage primary care in increasing the provision of HIV testing, particularly the amongst those groups most at risk.  The 3Cs and HIV Programme, developed by the National Chlamydia Screening Office (NCSP), also offers opportunities to support increased HIV testing within General Practice.

Point of Care Testing (POCT); also known as rapid antibody tests, should be increased. POCT is defined as medical testing at or near the site of patient care and allows screening to be taken outside the hospital environment. Advantages of POCT include: the relative ease at which it can be performed, results are in one person’s visit, it removes the need to trace individuals who fail to return, and is also less invasive than standard HIV testing and addresses the reluctance to visit GUM or general practice clinics so increasing uptake of HIV testing particular within high risk groups. The development of POCT for HIV can shorten clinical pathways so that diagnosis and appropriate treatment will be available in shorter timeframes.

Within the City, significant numbers of HIV cases are diagnosed late.  Between 2010-2012 65.8 of new diagnosis were made late (slightly lower than the period 2009-2011 at 67.2%); however it remains significantly worse than the England average of 48.3%. Nationally, it is estimated that approximately 22% (21,900) of persons with HIV still remain undiagnosed and whilst there is no data available for Nottingham City, there is a need to ensure we increase rates of HIV screening across primary and secondary care.

Further work is needed to explore, describe and quantify the health needs for HIV counselling services and clarify the level of support required and whether there should be an emphasis on post diagnoses counselling as part of treatment.  Current guidelines reinforce that pre-test counselling should not be widely available and that HIV diagnosis should be likened to a chronic condition.

There is also the need to ensure we collect all available data on HIV in order to help inform service development and commissioning. Planning and commissioning of HIV services should be joined up across the local authority, NHS England Area Team, and providers of HIV services and care including clear referral pathways.

There is a need for more health promotion and HIV awareness and prevention activity including work to reduce stigma associated with HIV in those most at risk. Within Nottingham City HIV health promotion has been limited, we aim to work with providers of sexual health services to ensure health promotion and prevention remain a key area for development.  There are current gaps in work to help change risky behaviors before HIV is contracted. Investing in HIV prevention should be a priority due to its cost-saving potential, with each infection prevented saving between £280,000 and £360,000 of lifetime treatment costs (HPA, 2011b).

More training and education is needed, including more health staff education to reduce stigma, promote the prevention of HIV and encourage earlier presentation of HIV.  It could also be justified that such training and education needs also to be extended beyond clinical staff to include non-clinical staff as well. 

At present limited peer-led intervention or support groups are available within Nottingham City. It was felt by many service providers that perceived stigma was the main reason for this. More culturally appropriate peer-led interventions may improve the emotional and psychological well-being of persons living with HIV. Peer-led intervention could also help facilitate and improve interaction with groups that are currently difficult for service providers to access; for example high risk groups such as MSM and Black African communities, and vulnerable groups such as sex-workers.

There is also a need for a local HIV strategy to be devised and updated, that is tailored to the local context.

  1. Chlamydia screening:

Targeting vulnerable groups and those identified as most at risk of poor sexual health is crucial to achieve the recommended diagnosis rate of 2,300 per 100,000 15-24 year old population set out in the Public Health Outcomes Framework. In addition, screening should focus on reinforcing good practice, as identified in the Framework for Sexual Health Improvement

  • Integrating screening into the broader sexual health offer for young people and increasing screening in primary care, particularly in general practice
  • Ensure the programme remains accessible to young people and screening large numbers of at risk adults
  • Ensuring repeat screening, treatment and partner notification standards are met
  • Expand high quality internet screening 
  • Promoting annual screening and additional testing on each change of partner

In order to meet the Public health Outcomes Framework indicator, a good level of coverage for Chlamydia testing is required, ensuring that services are accessible and provided across a range of venues. Chlamydia screening which is integrated with a range of clinical sexual and reproductive health services, including primary care and contraceptive services, can allow specialist providers to focus resources on more complex and symptomatic patients, while helping to reduce the overall burden of disease.

There are currently two services where Chlamydia screening home testing kits can be requested (NUH and Preventx). Anecdotally, it has been suggested that this can be confusing for patients, some have requested kits from both websites and also turned up at a sexual health clinic for a test.

