Sexual Health


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Sexual Health

  1. 1. Sexual health Sexually transmitted infections Nationally, diagnoses of sexually transmitted infections (STIs) have been steadily rising in the UK since 2001. The most recent Health Protection Agency (HPA) data indicate that this trend is continuing: between 2005 and 2006 there was a 2% rise in both new diagnoses and total numbers of STIs (recurrent and follow-up presentations) in genito-urinary medicine (GUM) clinics. The overall increase in STIs masks a more complicated picture for specific infections and in specific age and other risk groups.i Genital Chlamydia infection remains the most commonly diagnosed STI in the UK and Gonorrhoea the second. Infection rates are highest in the younger age groups (40% per cent of infections in women were in teenagers) and in men who have sex with men (MSM). In contrast to Chlamydia, cases of gonorrhoea have been in decline since 2003, with an overall 1% drop in 2006. However, STIs in MSM have continued to increase, rising by 3% in 2006, suggesting that sexual risk-taking behaviour in this community is increasing. Diagnoses of first episodes of genital herpes have been rising nationally since the early 1990s, reaching 21,698 in 2006 (a 9% rise on 2005). This latest rise was particularly pronounced among young adults, with numbers of diagnoses increasing by 16% in 16-19 year-old women and by 10% in 20-24 year-old men. Again, data suggest that sexual health risk taking may be increasing in younger age groups, but other factors, such as increasing numbers of diagnoses in people who have recently moved to the UK may also be important. Syphilis, a very common STI in the early 1900s, remains relatively uncommon and occurs mainly in MSM. The true incidence of STIs in Barnet is not known, since figures on the numbers of people with a STI are rarely presented on the basis of a person’s residence. Most data are reported at GUM clinic level, but since these clinics see people regardless of their place of residence, figures from clinics include diagnoses made on people living outside of the ‘host’ PCT area where the clinic is situated. Data can also be distorted when the place of residence of a patient attending a clinic is unknown and this varies between GUM clinics, as shown in , which shows the GUM clinics most likely to be attended by Barnet residents. Table 1 ‘Unassigned PCT’ from Unify data, selected GUM clinics (2007) Proportion of attendances GUM clinic recorded as “Unknown PCT” (%) Claire Simpson Clinic (Barnet Hospital) 30.4 The Marlborough Clinic (Royal Free Hospital) 16.8 The Archway Sexual Health Clinic 14.6 Mortimer Market Centre 11.4 Jefferiss Wing St Mary’s Hospital 3.8 Northwick Park Hospital 12.4 Central Middlesex Hospital 2.1
  2. 2. The potentially distorting effect of clinic-based data and under-recording of PCT of residence is demonstrated in Table 2, which shows the number of cases of different infections that would be expected at the Claire Simpson Clinic Barnet’s main GUM provider) based on the extrapolation of national data and the number of cases actually reported. Table 2: Diagnoses of STIs in Barnet residents extrapolated from Unify data and reported by Claire Simpson Clinic in 2006 Gonorrhoe Genital Genital Syphilis Chlamydia a Herpes warts Number expected 25 136 166 343 476 annually: Unify data Number of diagnoses 0† 43 128 218 222 reported Source: Claire Simpson Clinic and Health Protection Agency † The Claire Simpson Clinic believes that this number should be 6-9, i.e. that reported incidence is erroneous It is also important to note that data from different GUM clinics may not be equally accurate, complete or representative of attendance by Barnet residents. Also, it is assumed that the rates of STIs in Barnet residents visiting a GUM clinic are equal to those attending who live in other boroughs. However, people from inner city boroughs may be more likely to have a STI or, conversely, people from Barnet attending inner city GUM clinics may be more likely than local residents to have a STI; there is no obvious method for correcting for this limitation. Therefore, GUM clinic data can only provide an approximation of the numbers of STIs in Barnet residents. That said, whilst local GUM clinic data are a poor indication of the local incidence and prevalence of STI, they do give a reasonable idea of trends and these continue to rise in Barnet, as elsewhere. HIV/AIDS The number of people in Barnet known to have HIV infection has increased steadily since 2002. This is shown in Table 3. In 2006, there were 518 people known to have HIV infection living in Barnet. Table 3: HIV positive people in Barnet Survey year Male Female Total 2002 237 165 402 2003 250 193 443 2004 253 194 447 2005 281 223 504 2006 283 235 518
