Scotland s Sexual Health Information

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2 NHS National Services Scotland/Crown Copyright 29 First Published 29 Brief extracts from this publication may be reproduced provided the source is fully acknowledged. Proposals for reproduction of large extracts should be addressed to: ISD Scotland Publications Information Services Division NHS National Services Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: +44 () nss.isd-publications@nhs.net BBV/STI Team Health Protection Scotland Clifton House Clifton Place Glasgow G3 7LN Tel: +44 () NSS.HPSbbvsti@nhs.net Women and Children s Health Information Programme Information Services Division Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: NSS.ISDwchip@nhs.net Sexual Health Epidemiology Group 29. Health Protection Scotland and Information Services Division, November 29 Telephone

3 CONTENTS CONTENTS ACKNOWLEDGEMENTS i ii INTRODUCTION 1 CHAPTER 1 - Policy and Workload 2 Policy 2 Workload 4 CHAPTER 2 - Sexually Transmitted Infections 7 Genital chlamydia 1 Gonorrhoea 13 Genital herpes 16 Infectious syphilis 18 Human papillomavirus (HPV): genital warts and cervical cancer 2 HIV infection 23 CHAPTER 3 - Sexual Health in Population Groups 26 Sexual Health among Men who have Sex with Men 26 Sexual health in the heterosexual population 3 Young People 3 Mid s (ages 25-44) & Older s (age 45 and over) 36 Mid s (ages 25-44) 36 Older s (age 45 and over) 4 Archway Glasgow: Sexual Assault Referral Centre (SRC) 43 CHAPTER 4 - Ethnicity and Diversity 44 CHAPTER 5 - NHS Board Summary 46 CHAPTER 6 - Conclusions and Challenges 49 APPENDIX - Sexual Health in Scotland 51 REFERENCES 55 ABBREVIATIONS 56 i

4 ACKNOWLEDGEMENTS Membership of Sexual Health Epidemiology Group Sharon Cameron Jim Chalmers* Glenn Codere Beth Cullen* Jayshree Dave Kirstine Eastick David Goldberg* Shirley Fraser* Nicholas Kennedy Tosh Lynch Alan MacAldowie Lisa McDaid Kenny McIntyre Dona Milne Felicity Naughton Helen Palmer Alastair Philp Zareena Rafiq* Sharmini Ramasami* Etta Shanks Louise Shaw Ewen Stewart Bishan Thacker Carolyn Thompson Gavin Venters Lesley Wallace* Andy Winter Family Planning, Edinburgh (Chair), Information Services Division Health Protection Scotland Health Protection Scotland Scottish Bacterial STI Reference Laboratory, Edinburgh Scottish Bacterial STI Reference Laboratory, Edinburgh Health Protection Scotland NHS Health Scotland Department of Infectious Diseases, Lanarkshire Sandyford Initiative, Genitourinary Medicine, Glasgow Information Services Division MRC Social and Public Health Sciences Unit Information Services Division Scottish Government Scottish Government Scottish Bacterial STI Reference Laboratory, Edinburgh Information Services Division Information Services Division Genitourinary Medicine, Edinburgh Information Services Division Health Protection Scotland General Practitioner, Edinburgh Bacteriology, Royal Infirmary, Glasgow Genitourinary Medicine, Edinburgh National Information and Statistics Group Health Protection Scotland Sandyford Initiative, Genitourinary Medicine, Glasgow * - denotes member of editorial team for this report - denotes principal author of Chapters 1 and 2, Chapter 3 (Sexual Health among Men who have Sex with Men, and all the sexually transmitted infection sections of Sexual Health in the Heterosexual Population), Chapters 4, 5, and 6. - denotes principal author of teenage pregnancy, abortion, and contraceptive use sections of Chapters 3, 5 and 6. ii

5 INTRODUCTION This is the fifth annual report produced by the Sexual Health Epidemiology Group (SHEG) (previously known as the Sexually Transmitted Infections Epidemiology Advisory Group (STIEAG)) for Scotland. It continues to utilise a number of different data sources to describe a wider picture of sexual health, rather than sexually transmitted infections (STIs) alone. The aim of the report remains the same - to promote a better understanding of sexual health in Scotland. The full report contains updated figures, tables and text for 28 (with the exception of teenage pregnancy which is for 27 conceptions) and can be accessed online through the websites for Health Protection Scotland (HPS) and Information Services Division (ISD) ( and A summary is also available which provides readers with the headline data and the most important developments since the previous year s SSHI report ( The Conclusions and Challenges and the NHS Board Summary provide a round up of sexual health services. Please note that further data and information can be obtained at both the Health Protection Scotland (HPS) and Information Services Division (ISD) websites on a range of subjects including STIs, teenage pregnancies, and the use of contraception. ( nhs.uk/bbvsti/index.aspx and org/sexual_health.) We hope that readers will take advantage of the signposting to delve deeper into the resources that HPS and ISD provide. The editorial group are keen to receive feedback from readers. Please let us know whether this format is useful and if there is a reasonable balance of information. Also let us know if you would like to see other information included or the information presented in a different way. National Statistics National Statistics is a quality marker applied to some of the UK s official statistics. It is important that official statistics are trusted and statistics labelled as National Statistics must meet certain criteria. They should, for example, be fit for purpose, methodologically sound, politically independent and transparently produced. All National Statistics are produced in accordance with the Framework for National Statistics and they must comply with the principles embodied in the Code of Practice. The majority of statistics released by ISD are published under National Statistics. HPS data and publications, however, are not bound by National Statistics. The SSHI report contains data collected and analysed by both HPS and ISD. Where data are National Statistics, this will be indicated by the National Statistics kitemark. A list of tables has also been compiled that indicates which of the tables and charts in the report are defined as National Statistics. 1