  1. Primary care services:

Currently there is a number of sexual health Locally Commissioned Public Health Services (LCPHS) (similar to the previous Locally Enhanced Services) within general practice and community pharmacies. 

Within general practice this includes the provision of asymptomatic chlamydia screening, as well as asymptomatic sexual health (chlamydia, gonorrhoea, syphilis and HIV) screening.  Across the City, uptake of STI screening is varied and in some area there are some potential gaps in provision especially areas of highest need.  Activity will need to take place to review overall as part of the reprocurement of LCPHS.  In addition a number of general practices offer the provision of Long Acting Reversible Contraception (LARC’s).  The rate of GP prescribed LARC during 2012/13 per 1,000 female population was lower than the England average.

Within community pharmacies, there is the C-Card (condom scheme) Locally Commissioned Public Health Services, as well as Emergency Hormonal Contraceptive (EHC) and Chlamydia screening and testing.  Chlamydia screening LCPHS uptake in community pharmacies is currently low, with only six community pharmacies providing Chlamydia screening. However, the provision of treatment for Chlamydia in pharmacies has been found to be successful and highly utilised, with over 40 pharmacies signed up to deliver this LCPHS.

  1. Secondary care sexual health services:

Sexual Health Services need to continue to be closer to home and provide a range of services to meet the needs of the population. Whilst the current GUM and CASH services cover most of the areas of highest need in the city, there are some potential gaps in provision in the high need areas of Aspley and Basford.

The provision of integrated sexual health services is supported by current accredited training programmes and guidance from relevant professional bodies including FSRH (Faculty of Sexual and Reproductive Healthcare), BASHH (British Association for Sexual Health and HIV), BHIVA (British HIV Association), MEDFASH (Medical Foundation for HIV and Sexual Health), RCOG (Royal College of Obstetricians and Gynaecologists) and NICE (National Institute for Health and Care Excellence) and relevant national policy and guidance issued by the Department of Health and Public Health England. Integrated sexual health services can improve sexual health and patient experience by providing easy access to services through open access ‘one stop shops’, where the majority of sexual health and contraceptive needs can be met at one site, in services with accessible locations.

The sexual health services delivered by NUH are not yet integrated in line with the model proposed during 2012. The services should continue to be integrated in line with best practice to ensure that the model agreed is delivered effectively and according to need. All venues must be You’re Welcome accredited to ensure that services are young people friendly.

The delivery of clinic in a box by School Nurses and Health Visitors is not currently consistent. In addition, restrictions on delivery in schools and School Nurse workload are an issue and need exploring.

  1. Sexual health promotion and sex and relationship education (SRE):

The provision of sex education is a statutory requirement for maintained secondary schools. However, what schools include in their sex education programme is a matter for local determination, therefore Sex and Relationship Education (SRE) provision across schools is inconsistent.

The Framework for Sexual health Improvement (2013) suggests opportunities for the use of technology and social media in health promotion/education and technology to support self-care, such as the ‘My contraceptive’ online tool developed by Brook and FPA to help people choose the right contraception method for them, and the Terrence Higgins Trust online resource ‘MyHIV’, which helps people to manage all aspects of their HIV. Current websites which provide sexual health information on clinic locations are uncoordinated and out of date. There is no social networking in place for promotion of sexual health clinics and young people’s outreach clinics, this requires development.

The Framework for Sexual Health Improvement (2013) recognises the importance of service providers being aware of child protection and safeguarding issues and taking very seriously the possibility of abuse and/or exploitation. It is important to continue work on increasing awareness around the signs and symptoms of child sexual exploitation.

  1. Vulnerable groups:

Sex workers often lead chaotic lives, therefore accessing services with standard opening hours is challenging. Outreach work with sex workers has successfully identified STIs in this group and local experience suggests that persuading sex workers to access treatment can be difficult. Integrating screening and treatment into one site would help to ensure access necessary treatments for this high risk group.  Appropriate screening methods should be considered for testing in line with the needs of vulnerable groups.

