STIs: testing times

07 December 2018

Sexually transmitted infection rates among young people remain too high. Journalist Rima Evans asks if attempts to limit transmission are working.

Sexual health check-ups should be normalised and become as routine as going to the dentist, says Dr Mark Lawton of the British Association for Sexual Health and HIV (BASHH). ‘Sexual health is about staying well, so why shouldn’t frequent testing, for example, just be considered a regular, normal part of our healthcare?’

But it isn’t. Data on sexually transmitted infections (STIs) from Public Health England (PHE) released in June confirms that. While the overall rate of STIs remained stable in 2017 compared with 2016, the detail reveals worrying trends. For example, there was a 20% increase in syphilis, from 5955 cases in 2016 to 7137 cases in 2017 (PHE, 2018).

There were also 44,676 diagnoses of gonorrhoea, a 22% increase from 2016. PHE stresses that this is concerning, given the growing resistance of the gonorrhoea bacteria to antibiotics (PHE, 2018).

This picture is mirrored in Scotland and Wales. In Scotland, syphilis diagnoses increased by 12% in 2017 and gonorrhoea cases by 10% (Health Protection Scotland, 2018). In Wales, there was a 53% increase in diagnoses of syphilis and 21% in gonorrhoea (Public Health Wales, 2018).

In Northern Ireland, although syphilis cases remained unchanged between 2016 and last year, gonorrhoea cases rose by 15% (Public Health Agency, 2018).

Youth impact

Dr Anatole Menon-Johansson, medical director at sexual health charity Brook, says the syphilis numbers in England are ‘the largest reported since 1949’. He says: ‘It’s consistent with the increasing trend seen in recent years: since 2008, overall syphilis diagnoses have risen by 148%.’

While this is mostly associated with transmission in gay, bisexual and other men who have sex with men (MSM), he notes an increase in gonorrhoea and syphilis among young women as well.

Overall, it is young people who continue to experience the highest diagnosis rates of the most common STIs. In England, more than 1.3 million chlamydia tests were carried out, with over 126,000 diagnoses made among young people aged 15 to 24 (PHE, 2018). Across the rest of the UK, it’s also clear that this is the age group bearing the greatest impact from chlamydia – for example, 67% of all diagnoses were made in those aged under 25 in Scotland (Health Protection Scotland, 2018).

Sex education

Young people’s persistently high risk calls into question whether measures in place to reduce transmission such as sex education are effective.

But there are other factors at play: PHE (2018) noted the rise of group sex facilitated by social networking apps (such as Grindr and Tinder) and ‘chemsex’, high-risk gay sex fuelled by drugs. Also to blame may be a combination of not using – or incorrectly using – protection, multiple sexual partners, a lack of education around sexual health and STIs, more difficult access to services worsened by funding cuts, and not notifying current or previous partners when testing positive for an STI.

Social stigma or concerns about confidentiality can affect young people’s willingness to get tested. Mark also explains that while young people may be influenced by a media culture where sexual activity is freer and more open, the message about using condoms has yet to catch up.

The emphasis has to be on continued education, experts say. ‘Evidence shows that good, comprehensive relationships and sex education which starts before the onset of sexual activity does not make children and young people more likely to have sex,’ explains Anatole.

‘In fact, it helps them to delay starting sex and makes them more likely to use contraception when they do. Children and young people repeatedly tell researchers that they believe the sex education they receive is too little, too late and too biological and they often don’t know where to go for advice.’

He criticises sex education in England as being too inconsistent because it’s still not mandatory, although that is set to change from September 2020. ‘While some schools have regular timetabled lessons, many young people will just have one day a year of lessons about sex and relationships,’ he says.

‘The “gold standard” is good-quality, evidence-based RSE [relationships and sex education], which links young people into good-quality, young-people-friendly sexual health services.’

Getting the message

Good sexual health messages should also advocate not being afraid or embarrassed to be regularly tested, especially if a person believes they may be at risk. Beth Cullen, healthcare scientist at Health Protection Scotland, says in the case of chlamydia, for example, 80% of women and 50% of men are asymptomatic: ‘A number of STIs will therefore remain undiagnosed, and as a consequence the prevalent pool of infection is maintained and there is onward transmission. If individuals were more aware of the necessity of testing and treatment, it may reduce the pool of infection and therefore the risk of transmission.’

PHE launched a sexual health campaign targeting 16- to 24-year-olds at the end of last year, Protect Against STIs, but it’s still too early to tell if its message promoting condom usage has been effective.