6 CHAPTER 1 - Policy and Workload Policy Policy Outline Respect and Responsibility Scotland s sexual health strategy, Respect and Responsibility: A Strategy and Action Plan for Improving Sexual Health, published by the Scottish Government in January 25, is now in the second phase of funding, Resource/Doc/35596/12575.pdf. This strategy was supported by an extra investment of 15 million over the three financial years April 25 to March 28. An additional 15 million has been invested, from within the Scottish Government s Better Health, Better Care: Action Plan (27), to support the strategy until 211. Following a stock taking review of the strategy in 27, the next phase will continue to support sexual health service provision in addition to tackling/developing cultural and behavioural change. This latter issue will be addressed during 29/1 through social marketing campaigns led by the Scottish Government s Health Improvement Social Marketing Strategy and NHS Health Scotland. Respect and Responsibility: sexual health outcomes In the second phase of Respect and Responsibility, the focus is shifting towards achieving cultural and behavioural change. A document, Respect and Responsibility: Delivering improvements in sexual health outcomes details actions across four broad themes: (i) knowledge and awareness; (ii) leadership, co-ordination and performance management; (iii) standards and service provision and, (iv) young people. These actions are designed to improve the sexual health and wellbeing of people in Scotland by achieving long term objectives such as: a reduction in levels of regret and coercion, a reduction in levels of unintended pregnancy, a reduction in sexually transmitted infections (STIs) and in HIV transmission, and increased access to sexual health information and to sexual health services. R&Routcomes28211_final.pdf HIV: Treatment and care needs assessment The Scottish Public Health Network (ScotPHN) was commissioned by the Scottish Government to perform a health care needs assessment (HCNA) for people living with HIV in Scotland. The report, Treatment and Care Needs Assessment: People living with HIV, following a stakeholder event held in 28 and having completed its consultation process, will be published during com/resources/networks/scotphn/projects/hiv.aspx 2 The HCNA recommends a number of improvements that will allow services to meet the current and future complex demands of people living with HIV. Key recommendations have informed the HIV Action Plan. HIV Action Plan An HIV Action Plan for Scotland will be published by the Scottish Government in December 29. The aim of this plan is primarily to prevent HIV transmission and to provide high quality treatment and care to all those who require it. In anticipation of the national HIV Action Plan, NHS Health Scotland is working with key voluntary and statutory agencies to develop HIV key messages and visual materials targeted at men who have sex with men (MSM). Sexual Health Services Standards (NHS Quality Improvement Scotland) Sexual health services standards were developed and published in April 28 by NHS Quality Improvement Scotland (NHS QIS) and can be accessed at SEXHEALTHSERV_STANF_MAR8.pdf 3 NHS QIS have developed a self assessment framework tool to support NHS boards in providing information to achieve the standards. Each NHS board will receive a visit which is intended to monitor their performance against the standards. 2

7 Advisory Groups National Sexual Health and HIV Advisory Committee (NSHHAC) A National Sexual Health Advisory Committee (NSHAC) was formed in 25 to support the implementation of Respect and Responsibility. This committee was recently reformed and renamed as the National Sexual Health and HIV Advisory Committee (NSHHAC) to highlight the importance of HIV in sexual health. This is chaired by the Minister for Public Health and Sport. The work of the committee continues with the aim of improving the sexual health and wellbeing of people living in Scotland. The Scottish Government launched a sexual health website in June 29: sexualhealthscotland.co.uk/ as part of the first phase of their new sexual health campaign. The website is supported by following campaigns: Giving You More Choice, a campaign to promote long acting reversible methods of contraception (LARC) in women aged 18-44, launched in July 29. The campaign was developed by NHS Health Scotland to support the NHS QIS sexual health services standard and is underpinned by convenience advertising, media articles, posters and a specific patient leaflet designed and tested with women. It s Healthy To Talk About It, launched in August 29. This campaign promotes relationships and sexual health among men and women aged 2 to 4. It is supported by promotional posters, radio and cinema adverts, and a series of sexual health leaflets along with the national publicfacing website. The creation of a research advisory group has been supported by NSHHAC following a review of the research literature on the sexual health and wellbeing of fourteen vulnerable groups in Scotland by an NSHHAC subgroup. The review identifies key priorities for further research. The summary report and the technical reports on each of the vulnerable groups can be found at: healthscotland.com/topics/health/wish/evidence. aspx Data collection on aspects of sexual health at Health Protection Scotland (HPS) and Information Services Division (ISD) supports the strategy, notably in the Key Clinical Indicator (KCI) reports. 4 Sexual Health Epidemiology Group (SHEG) The Sexual Health Epidemiology Group (SHEG), formerly the Sexually Transmitted Infection Epidemiology Advisory Group (STIEAG), is an advisory group on sexual health with a direct link to NSHHAC. The remit of SHEG is to promote and support the development and use of sexual health information in Scotland. There are four main areas of activity: to advise on sexual health data collection and on the epidemiology of STIs; to support the continued development of sexual health information; to coordinate and link with other professional groups, and to report on sexual health information. SHEG is a multidisciplinary group representing expertise across several dimensions in sexual health. Please see the cover pages for membership details. Data Systems Developments National Sexual Health System (NaSH) NaSH is a new electronic information system which was developed to support sexual health services throughout Scotland. This is part of the NHS Scotland National ehealth Strategy. In addition to providing an electronic patient record (EPR) for sexual health, this system will provide secondary data for national reporting. The system has a comprehensive dataset which may improve and enrich the data used in this report in the future. Once fully implemented, the system will not only support specialist sexual health services but also provide a valuable source of data on sexual health in Scotland. The NaSH system went live in March 28 and is currently being rolled out in all specialist sexual health services in Scotland; in both genitourinary medicine (GUM) and sexual and reproductive health clinics. Most NHS areas will have adopted this system by the end of December 29. However, the system, in some areas, will not be used as a full electronic patient record initially. Eventually, NaSH may be used in other settings providing sexual health care, for example Primary Care practices providing enhanced services. For further information see: nhs.uk/ 3

