Features

The sorry state of sexual health

20 March 2020

As rates of sexually transmitted infections (STIs) in England soar, journalist Juliette Astrup asks what it would take to tackle these trends and what you can do to help.

A new STI is diagnosed every 70 seconds in England, with cases of gonorrhoea up 249% and syphilis up 165% in the last decade, finds a damning new report from two sexual health charities (BASHH, 2020).

The Sexually transmitted infections in England: the state of the nation report, published by the British Association for Sexual Health and HIV (BASHH) in partnership with the Terrence Higgins Trust (THT), slams the ‘brutal’ public health funding cuts, which have seen sexual health spending slashed by a quarter since 2014.

It also outlines widening sexual health inequalities, the worrying spread of antibiotic-resistant strains of diseases and deteriorating access to services, calling for the government to bring in a robust cross-sector sexual health strategy supported by proper funding to reverse these trends. 
It has been seven years since the government last published a framework on sexual health.

Dr John McSorley, president of BASHH, says: ‘Years of government funding cuts and disruption, caused by fragmented commissioning structures, have placed incredible pressures on sexual health services in this country. At a time when we are seeing significantly increased demand from the public 
and record levels of sexual infection, including the spread of difficult-to-treat antibiotic-resistant strains of disease, the decision to disinvest in this vital public health area is nonsensical.’

Trends within the trend

Nearly half a million (447,694) cases of STIs were diagnosed in England in 2018 alone, and the report paints a worrying picture of trends: new diagnoses have increased by 5% in 2018 from 2017, and syphilis is now at its highest rate since the Second World War (BASHH, 2020). The burden of STIs was also found to disproportionally impact young people, gay and bisexual men, individuals from some ethnic minority populations and people living with HIV. These are all trends which need to be better understood and addressed, says the report.

Young people account for nearly half of all new STI diagnoses (48%), with gay men accounting for three in four (75%) of all syphilis diagnoses, while some of the highest overall rates of STIs were reported in black Caribbean and black non-Caribbean/non-African populations – all trends which need to be better understood and addressed, says the report.

Calls for action

As Jonathan McShane, chair of the THT, says: ‘The impact of this is being felt most by groups already facing discrimination and stigma, who are shouldering the heaviest burden of new STIs. Yet very little has been done to tackle these widening health inequalities.’

Comprehensive action and a joined-up strategy are chief among the charities’ recommendations, and they have welcomed the government’s commitment last October to the creation of a new national sexual health strategy.

Amber Newbigging-Lister, policy and campaigns officer at the THT, says: ‘The lack of funding, the short-sighted public health cuts and the lack of prioritisation of sexual health is what we are seeing reflected in these trends.

‘The issue is also that STIs have been viewed in a silo, separate to sexual and reproductive health and broader health, which the fragmented commissioning model has also contributed to. We want to see a national vision with much more cross-sector working.

‘It is great news that the government has made a commitment to a national sexual health strategy – but the devil will absolutely be in the detail. There needs to be that cross-sector holistic approach and there needs to be the support in public health funding – without that, it’s difficult to see how any changes could be put in place.

‘We want that strategy to have clear, ambitious targets, and to involve statutory and non-statutory organisations. We want the government to get around the table and co-produce this strategy with organisations working in this sector, these services and with people who might be affected by these issues – that is key to making sure we get it right.’

Among its other key recommendations, the report calls for access to the most accurate diagnostic tests – upholding and extending treatment, guidelines and surveillance measures for antimicrobial resistance in STIs, where necessary – and for proper recognition of sexual health inequalities.

It is also clear about the urgent need to update the evidence based around the changing behaviours associated with increased risk of STIs, and then to ensure that this evidence is translated into targeted prevention interventions.

‘Many young people appear not to have a clear understanding of how STIs spread and their responsibility to have safe relationshIPS’


Sexual health in the other three nations

Northern Ireland

Gonorrhoea diagnoses in 2018 were the highest on record, up 30% to 882 in 2018. Cases of chlamydia increased by 6%, with 1787 diagnoses in 2018.  Diagnoses of genital herpes were up 8% to 501 in 2018, and diagnoses of genital warts (first episode) decreased by 10% to 1436 in 2018. Diagnoses of syphilis increased by 72%, with 86 in 2018.

Recommendations from the PHA’s latest sexual health surveillance report include the continued promotion of safer sex messages and that commissioners should continue to seek to expand access to STI testing opportunities.

Public Health Agency, 2019

Wales

STIs continue to rise in Wales, with a 22% rise in syphilis cases, a 14% rise in gonorrhoea and a 7% increase in episode herpes between October 2018 and March 2019 when compared with the same period a year previously. Significantly, there was a 76% increase in syphilis diagnoses in people aged less than 25 years.  

In Wales, health boards are already implementing recommendations from the 2018 Public Health Wales review of sexual health services, with the aim of improving access to services and patient experience, and reversing STI trends.

Having begun with local needs assessments and service audits, priorities include staff training, increased capacity through the provision of more drop-in clinics, information sharing across relevant health care professionals, and the development of a national surveillance system.

Public Health Wales, 2019; 2018

Scotland

STIs rose in Scotland from 2017 to 2018. There were 16,338 diagnoses of chlamydia, a 4% increase, with 66% of all those diagnosed aged under 25.