Based on high proportions of Chlamydia positive screens and the vulnerable nature of the client group, there needs to be good access to STI screening and treatment for young offenders who are likely to be hard to reach. 

  1. Local termination of pregnancy services:

Termination of pregnancy services play a key role in reducing the risk of repeat unwanted pregnancy through the provision of LARC, as well as helping women to improve their overall sexual health. The local authority will need to work closely with the CCG around future commissioning arrangements to ensure services are fully linked into sexual health services in the area.

  1. Local Sexual Health strategy

There is currently no sexual health strategy for the City.

Nottingham is developing an HIV Strategy and Action Plan for the City which aims to:

  1. Ensuring effective HIV Prevention in Nottingham City
  2. Addressing late diagnosis of HIV in Nottingham City

Commission effective HIV prevention and screening services

9. Knowledge gaps

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There is little data available on the sexual health of people with disabilities, as this is not yet included in any of the national sexual health datasets. 


 

 

What should we do next?

10. Recommendations for consideration by commissioners

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HIV testing and diagnosis:

  • Increase access to HIV testing by targeting vulnerable populations to reduce late diagnosis. Whilst recognising that whilst anybody can become infected with HIV, local trends suggest that some groups have a higher proportion living with HIV such as Black African men and women (many of whom are migrants) and gay and bisexual men.
  • Ensure commissioning arrangements support effective HIV prevention and screening services.
  • Local Authority Commissioners will need to work with NHS England local Area Teams to ensure effective and coordinated HIV treatment and care and ensure clear pathways exists to facilitate effective HIV treatment and care.
  • Ensure systems are in place to deliver effective monitoring of HIV resources and available data within Nottingham City.
  • Increase the role of Primary Care including general practice in HIV Testing, therefore increasing both the skills training and the role of GPs and nurses particularly in high prevalence areas.
  • Increase Point of Care Testing (POCT); also known as rapid antibody tests, defined as medical testing at or near the site of patient care and allows screening to be taken outside the hospital environment.
  • Explore and quantify the health needs for HIV counselling services and clarify the level of support required.
  • Ensure data is available to inform service development and commissioning

Chlamydia Screening:

  • Continue to reinforce good practice in line with Chlamydia screening, ensuring that testing remains accessible to young people through a range of commissioned services
  • Ensure outreach provision is targeted at young people who have limited access to sexual health services (homeless young people, looked after young people and those leaving care, youth offenders and BME young people)
  • Ensure internet testing services are not duplicated. Internet testing kit return rates should be high (approximately 75%) and positivity percentage should match the city average
  • Consider expanding internet testing services, which prove to be effective in Nottingham City
  • Consider the offer of home testing kits to be sent 3 months following a positive Chlamydia diagnosis, this will aim to reduce reinfection rates
  • Ensure the message of annual screening and additional testing on each change of partner is promoted to young people
  • Continue to promote adherence to treatment and partner notification professional guidelines

Primary care sexual health services:

  • Review overall provision of STI screening and treatment, and LARC provision as part of the re-procurement of LCPHS.
  • Commission STI screening and LARC provision in localities where there are some potential gaps in provision
  • Ensure a review of primary care provision of existing sexual health ‘Locally Commissioned Public Health Services’ (LCPHS)
  • Develop commissioning plans for the reprocurement of sexual health ‘Locally Commissioned Public Health Services’ post April 2015
  • Identify geographical areas of need, and work with providers to increase activity levels of STI (sexually transmitted infections) testing including HIV testing, and increase take-up of LARCs (long-acting reversible contraception)
  • Continue to work with community pharmacies to provide treatment for Chlamydia

Secondary care sexual health services:

  • Ensure the delivery of an integrated sexual health service is implemented and that services are in line with best practice and need
  • Ensure prevention efforts are maintained, with a focus on groups at highest risk such as young people, persons of black ethnicity and MSM. This is vital to control STI transmission
  • Ensure all sexual health clinical venues are You’re Welcome accredited by March 2015
  • Shadow the Integrated Sexual Health Tariff to inform the development a cost effective model for commissioning and providing sexual health services in Nottingham City
  • Ensure sexual health clinics are in line with areas of high need by mapping access to sexual health clinics and primary care services, including the uptake of LARC
  • Following the integration of sexual health services, undertake a health equity audit of all sexual health services to ensure they are accessible to the whole population
  • Develop the link between Public Health Nurses for Children and Young People and community sexual health services through the new school health model
  • Develop the provision of clinic in a box through Public Health Nurses, linking with the Sexual Health Promotion facilitator in the new school health service model
  • Ensure that all mainstream youth services and the Youth Offending Team offer C-Card and proactively promote information about the full range of contraception and NUH Sexual Health services

Sexual health promotion and sex and relationships education (SRE):

  • Review the provision of sex and relationships education in schools to inform and develop consistent provision
  • Fully evaluate the Awaredressers project
  • Carry out engagement activity to establish how, when and where people would like to receive information about local services
  • Improve access to up-to-date sexual health service provision information through the development of a co-ordinated sexual health website for Nottingham City and Nottinghamshire County

Vulnerable groups:

  • Continue the provision of specialist services for prostitutes/ sex workers to meet relevant needs. Ensure services provide screening and treatment, contraception, vaccinations, health promotion and access to other support all in one site
  • Review the sexual health service access pathway for young offenders and develop accordingly
  • Continue to ensure sexual health services are accessible and meet the needs of MSM and LGBT communities, including appropriate testing


 

 

Termination of Pregnancy Pathway Development:

NHS Nottingham City CCG in conjunction with the Local Authority and TOP providers has committed to supporting a review of the TOP pathway in order to establish that accessibility, quality and value for money is being achieved. Initial scoping meetings and planning has commenced and the following actions have been identified as required in 2013/14:

  • Review of the pathway and commissioned services working closely with commissioners, clinicians, service users, service providers, public health and the local authority to include:
    • Needs assessment and capacity planning/gap analysis
    • Service/pathway design, redesign and transformation with a strengthened governance and supervision structure
    • Best practice review and service specification development including the development of a TOP provider network
    • To analyse and use information (health needs assessment, activity levels, benchmarking data etc.) to develop service improvement / development plans taking into consideration funding, workforce implications and information technology requirements.
    • To develop a robust performance management framework to monitor progress against implementation of the pathway.

Joint working:

  • The local authority will need to work with the CCG and NHS England to ensure that the care and treatment people receive is of a high quality and is not fragmented, this should include:
  • Offering comprehensive and seamless HIV testing and treatment services
  • Ensuring future commissioning arrangements for termination of pregnancy services continue to embed the improvement of sexual health and reduce the risk of repeat unwanted pregnancy

Agree pathways and commissioning arrangements for services associated with and taking place in sexual health services (e.g. menorrhagia and cervical screening) with appropriate commissioners, taking a whole system approach and using the ‘making it work’ commissioning guide for sexual health, reproductive health and HIV.

Key contacts

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Ellyn Dryden, Public Health Manager, ellyn.dryden@nottinghamcity.gov.uk

Carl Neal, Public Health Manager, carl.neal@nottinghamcity.gov.uk

Alison Challenger, Consultant in Public Health, alison.challenger@nottinghamcity.gov.uk

References

A Health Needs Assessment of Young Offenders in Nottingham City (2012) available at: http://www.nottinghaminsight.org.uk/insight/handler/downloadHandler.ashx?node=79041

Association of Southeast Asian Nations Secretariat (USAID) (2007), World Health Organization Regional Office for the South-East Asia Psychiatric illness, psychosocial care and sexual health: treatment and care for HIV-positive injecting drug users.

CHANGE (2010) Let’s talk about sex and relationships: the views of young people with learning disabilities.

Cheng WS, Garfein RS, Semple SJ, Strathdee SA, Zians JK, Patterson TL (2010). Increased drug use and STI risk with injection drug use among HIV-seronegative heterosexual methamphetamine users. Journal of Psychoactive Drugs.