8 Workload Workload in the GUM clinic setting Overall workload, presented as all counts of diagnoses, screens and conditions seen, increased by 16% across Scotland between 27 and 28. This compares with a 13% increase in each of the previous two years. This workload increased in all NHS board areas except NHS Fife and NHS Forth Valley. Figure 1.1: All aspects of care (diagnosis and/or screening and/or treatment) recorded in GUM clinic settings, by gender, Men Women Total In 28, there was an almost four-fold variation in rates of episodes of care (diagnosis and/or treatment) by NHS board of residence of patients. The highest episode rate was observed among the residents of NHS Lothian; this is a similar observation to that in the previous two years. The variation in these rates is partly due to the lack of provision of local genitourinary medicine (GUM) clinic services in some NHS board areas. It is clear that some patients cross NHS boundaries to access services. NHS board Figure 1.2: All episodes of care (diagnosis and/or treatment) in GUM clinic settings by NHS board of residence and by NHS board of treatment, 28. Lothian Glsgw & Clyde Tayside SCOTLAND Borders Fife Grampian Forth Valley Ayr & Arran Highland Lanarkshire Dmfr & Gall NHS board of residence Rate per 1, NHS board of treatment The denominator is the population aged Mid-year population data for 28 available from GROS 5 45 Workload in the primary care setting These data are based on estimates of the number of consultations with general practitioners (GPs) and practice nurses using the Practice Team Information (PTI) sample of practices (see Appendix 1 for further details on how these estimates are calculated). The estimates indicate an increase in primary care workload for genital chlamydia, genital herpes and genital warts in Scotland between 26/27 and 27/28. There appears to be a two-fold increase in female consultation rates for genital warts. However, the confidence intervals around these rates are large because of the relatively small numbers of consultations involved, and these data are compatible with a much smaller rise in consultation rates. Furthermore, this rise is not seen in GUM clinic attendance. Overall workload for men decreased between 23/24 and 27/28, while that for women increased. Although some of the apparent rise in female consultation rates for genital warts may be an artefact of random fluctuation because of relatively small numbers of consultations, it is possible that there has been an effect of the publicity regarding the introduction of a human papilloma virus (HPV) vaccine in September 28. The vaccine, available to young girls aged 12-18, aims to prevent up to 7% of cervical cancers. Around 3-4 types of the human papilloma virus infect the genital tract; types 6 & 11 can cause genital warts while types 16 & 18, among others can cause cervical cancer. (See Chapter 2 for further information). 4

9 Figure 1.3: Estimated number of male consultations for genital chlamydia, genital herpes and genital warts seen in primary care, Scotland, 23/24-27/ /24 24/25 25/26 26/27 27/28 Chlamydia Genital herpes Genital warts Consultations in the primary care setting include a visit to the general practitioner or the practice nurse and their clinical assistants Note: these data are not comparable to previous presentations of data as the statistical model used to calculate these estimates has been updated. These data are estimated using statistical modelling; the 95% confidence intervals for each data point are not shown. Data source: Practice Team Information Figure 1.4: Estimated number of female consultations for genital chlamydia, genital herpes and genital warts seen in primary care, Scotland, 23/24-27/ Chlamydia Genital herpes Genital warts Estimated number of consultations Figure 1.5: Estimated number of consultations for contraceptive management in men and women in the primary care setting, Scotland, 23/24-27/ /24 24/25 25/26 26/27 27/28 Estimated GP consultations Estimated Practice Nurse consultations Note: these data are estimated using statistical modelling; the 95% confidence intervals for each data point are not shown. Data source: Practice Team Information In women, the decrease observed during the previous five years is primarily due to a reduction in the number of consultations in those aged less than 25 and those aged In men, whilst the numbers of consultations increased between 26/27 and 27/28 in all those aged less than 4, the overall reduction observed was due to a reduction in consultations for those aged over 4. Figure 1.6: Estimated number of consultations for contraceptive management in women by age group in the primary care setting, Scotland, 23/24-27/28. 1% 8% Consultations in the primary care setting include a visit to the general practitioner or the practice nurse and their clinical assistants Note: these data are not comparable to previous presentations of data as the statistical model used to calculate these estimates has been updated. These data are estimated using statistical modelling; the 95% confidence intervals for each data point are not shown. Data source: Practice Team Information Overall there has been a 17% reduction in consultations for contraceptive management with GPs and practice nurses from 649,54 in 23/24 to 536,58 in 27/28. While there are year on year fluctuations, primary care workload for contraceptive management has decreased among both men (39%) and women (17%) during the past five years. The number of consultations with GPs was over two-fold higher than those with practice nurses; this is primarily due to practice nurses without specialist training being unable to prescribe certain contraception directly. Proportion 6% 4% 2% % 23/24 24/25 25/26 26/27 27/28 < >4 Note: these data are estimated using statistical modelling; the 95% confidence intervals for each data point are not shown Data source: Practice Team Information 5