In 2018, gonorrhoea diagnoses increased by 24% to 3233 diagnoses – the largest annual total recorded since the mid-1980s and up 103% from 2013. Cases of syphilis increased by 14% to 455 in 2018 – the highest annual total recorded since the establishment of the surveillance system in 2002-03.

The findings ‘underline the importance of a coordinated public health response to meet the challenges for the control and prevention of STIs in Scotland’, Health Protection Scotland concludes.

Health Protection Scotland, 2019


Can you help raise awareness?

Until the new evidence emerges, public health practitioners can still make an impact. For example, the report highlights the need for sexual health champions to speak out about STIs, because ‘the lack of voices, champions and visibility of sexual health in mass media runs the risk of perpetuating stigmatising attitudes’.

Amber of the THT adds: ‘Practitioners are essential for leading in this conversation and raising awareness, especially early on in schools, addressing stigma and even simply providing access to condoms – but again that can be down to how well services are supported to provide that kind of provision. We know that even though they are under enormous pressure, services have a positive impact on the sexual health of those they come into contact with.’

Lucretia Baptiste is a longstanding member of Unite-CPHVA, with years of experience in sexual health services for young people. She agrees that, alongside better equipped services for under-25s, with funding specially focused on meeting the needs of this age group, health promotion is an important aspect.

She says: ‘Many young people appear not to have a clear understanding of how STIs spread and their responsibility to have safe relationships. Many young people report not using condoms despite having sexual relations with multiple contacts. There needs to be a stronger focus on relationships and safer sex in schools and colleges. Some young people are not sure when they should be tested and sometimes mistakenly refuse or decline services offered.

‘It is really important that all practitioners working with young people are aware of where they can refer for specialist advice, as well as what, when and where services are available. Some areas, for example, run outreach services where young people can be seen in school, college or at home, if necessary, for drop-in services.’

‘School nurses need training to support young people at drop-ins or after-school sessions. Practitioners need not work alone, as health promotion groups can be arranged, and they can visit services to understand how the clinics run and what is provided. Knowledge is important – practitioners can accompany young people sometimes if they are worried or shy about attending an STI service.’

Next steps

While the sexual health of the nation is currently in poor shape, there is at least a clear prescription set out in this comprehensive report from these leading charities. How far the government is prepared to administer this, and adopt the proposals in its forthcoming national sexual health strategy, remains to be seen.

A spokesman for the Department of Health and Social Care says: ‘More people than ever are now able to access sexual health services, and we strongly urge people to take advantage of this free, local service if they consider themselves to be at risk.

‘Our new sexual and reproductive health strategy will be published this year.’

There is a long way to go if the current increasing trends in STIs are to be, at the very least, managed, and, ultimately, reversed. In the meantime, community practitioners working with young people can continue to make a difference through education and support, but also in raising their voices and contributing their knowledge and experience to help shape the sexual health strategy for the future.


Sexual health in England

  • The most commonly seen STI in England is chlamydia with nearly 220,000 diagnoses in 2018. Chlamydia has increased 6% between 2017 and 2018 and 15% since 2009
  • 7541 cases of syphilis were diagnosed in 2018 – a 5% rise from 2017 but an increase of 165% over the past decade
  • Diagnoses of gonorrhoea have increased by 26% between 2017 and 2018 to 56,259 diagnoses in 2018 – and have rocketed by 249% in the past 10 years
  • 23%- Genital herpes cases have increased by this amount in the past 10 years, although they have largely plateaued for the past five, with a 3% rise between 2017 and 2018
  • Since surveillance on Mgen (Mycoplasma genitalium) began in 2015, diagnoses have increased 2171% with 1794 cases in 2018 – a rise likely due to an increase in testing with the advent of a Mgen-specific test
  • There were 447,694 new diagnoses of STIs in 2018
  • Trichomoniasis and shigella are less common, but since 2017 there have been 8% and 91% increases in new diagnoses respectively
  • Genital warts cases are declining, with a 3% fall since 2017 and a 27% reduction since 2009

Resources  


References

British Association for Sexual Health and HIV, Terrence Higgins Trust. (2020) Sexually transmitted infections in England: the state of the nation. See: https://www.tht.org.uk/sites/default/files/2020-02/State%20of%20the%20nation%20report%20v2.pdf (accessed 26 February).

Health Protection Scotland. (2019) Genital chlamydia and gonorrhoea infection in Scotland: laboratory diagnoses 2009-2018. See: https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2791/documents/1_genital-chlamydia-gonorrhoea-scotland-2009-2018.pdf (accessed 26 February).

Public Health Agency. (2019) Sexually transmitted infection surveillance in Northern Ireland. See: https://www.publichealth.hscni.net/sites/default/files/2019-08/STI%20surveillance%20report%202019.pdf (accessed 26 February).

Public Health Wales. (2019) Sexual health in Wales surveillance scheme. See: https://phw.nhs.wales/topics/sexual-health/sexual-health-reports/sexual-health-in-wales-surveillance-scheme-quarterly-report-july-2019/ (accessed 26 February).

Public Health Wales. (2018) A review of sexual health in Wales. See: http://www.wales.nhs.uk/sitesplus/documents/888/A%20Review%20of%20Sexual%20Health%20in%20Wales%20-%20Final%20Report.pdf (accessed 26 February).
 

 

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