Northern Ireland’s Public Health Agency ran a public information campaign in 2015, which it says had a positive impact. A spokesman said: ‘Post-campaign evaluation showed that 68% of 16- to 34-year-olds were aware of the campaign. Campaign recognition was even higher among those considered “at risk” – through risky sexual behaviour in their most recent sexual experience, or multiple partners  and unprotected sex in the past year – where 83% were aware of the campaign.

‘A total of 51% of those at risk and aware of the campaign said it had encouraged them to think about their sexual health.’

More tests for men who have sex with men

‘At [sexual health charity] Brook, we see disproportionately far more young women than young men,’ says Dr Anatole Menon-Johansson. ‘Last year, 85% of Brook clients were female.’

Yet it is gay, bisexual and other men who have sex with men (MSM) that are identified as carrying one of the biggest burdens of STIs (PHE, 2018).

In Scotland, over the past five years, a 64% increase has been observed in gonorrhoea diagnoses that is considered to be due, largely, to an increase in transmission among the MSM group (HPS, 2018).

Clearly, there needs to be a harder push for young men to be tested for STIs regularly or when they change their partner, according to Anatole.

‘We also need to encourage those who do test positive for an STI to contact previous partners to encourage them to get tested and treated.’

PHE recommends that MSM should be advised to test annually for HIV and STIs – and every three months if having condomless sex with new or casual partners (PHE, 2018).

Support from CPs

Young people can undoubtedly benefit from community practitioners’ input and support, primarily through reinforcement of the messages around safe sex and explaining exactly what that means.

Anatole says health visitors and school nurses play a critical role in ensuring that young people can act on the knowledge they have gained in RSE lessons about STI and pregnancy prevention, contraception and condom use by signposting them to accessible and appropriate sexual health services.

‘Additionally, they can support teachers by providing a link between school and home in order to provide a fully confidential support network within school grounds,’ he says.

Mark explains that school nurses’ visibility and accessibility are important factors in encouraging a young person to seek advice or help: ‘School nurses can help reduce stigma around attending a clinic, providing reassurance that sexual health services are confidential – assuming there are no safeguarding concerns – and that they are not there to judge in any way. Also, they can remind young people they don’t have to have a parent with them or be referred from their GP.’

Internet testing

Community practitioners should also be aware of the growing provision of innovative online digital sexual health services they can steer young people towards where appropriate. These services, such as SH:24, can offer contraception and testing for STIs and may or not be provided by the NHS.

Anatole explains how they work: ‘Where publicly funded, people can order free testing kits online or pick them up from their local sexual health services, provide a swab or urine sample themselves at home, post the kits to a lab for free and receive their results by text or phone.’

He points to their success. ‘A 2017 study by the London School of Hygiene and Tropical Medicine and King’s College London, in partnership with SH:24, involved 2000 young people in south London. It found that testing uptake was nearly doubled in a group that was invited to use internet-accessed STI testing through postal self-sampling test kits for chlamydia, gonorrhoea, HIV and syphilis.’

Mark of BASHH says that online services are a useful addition to face-to-face services but shouldn’t be a substitute. ‘They also shouldn’t be implemented as a way to save money,’ he warns. ‘If it’s a way of encouraging someone to get tested who wouldn’t get tested in a traditional setting that’s a huge positive.

‘But younger people in particular need quick and easy access to clinics where they can have all their needs met. In addition to testing, this includes identification and support of safeguarding concerns, contraception and wider health promotion. It would be fairly easy for a very young person to give false details to access testing and miss the usual safety net of seeing a specialist clinician.’

Working well

One success story in the fight to reduce the prevalence of STIs is the falling trend of genital warts diagnoses across England, Wales and Northern Ireland. In England, the rate among girls aged 15 to 17 has seen a 90% decrease relative to 2009 (PHE, 2018), which it attributes to the success of the national human papilloma virus immunisation programme.

The principal ongoing challenge, says Beth Cullen, given still-high transmission rates, is undoubtedly to provide and equip young people with the relevant information and skills they need to maintain sexual health into adulthood.


  • SH:24 provides free and confidential sexual health services 24 hours a day, including postal STI tests in partnership with NHS trusts. Visit sh24.org.uk
  • For those who don’t live in the 14 areas of England that SH:24 covers, Fettlehealth offers (paid-for) online tests for STIs and treatments for chlamydia at fettle.health
  • PHE offers a sexual health toolkit for its Protect Against STIs campaign at bit.ly/PHE_protect_STIs
  • A surveillance report on chlamydia and gonorrhoea infection in Scotland can be found at bit.ly/SCT_STIs
  • See the key HIV and STI trends in Wales at bit.ly/WLS_HIV


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