10 Figure 1.7: Estimated number of consultations for contraceptive management in men by age group in the primary care setting, Scotland, 23/24-27/28. 1% 8% Proportion 6% 4% 2% % 23/24 24/25 25/26 26/27 27/28 < >4 Note: these data are estimated using statistical modelling; the 95% confidence intervals for each data point are not shown Data source: Practice Team Information Workload in the community sexual and reproductive health clinic setting There are currently no national data which provide information on the workload of community sexual and reproductive health clinics. The new electronic information system for sexual health (NaSH), currently being rolled out throughout Scotland, should address this gap and provide additional information from specialist sexual health services. 6

11 CHAPTER 2 - Sexually Transmitted Infections The data on sexually transmitted infections (STIs) presented in this chapter use a combination of both diagnoses made in the genitourinary medicine (GUM) clinic setting (derived from the STI Surveillance System (STISS) database) and those made in all settings, represented by laboratory positive diagnoses. During the previous five years, the trends for the four major STIs: genital chlamydia; gonorrhoea; genital herpes, and genital warts indicate a general increase in diagnoses with the exception of gonorrhoea infection in men. This is the second successive year that a decrease in male gonorrhoea infection has been observed. In women, the largest overall increase, between 24 and 28, was observed for diagnoses of gonorrhoea infection in the GUM clinic setting (77%, 154 to 273). Figure 2.1: Diagnoses of selected sexually transmitted infections in women, Genital herpes and gonorrhoea diagnoses Genital chlamydia and genital warts doagnoses Genital herpes Gonorrhoea Genital warts Genital chlamydia and laboratory reports In men, the largest overall increase in the previous five years was observed in genital herpes diagnoses (35%, 524 to 75). Also of note is the 32% rise (5415 to 7137) observed in genital chlamydia diagnoses during the same period. Figure 2.2: Diagnoses of selected sexually transmitted infections in men, Genital herpes and gonorrhoea diagnoses Genital chlamydia and genital warts doagnoses Genital herpes Gonorrhoea Genital warts Genital chlamydia and laboratory reports 7

12 In all cases the median age for women diagnosed with an STI in the GUM clinic setting is lower than that for men. The median age at diagnosis is higher for syphilis, HIV and trichomoniasis. If median age data on diagnoses of sexually transmitted infections (STIs) in MSM are removed from the male data analysis, the median age for syphilis, HIV and trichomoniasis remains higher than that for other STIs. Thus, it would be appear, contrary to previous assumptions, the raised median ages of diagnosis for HIV and syphilis, in particular, are not a reflection of these being higher in MSM than in heterosexual men. Figure 2.3: Median age for sexually transmitted infections in women and men, diagnosed in GUM clinic settings, % Quartile Median age 75% Quartile Male Female 1 Chlamydia Gonorrhoea Warts NSGI Candidiasis Diagnosis Bacterial Vaginosis Herpes HIV Syphilis Trichomoniasis M Male, F-Female A summary of the trend in diagnoses of STIs in recent years is represented in Tables 2.1 and 2.2. These indicate those observed over a five year period and in certain population groups in addition to gender. 8

13 Table 2.1: Key changes in STI diagnoses by gender and sexual orientation, Scotland, All men All women Heterosexual men MSM 1 yr 5 yrs 1 yr 5 yrs 1 yrs 5 yrs 1 yr 5 yrs Chlamydia* N/A N/A N/A N/A Gonorrhoea Genital herpes Genital warts Infectious Syphilis HIV Workload in GUM clinic Setting N/A N/A N/A N/A * Chlamydia diagnoses represented in the table refer to diagnoses made in all settings no change 2-1% increase 11-2% increase 21-4% increase 41%+ increase Note: these codes also apply to the arrows indicating a decrease Data sources: Laboratory reports, STISS, HIV diagnosis/death reports, abortion notifications and birth registrations Table 2.2: Key changes in STI diagnoses by age, Scotland, Chlamydia* Gonorrhoea Genital herpes Genital warts Men <25 Women <25 Men Women Men 45+ Women yr 5 yrs 1 yr 5 yrs 1 yr 5 yrs 1 yr 5 yrs 1 yr 5 yrs 1 yr 5 yrs Infectious Syphilis N/A N/A N/A HIV Workload in GUM clinic Setting N/A N/A N/A N/A N/A N/A * Chlamydia diagnoses represented in the table refer to diagnoses made in all settings no change 2-1% increase 11-2% increase 21-4% increase 41%+ increase Note: these codes also apply to the arrows indicating a decrease Data sources: Laboratory reports, STISS, HIV diagnosis/death reports, abortion notifications and birth registrations In comparison to the rest of the UK, the rates of new episodes of infection per 1, population in Scotland were lower, in general, for both men and women than those observed in most of the ten strategic health authorities in England but higher than those reported among men and women in Wales and Northern Ireland. The notable exceptions are the rate of diagnoses of infectious syphilis and genital warts in men - fifth highest of thirteen regions. (Table 2.3). 6 Table 2.3: Comparison of rates of diagnoses of selected sexually transmitted infections in Scotland by rank order versus Wales, Northern Ireland, and the ten Strategic Health Authority regions in England, 28. INFECTION Ranking (in comparison to 13 areas of the UK) Men Women GENITAL CHLAMYDIA 7TH 8TH GONORRHOEA 9TH 9TH GENITAL HERPES 1TH 11TH INFECTIOUS SYPHILIS 5TH 7TH= GENITAL WARTS 5TH 1TH Data on comparison rates for chlamydia are based on diagnoses in the GUM clinic setting only and thus compare only a proportion of the total number of diagnoses made in the UK Data source: All new STI episodes made at genitourinary medicine (GUM) clinics in the UK 9