  3. 3. The ethnicity of Barnet residents known to have HIV infection is shown in Table 4 and the age distribution in shown in Table 5. Table 4: The ethnic groups of Barnet residents with HIV infection Black African Survey YearWhite Other Not known Total / Caribbean 2002 123 219 33 27 402 2003 142 239 37 25 443 2004 153 240 40 14 447 2005 154 268 69 13 504 2006 168 273 64 13 518 Table 5: The age distribution of Barnet residents with HIV infection Age band 0-15 16-24 25-34 35-44 45-54 55+ (years) Number of people with 20 20 98 244 99 37 HIV In common with many other areas, HIV is more common in people in Black African and African Caribbean ethnic groups. However, unlike most of the other PCTs in the north central part of London, especially the inner-city ones, HIV infection is becoming increasingly common in Black women in Barnet rather than in the Black MSM group. It is possible that the male partners of many of these women contract the infection abroad. But the important point is that it is heterosexual transmission of HIV that is becoming a larger issue that it is in MSM in Barnet. In 2005, 132/504 (26.2%) of known cases of HIV in Barnet were in MSM, 316/504 (62.7%) were in heterosexual men or women, 26/504 (5.2%) were acquired by mother-to-child transmission, and the remainder were acquired through other or unknown means. Teenage pregnancy Barnet has one of the lowest rates of teenage pregnancy (TP) in London, and this is also lower than similar boroughs (including those matched for deprivation) such as Merton, Hounslow and Enfield. Not only is it lower than the London average, but it is also lower than the national average. This is shown in Figure 1: The trend in teenage pregnancy in Barnet, London and England.
  4. 4. Figure 1: The trend in teenage pregnancy in Barnet, London and England 60 50 Under 18 conception rate per 1000 40 30 20 London England 10 Barnet rolling average 0 March March March March March March March March March March June June June June Sept Sept June June Sept Sept June Sept June June June Sept Sept Sept Sept Dec Dec Dec Dec Dec Dec Dec Dec Dec 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: Office for National Statistics Figure 2: The trend in teenage pregnancy in Barnet Quarterly rate 45 Rolling average 40 Under 18 conception rate per 1000 35 30 25 20 15 10 5 0 March March March March March March March March March March Sept Sept Sept Sept Sept June June June June June Sept Sept Sept Sept June June Dec Dec June Dec Dec Dec June June Dec Dec Dec Dec 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 The dashed line in Figure 2 shows that the trend in teenage pregnancy in Barnet was increasing until the second quarter of 2004 but that is has decreased since then. Approximately 68% of teenagers who conceived in Barnet in 2006 had a termination of pregnancy (TOP), the remainder having had either a live or still birth. Data on the residential postcodes of all TOPs performed by Marie Stopes, the PCT’s main provider of abortion services, on women in Barnet aged under 18 years show that 15.2% of teenage abortions were performed on young women who had had at least one previous TOP. Teenagers who have had one TOP are a high risk group for further unplanned pregnancy. Abortion services In terms of access to abortion services for all women of child-bearing age, there were 2444 TOPs performed on Barnet residents in 2006. This is above the national average rate and
  5. 5. probably reflects either better access to termination services or lack of access to contraception services. As Barnet has such a low number of teenage conceptions (which include abortions as well as births) relative to most other PCTs in London, this latter possible explanation is unlikely. Chlamydia trachomatis is the most common curable sexually transmitted infection in the UK. The infection can have serious long term consequences including pelvic inflammatory disease leading to infertility, ectopic pregnancy and chronic pain in some affected women, and neonatal ophthalmitis and pneumonitis in children born to infected women. Up to 70% of infected women and 50% of infected men are asymptomatic, a large number of cases are never diagnosed. For these reasons, Chlamydia screening is considered an effective way of reducing sexual ill-health at a population level. The group considered to be greatest risk of the long-term consequences of Chlamydia infection is young people, in this context defined as those aged 15-24 years old.i The relationship between diversity and deprivation and sexual health problems There is a clear relationship between rates of sexual ill-health, poverty and social exclusion. Certain groups are particularly at risk of poor sexual health, including: young people, especially those in, or leaving, care;  people from Black and ethnic minority groups;  gay and bisexual men;  injecting-drug users;  adults and children living with HIV and other people affected by HIV;  sex workers; and  people in prisons and youth offending establishment.  