Department of Health, (2007). Dr Julie Fish. Reducing health inequalities for lesbian, gay, bisexual and trans people - briefings for health and social care staff. Briefing 11: Trans people’s health 

Department of Health (2012) Improving outcomes and supporting transparency. Part 1: A public health outcomes framework for England, 2013-2016

Department of Health (2013a) A Framework for Sexual Health Improvement in England. Available at: https://www.gov.uk/government/publications/a-framework-for-sexual-health-improvement-in-england [accessed 18th April 2013]

Department of Health (2013b) Commissioning Sexual Health services and interventions. Available at: https://www.gov.uk/government/publications/commissioning-sexual-health-services-and-interventions-best-practice-guidance-for-local-authorities [accessed 18th April 2013]

Health Development Agency (2004) Teenage pregnancy: An overview of the research evidence.

Health Needs Assessment of Young Offenders in Nottingham City (2012). NHS Nottingham City and Nottinghamshire County, Nottingham City Council.

Health Needs Assessment of HIV (2013). NHS Nottingham City and Nottingham City Council.

Health Protection Agency (2008) Sexually transmitted Infections and Young People in the United Kingdom: 2008 Report.

Health Protection Agency (2010). Survey of Prevalent HIV infections Diagnosed (SOPHID) in the East Midlands.

Health Protection Agency (2011a). Survey of Prevalent HIV infections Diagnosed (SOPHID) in the East Midlands: Nottingham City PCT. Table 8a: Numbers of HIV diagnosed persons seen for HIV care by Primary HIV care Trust of residence and survey year (2007-2011).

Health Protection Agency (2011b) HIV in the United Kingdom: 2011 report. Available at: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317131685847

Health Protection Agency (2011c) Health Protection Report Vol 5, No. 24. Available at http://www.hpa.org.uk/hpr/archives/2011/hpr2411.pdf [accessed 18th April 2013]

Health Protection Agency (2012a) HIV in the United Kingdom: 2012 report. Available at http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317137200016 [accessed 18th April 2013]

Health Protection Agency (East Midlands) (2012b) Survey of Prevalent HIV infections Diagnosed (SOPHID) in the East Midlands: Nottingham Unitary Authority.

Lee A (2012). Update on HIV and HIV Testing in Nottingham City. Nottingham City CCG.

Lucas (2013).  Unprotected Nation: the financial impact of restricted contraceptive and sexual health services.  Development Economics

Marks G, Crepaz N, Janssen RS (2006) Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA.

NHS information for Health and Social Care (2012) NHS Contraceptive Services- England 2011-12.

Office for National Statistics Local Authority under 18 conception statistics 1998-2010 version 28/02/2012: http://media.education.gov.uk/assets/files/xls/la%20under%2018%20conception%20statistics%201998%202010%20version%2028%2002%202012.xls

Office for National Statistics Live births by country of birth of mother and area of usual residence 2011: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-231415 and 2001 to 2009: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-39699

Office for National Statistics Census 2011: Number of non-UK short-term residents by sex, local authorities in England and Wales

http://www.ons.gov.uk/ons/rel/census/2011-census/population-and-household-estimates-for-england-and-wales/rft-m02.xls

Office for National Statistics Births data (VS Tables). 

Public Health England (2012). Local Authority Sexually Transmitted Infections and HIV Epidemiology Report (LASER).

Public Health England (2013a). HIV in the United Kingdom: 2013 Report. Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317140300680

Public Health England (2013b). Number and rates of acute STI diagnoses in England, 2009-2012. Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1215589013908

Public Health England (2014a). Chlamydia testing data for 15-24 year olds in England 2013, Public Health England. Available at: http://www.chlamydiascreening.nhs.uk/ps/data.asp

Public Health England (2014b). Sexually transmitted infections and chlamydia screening in England, 2013. Volume 8, number 24. Available at: http://www.hpa.org.uk/hpr/archives/2014/hpr2414_AA_stis.pdf

Strathdee SA, Sherman SG (2003) The role of sexual transmission of HIV infection among injection and non-injection drug users. Journal of Urban Health.

Stonewall (2011). Gay and Bisexual Men’s Health Survey

The Lesbian and Gay Foundation (2013). Beyond babies & breast cancer: Expanding our understanding of women’s health needs. Health care needs of lesbian and bisexual women: an overview of available evidence

References

Glossary