14 Genital chlamydia Background and recent trends 7,8 Chlamydia trachomatis is the most frequently diagnosed bacterial STI in GUM clinics. It is readily treated with antibiotics but infection is asymptomatic in up to 8% of women and 5% of men. This highlights the importance of accessibility to testing and treatment for those who are at risk, thus minimising the pool of undiagnosed infection. Undiagnosed, untreated and/or repeated genital chlamydia infection may cause pelvic pain and scarring of the fallopian tubes in women which can result in ectopic pregnancy and infertility. However, the levels of these sequelae are much lower than previously believed. For men, the complications of genital chlamydia infection can include urethritis, epididymitis, chlamydia-associated arthritis (Reiter s syndrome) and, in some cases, infertility. 9,1 The number of chlamydia diagnoses in Scotland has remained steady over the past three years; a total of 19,54 diagnoses were recorded in 28. Overall, half (51%) of all chlamydia infections were diagnosed and managed in non-gum clinic settings. Figure 2.4: Diagnoses of genital chlamydia, made in all and GUM clinic settings, by gender, Women - All Women - GUM Men - All Men - GUM GUM clinic diagnoses represent all diagnoses of upper and lower genital tract infection, rectal and other sites of chlamydia infection 27 data revised since last report and laboratory reports Who was affected: 28 Consistent with previous years, there were more diagnoses in women than in men (ratio 1.6:1); this is likely to be a result of the implementation of the first Scottish Intercollegiate Guideline Network (SIGN) guideline 42, published in 2, which specifically recommends the opportunistic screening of women. 11 This guideline has now been revised. Please see information on the latest guideline, SIGN 19, on the Management of Chlamydia trachomatis infection 12. Between 27 and 28, diagnoses in women and men increased overall by 6% and 9%, respectively. Note that diagnoses among women in the GUM clinic setting decreased in this time period. Two thirds (65%) of men were diagnosed at GUM clinics; in contrast, almost two thirds (6%) of women were diagnosed in clinical settings other than the GUM clinic. This finding is consistent with previous years observations. In 28, 72% of all genital chlamydia diagnoses were in those aged less than 25 (63% and 79% of all male and female diagnoses, respectively). The majority of these were in men and women aged The largest increases in positive diagnoses between 24 and 28 were observed in men and women aged Of women diagnosed at GUM clinics, 1.3% had complicated chlamydia, defined as upper genital tract or pelvic infection; this form of infection was most prevalent among women aged less than 25. In the GUM clinic setting, this fraction of all chlamydia diagnoses has been decreasing in recent years. Of men diagnosed at GUM clinics, 6% had rectal chlamydia infection; almost two thirds (61%) were aged 25-44, and a further 2% were aged This finding is consistent with the previous year s observation. Rectal chlamydia infection is a marker of unsafe anal intercourse and can increase the risk of HIV transmission. 13 Figure 2.5: Diagnoses of genital chlamydia in women, made in all settings, by age group, >45 Data source: Laboratory reports 1

15 Figure 2.6: Diagnoses of genital chlamydia in men, made in all settings, by age group, >45 Data source: Laboratory reports Geographical distribution: 28 The highest rates of genital chlamydia diagnoses made in all settings among men and women were observed in Greater Glasgow & Clyde NHS Board. In the previous four years, diagnoses were highest in Tayside NHS Board. For men and women, the highest rates of genital chlamydia diagnoses at GUM services were observed among residents of Tayside. The largest increases in female and male diagnoses rates, excluding the island NHS boards, were observed in Greater Glasgow & Clyde and Forth Valley NHS Boards. As in previous years, the highest rates of rectal chlamydia diagnosed in the GUM clinic setting were observed in Lothian and Greater Glasgow & Clyde NHS Boards; this is consistent with higher attendances of MSM at GUM clinics in these locations. NHS board Figure 2.7: Rates of diagnoses of genital chlamydia in men and women, made in all settings, by NHS board of diagnosis and treatment, 28. Glsgw & Clyde Tayside Forth Valley Lothian SCOTLAND Fife Dmfr & Gall Grampian Ayr & Arran Borders Lanarkshire Highland Western Isles Orkney Shetland Rate per 1, Women Men These data are based on laboratory reports for which NHS board of diagnosis and treatment, but not NHS board of residence, information is available The denominator is the female population aged Mid-year population data for 28 available from GROS 5 Data source: Laboratory reports NHS board Figure 2.8: Rates of diagnoses of genital chlamydia in men and women, made in GUM clinic settings, by NHS board of residence, 28. Tayside Glsgw & Clyde Borders Fife SCOTLAND Forth Valley Lothian Grampian Highland Ayr & Arran Lanarkshire Dmfr & Gall Shetland Western Isles Orkney Rate per 1, Women Men Only those who were resident in Scotland are included in these data The denominator is the female population aged Mid-year population data for 28 available from GROS 5 Pelvic inflammatory disease and ectopic pregnancy The natural history of chlamydial infection is not fully understood but in a proportion of women, chronic inflammation leads to scarring and damage to the fallopian tubes and surrounding tissue. This may lead to ectopic pregnancy and infertility, specifically tubal factor infertility (TFI). Acute pelvic inflammatory disease (PID) can result from ascending chlamydial infection; a number of other micro-organisms can also cause PID, most notably other sexually transmitted infections (STIs) such as Neisseria gonorrhoeae. Acute PID is difficult to diagnose as it is not a well defined disease. Diagnosis can be based on a number of parameters including clinical presentation, symptomology and laparoscopic investigations. There has been a 25% reduction (136 to 115) in the number of PID cases managed as hospital inpatients during the past ten years. Following a decrease in admissions for ectopic pregnancy (all causes) in the late 199s, the numbers have remained stable, averaging 755 diagnoses per year between 24 and