People in these groups are not only more likely to engage in sexually risky behaviour, but will often make only poor use of existing services and are therefore hard to reach.ii Ethnicity is relevant to the planning of sexual health services in several ways. First, certain communities are more likely to experience a high incidence of specific STIs, for example HIV is much more common in the Black African community, and the majority of women with HIV in Barnet are from this community. Secondly, services may need to be modified so that that can be made religiously and/or culturally acceptable to certain communities, for example sex and relationships education (SRE) programmes for young people from certain orthodox Jewish and Islamic communities. Thirdly, cultural values and ethnicity may affect health beliefs and behaviours and health-seeking activities and can be important influences on health and well- being. There is limited evidence on this issue, but for instance there is some indication that men from the Black African community are less likely to attend GUM clinics.iii,iv,v An increasing number of women are becoming infected with HIV in Barnet, although the numbers involved remain relatively small. Figure 3 shows that whilst there is a small year-on- year increase in the number of HIV-infected people accessing services, the proportion of women doing so is increasing faster than that of men. Figure 3: The number of HIV-infected Barnet residents accessing care
  6. 6. 300 Male Female 250 Number of people accessing care 200 150 100 50 0 2002 2003 2004 2005 2006 Source: Health Protection Agency Figure 4 shows the number of HIV-infected people accessing services by ethnic group. A small part of the year-on-year increase shown here may be attributed to a reduction in the number of people for whom their ethnic group is unknown. However, there is a clear picture: the groups most affected by HIV/AIDS in Barnet are the Black and African Caribbean and the White, and the numbers of people infected is increasing. Knowing people’s ethnicity is also important in terms of designing services: there is evidence that many people from the African community are uncomfortable visiting GUM clinics, and that in this community a different approach is needed. Since in general sexually active women of all communities are more likely to attend health services, increasing testing in these settings is an important method for increasing uptake of HIV screening in women, for example in antenatal or family planning clinics. For men, however, a more community-orientated approach is most likely to achieve results.
  7. 7. Figure 4: The number of HIV-infected Barnet residents in different ethnic groups accessing care White 300 Black and African Caribbean Other 250 Not known Number accessing care 200 150 100 50 0 2002 2003 2004 2005 2006 Source: Health Protection Agency In terms of age and general sexual health services, the greatest numbers of people seen in the main GUM clinics serving Barnet’s population are aged 15-35 years (77% of attendees) and 60% of attendees are women. Local targets There are two main targets. The first is to screen people aged 15-24 years for genital Chlamydia infection. The target for 2008/09 is to screen 6,699 people. The other main target is to reduce the number of teenage pregnancies. The trajectory for this is shown in Figure 5. Figure 5: Teenage pregnancy rates in Barnet – current and future trajectory actual estimate trajectory Conception rate per 1,000 females aged 15-17 35 30 25 20 167 168 149 15 10 131 107 84 5 0 2005 2006 2007 2008 2009 2010 Key things that need to be done
  8. 8. The key activities required are: increasing the provision of sexual health services in GP practices;  increasing the number of young people screened for genital Chlamydia infection; and  ensuring that all sexual health services (including sexual health promotion and sexual  relationship education) are designed to enable access by people from different ethnic and religious backgrounds.
  9. 9. i HPA (2007). Testing Times - HIV and other Sexually Transmitted Infections in the United Kingdom: 2007 London: Health Protection Agency, Centre for Infections. November 2007. ii Downing J, Jones L, Cook PA et al (2006) Prevention of sexually transmitted infections (STIs): a review of reviews into the effectiveness of non-clinical interventions. Evidence Briefing Update. London: National Institute for Health and Clinical Evidence. iii National Survey of Sexual Attitudes and Lifestyles II, National Centre for Social Research iv Sadler KE, McGarrigle CA, Elam G et al (2007) Sexual behaviour and HIV infection in black-Africans in England: results from the Mayisha II survey of sexual attitudes and lifestyles. Sexually Transmitted Infections 2007;83:523-529. v Fenton KA et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability survey. The Lancet 365: 1246 - 1255, 2005.