16 Figure 2.9: Admissions to hospital with a primary diagnosis of ectopic pregnancy or pelvic inflammatory disease, Etopic pregnancies The data for 28 are provisional Data source: SMR1 and SMR2 Pelvic Inflammatory Disease New variant Chlamydia trachomatis (nvct) In August 28, one case of the new variant Chlamydia trachomatis strain (nvct, the Swedish variant ) was identified in a patient attending a sexual health service in Scotland. (Ref to HPS weekly report nhs.uk/ewr/pdf28/839.pdf ) The nvct was first reported in South West Sweden, in the late summer of 26, when an unexpected 25% decrease in C. trachomatis infections was observed in a ten month period between 25 and Outside Sweden, nvct has only been detected sporadically. It was noted that certain commercial assays in use at the time were unable to detect this variant strain. 14 A study was performed in Scotland, using samples collected from five NHS board areas, between September and December, 28. The presence of the variant was recorded in.3% (3/927) samples at this time. There were no direct links with the outbreak in Sweden. On recommendation from the Scottish Bacterial Sexually Transmitted Infection Reference Laboratory (SBSTIRL), chlamydia testing laboratories have introduced assays which detect both the normal and new variant strains of C. trachomatis. To date, there have been no cases of nvct variant detected in England and Wales. An epidemiological study examining the clinical presentation of nvct in a region of Sweden, where this variant comprises 24% of all chlamydia diagnoses, reported that women with nvct were more likely to be asymptomatic suggesting a difference in virulence between nvct and the normal strain. 16 Chlamydia testing in Scotland Data on persons undergoing chlamydia testing are available for 28 from testing laboratories throughout Scotland. These data are collected as part of the requirement to address key clinical indicators (KCIs) for the National Sexual Health and HIV Advisory Committee (NSHHAC). 4 There has been a 14% increase in the number of tests performed between 27 and 28 (231,766 to 264,663). The majority of chlamydia testing (75%) is performed on women and, overall, 53% of tests are performed on those aged over 25. Of women undergoing testing more than three times as many positive diagnoses were made in those aged less than 25 than in older women. In all persons undergoing chlamydia testing, a higher prevalence was observed in men; in those aged less than 25, 16% of men were positive for chlamydia compared to 1% of young women. A greater focus of testing in young people, especially in men, is required to reduce the prevalence of infection and the risk of chlamydiaassociated sequelae. An updated version of the SIGN guideline on the management of genital chlamydia was published in March 29. This recommends the testing of symptomatic men and women and a focus on increasing uptake of chlamydia testing in the asymptomatic population at risk of infection, particularly in young people ac.uk/pdf/sign19.pdf Table 2.4: Prevalence of genital chlamydia in those undergoing testing by age group in men and women in Scotland, 28*. Age group (y) tested (%) ,619 (48) ,727 (52) Total (15-49) 193,346 (1) Women positive (%) 9629 (1) 2793 (3) tested (%) 28,872 (46) 33,32 (54) 12,422(6) 62,192 (1) Men positive (%) 4473 (16) 2724 (8) 7197 (12) * Please note these results may include duplicates and some ophthalmic sample-related ones. Data source: chlamydia testing laboratories in Scotland 12

17 Gonorrhoea Background and recent trends Molecular tests are increasingly being used in laboratories due to their high sensitivity compared to conventional techniques. This has led to an increase in the number of cases detected, particularly in community settings and in those who are asymptomatic. In 28, 173 laboratory diagnoses of gonorrhoea were made - this is a 6% increase on that reported in 27. These data, however, are not comparable to those collected in the years prior to 27. Please see Health Protection Scotland s (HPS) Weekly Report for more details on these diagnoses. 7 Diagnoses of gonorrhoea in the GUM clinic setting, which are then confirmed in the laboratory, are a subset of the total number of laboratory diagnoses recorded. Guidance on the use of molecular testing for gonorrhoea is available at hps.scot.nhs.uk/labs/sbstirl/naats-27-8.pdf Between 27 and 28, a 3% increase in laboratory diagnoses among women and an 8% decrease in those among men were observed. This is similar to 26 observations. aspx?id= In Scotland s GUM clinics in 28, the number of diagnoses of gonorrhoea decreased for the second consecutive year from 864 in 27 to 829 in 28; this was due principally to the 19% decrease in infection diagnosed in MSM. Note however, there was a 13% increase in diagnoses among women. 8 In 28, gonorrhoea diagnoses rates per 1, population among women and men in Scotland attending GUM clinics were both the fifth lowest when compared to those in the ten English Strategic Health Authority regions and the other countries of the United Kingdom. 6 Resistance to one or more antibiotics was detected in 46% of all gonococcal isolates. 17 Figure 2.1: Diagnoses of gonorrhoea, made in GUM clinic settings, by gender and sexual orientation, All Men MSM Women GUM clinic diagnoses represent all diagnoses of upper and lower genital tract infection, rectal and other sites of gonorrhoea infection MSM men who sex with men are a subset of all men diagnosed with gonorrhoea Who was affected: 28 These data refer to diagnoses in the GUM clinic setting where additional behavioural data are collected. Data on all diagnoses are available from the HPS Weekly Report. 7 Two thirds (556/829) of gonorrhoea diagnoses were among men. Less than half (4%) of all men with gonorrhoea infection were MSM. Fifteen per cent of infected men had rectal gonorrhoea - an indicator of recent, unprotected anal intercourse; this is similar to that reported in 27 and 26 but higher than the levels observed in 24 and 25. Note that among gonorrhoeainfected MSM, one third had rectal gonorrhoea. Co-infection is common; 4% of women and 27% of all men diagnosed with gonorrhoea were also infected with genital chlamydia. 13

18 Figure 2.11: Proportion of diagnoses of gonorrhoea, made in GUM clinic settings, who have chlamydia co-infection, by sexual orientation, Figure 2.13: of diagnoses of gonorrhoea in men, made in GUM clinic settings, by age group, Proportion (%) Heterosexual Men MSM Women >45 Three quarters (74%) of female diagnoses, compared to 54% of male diagnoses, were among those aged less than 25. Most diagnoses of gonorrhoea were in women aged and in men aged Between 27 and 28, a decrease in diagnoses among men was observed in all age groups except those aged The increase in diagnoses among women continued in those aged for the second year in succession; there has also been a large increase in diagnoses in those aged during the last two years. Figure 2.12: of diagnoses of gonorrhoea in women, made in GUM clinic settings, by age group, >45 Geographical distribution: 28 Female diagnoses rose in 28 and this is mainly due to the large increases in diagnoses among female residents of Lothian and Tayside NHS Boards. The overall decrease in the number of gonorrhoea diagnoses observed among men in the GUM clinic setting between 27 and 28 is a result of a decrease in the diagnoses rates in male residents of Highland, Lanarkshire and Greater Glasgow & Clyde NHS Boards. Of note, however, is the doubling of the diagnosis rate among male residents of Grampian NHS Board during 28. NHS board Figure 2.14: Rates of diagnoses of gonorrhoea in women, made in GUM clinic settings, by NHS board of residence, 28. Glsgw & Clyde Lanarkshire Lothian SCOTLAND Tayside Borders Highland Ayr & Arran Fife Dmfr & Gall Forth Valley Grampian Rate per 1, 3 35 The denominator is the female population aged Mid-year population data for 28 available from GROS 5 14

19 NHS board Figure 2.15: Rates of diagnoses of gonorrhoea in men, made in GUM clinic settings, by NHS board of residence, 28. Lothian Glsgw & Clyde SCOTLAND Lanarkshire Grampian Tayside Fife Highland Ayr & Arran Forth Valley Borders Dmfr & Gall Rate per 1, The denominator is the male population aged Mid-year population data for 28 available from GROS 5 Antibiotic resistance: Over one quarter (29%) of all strains of gonorrhoea circulating in the infected population in Scotland were resistant to the antibiotic, ciprofloxacin, despite its discontinued use since 23 as a first line treatment. 17 Note that with the increase in molecular testing, fewer samples are available for isolation and antibiotic susceptibility testing. Resistance data are based on 71% of episodes of gonorrhoea in Scotland in 28. Overall resistance to one or more antibiotics was detected in 46% of gonococcal isolates. This compares with 49%, 46%, and 41% in 25, 26 and 27 respectively. During 27, levels of resistance were highest (>5%) in isolates circulating in Grampian NHS Board. The high level azithromycin resistance reported in 27 was not observed in 28. Reassuringly, in 28, there were no isolates with reduced susceptibility to the antibiotic therapies currently in use - cefixime and ceftriaxone - and these remain the recommended first line therapies for gonococcal infection due to increasing resistance to ciprofloxacin. 17 However, reduced susceptibility to third generation cephalosporins is emerging in England and Wales and elsewhere in Europe in 27,.2% isolates demonstrated reduced susceptibility, this increased to 1.5% in Continued surveillance for antibiotic resistance is essential for guiding the choice of effective therapeutic regimens and every effort should be made to maintain culture from a high proportion of gonococcal episodes of infection. Note that the typing analysis of isolates submitted to SBSTIRL for characterisation indicated that these were representative of the mix of subtypes found by molecular testing in laboratories who do not offer culture technology. NHS board Figure 2.16: Proportion of gonococcal isolates that are resistant to ciprofloxacin by NHS board of diagnosis and treatment, 28. Grampian Tayside Highland Dmfr & Gall Lothian Borders SCOTLAND Fife Glsgw & Clyde Forth Valley Lanarkshire % Ciprofloxacin resistance 6 7 These data do not include seven isolates (four in Greater Glasgow & Clyde and one each in Grampian, Lothian and Tayside) with low level resistance (defined as minimum inhibitory concentration (MIC).5 to.5mg/l) The data represent NHS boards where more than five isolates were reported in 28 Data source: Scottish Bacterial Sexually Transmitted Infections Reference Laboratory 15

20 Genital herpes Background and recent trends Genital herpes is caused by infection with the herpes simplex viruses (HSV) of which there are two types (types 1 and 2). HSV infection may cause ulceration but may also be asymptomatic. Following initial infection, HSV remains dormant in cells and can reactivate with varying frequency. Genital herpes is diagnosed on the first clinical presentation with genital symptoms; this may not always be laboratory confirmed although every effort should be made to test. Thus, the data presented include information on both the laboratory confirmed (75% of suspected new diagnoses) and unconfirmed clinical diagnoses of HSV made in the GUM clinic setting only. In 28, 1644 people attending GUM clinics were diagnosed with genital herpes for the first time. Over the past five years, the number of new diagnoses in GUM clinics has risen by almost one third (28%). Three quarters (74%, 121/1644) of people who were diagnosed for the first time had self-referred to one of the GUM clinics, and approximately one fifth (18%: 294/1644) had consulted with, and had been referred by, their GP. Genital herpes is a lifelong infection and some people may experience recurrent infection: in 28, care was provided in the GUM clinic setting for an additional 973 recurrent episodes. In Scotland during 28 the rates of new episodes of genital herpes among men were lower than those observed in nine of the ten strategic health authorities in England, but higher than those reported in Wales and Northern Ireland. Among women, rates of first occurrence genital herpes were higher than those reported in Wales and Northern Ireland, but lower than those observed in all ten of the English strategic health authorities. 6 Figure 2.17: Diagnoses of genital herpes, made in GUM clinic settings, by gender, Women Men Diagnoses of first occurrence of infection with herpes simplex virus Who was affected: 28 A number of observations were noted in 28 which are consistent with those in previous years. These are: More than half of new genital herpes diagnoses made in GUM clinics (57%) were in women. Most diagnoses of genital herpes were made in women aged 2-24 and in men aged Of all new genital herpes diagnoses observed in 28, half (51%) of those in women and one third (33%) of those in men were made in persons aged less than 25. HSV type 1 infection was more common in women (57%), while, in men, diagnoses were predominantly due to HSV type 2 (58%). Further analyses of the data indicate that between 27 and 28: The overall 9% increase reflected 12% and 6% increases in diagnoses among men and women, respectively. In contrast to 27 data, the largest increases in diagnoses were among men and women aged 35-44; the number of diagnoses rose by one quarter (24%) in men and by one fifth (19%) in women. 16

21 Proportion (%) Figure 2.18: Diagnoses of genital herpes in women, made in GUM clinic settings, by age group, >45 Diagnoses of first occurrence of infection with herpes simplex virus Figure 2.19: Diagnoses of genital herpes in men, made in GUM clinic settings, by age group, >45 Diagnoses of first occurrence of infection with herpes simplex virus Figure 2.2: Diagnoses of genital herpes, made in GUM clinic settings, by gender and virus type, 28. 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % Women Gender Men Type 1 Type 2 Diagnoses of first occurrence of infection with herpes simplex virus Geographical distribution: 28 In the GUM clinic setting, the highest diagnosis rate of genital herpes in women was observed among Lothian NHS Board residents for the second year in succession. In women, increases in diagnoses rates, between 27 and 28, were observed among residents of six NHS boards, namely Ayrshire & Arran, Borders, Greater Glasgow & Clyde, Grampian, Highland, and Lanarkshire. In the GUM clinic setting, the highest diagnosis rate of genital herpes in men was observed in male residents of Greater Glasgow & Clyde NHS Board. In men, increases in diagnoses rates, between 27 and 28, were observed among residents of six NHS boards; Ayrshire & Arran, Tayside, Greater Glasgow & Clyde, Fife, Highland, and Lothian NHS Boards. NHS board NHS board Figure 2.21: Rates of diagnoses of genital herpes in women, made in GUM clinic settings, by NHS board of residence, 28. Lothian Glsgw & Clyde Borders Fife Highland SCOTLAND Grampian Ayr & Arran Tayside Lanarkshire Forth Valley Dmfr & Gall Rate per 1, Diagnoses of first occurrence of infection with herpes simplex virus The denominator is the female population aged Mid-year population data for 28 available from GROS 5 Figure 2.22: Rates of diagnoses of genital herpes in men, made in GUM clinic settings, by NHS board of residence, 28. Glsgw & Clyde Lothian Tayside SCOTLAND Highland Grampian Fife Ayr & Arran Forth Valley Lanarkshire Dmfr & Gall Borders Rate per 1, 6 Diagnoses of first occurrence of infection with herpes simplex virus The denominator is the male population aged Mid-year population data for 28 available from GROS 5 17

22 Infectious syphilis Background and recent trends Infectious syphilis is a bacterial infection which is characterised by three phases: primary, secondary, and early latent. This represents all cases which are diagnosed within two years of infection. Syphilis re-emerged in Scotland during 2/21 following outbreaks elsewhere in the UK; since then, the annual increase in diagnoses across the UK has largely been driven by an increase in infections in the MSM population. In 28, 264 infectious cases were recorded at GUM clinics; this exceeds the number of cases reported for 27 (249) and is the highest annual total recorded since Following a five-fold increase in diagnoses among MSM between 23 and 26, the numbers in this population have stabilised in recent years with 197 and 212 diagnoses being recorded in 27 and 28, respectively. In contrast, information from enhanced surveillance indicates that there has been an increase in the number of heterosexually acquired syphilis cases observed during the last few years (34 to 44); this followed a period of stability between 24 and 26 when 2-3 diagnoses were reported annually. 19 This observation would appear to be due largely to an increase in the number of diagnoses among women (12 in 26, 14 in 27, and 18 in 28). During 28, the syphilis diagnosis rate per 1, population among men attending GUM clinics in Scotland was the fifth highest when compared to those for the ten English Strategic Health Authority regions and the other countries of the United Kingdom. 6 Figure 2.23: Diagnoses of infectious syphilis, made in GUM clinic settings, by gender, All Men MSM Women Figure 2.24: Diagnoses of infectious syphilis, made in all settings, by sexual orientation, Data source: NESISS Heterosexual Men Heterosexual Women MSM & Quarter Who was affected: % (248/264) of all diagnoses were in men, the majority of whom were MSM (85%: 212/248); this finding is consistent with observations during the past six years. The highest number of diagnoses was in men aged Between 27 and 28, the largest increase was noted in those aged In MSM, the age at diagnosis ranged from 17 to 7 years with a median age of 34 years. Figure 2.25: Diagnoses of infectious syphilis in men, made in GUM clinic settings, by age group, >45 GUM clinic diagnoses include all cases of primary, secondary and early latent syphilis MSM are a subset of all the cases in men 18