British Psychological Society response to the British HIV Association. Guidelines on sexual and reproductive health of people living with HIV

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1 response to the British HIV Association About the Society The, incorporated by Royal Charter, is the learned and professional body for psychologists in the United Kingdom. We are a registered charity with a total membership of just over 50,000. Under its Royal Charter, the objective of the is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge". We are committed to providing and disseminating evidence-based expertise and advice, engaging with policy and decision makers, and promoting the highest standards in learning and teaching, professional practice and research. The is an examining body granting certificates and diplomas in specialist areas of professional applied psychology. Publication and Queries We are content for our response, as well as our name and address, to be made public. We are also content for BHIVA to contact us in the future in relation to this inquiry. Please direct all queries to:- Joe Liardet, Policy Advice Administrator (Consultations) The, 48 Princess Road East, Leicester, LE1 7DR consult@bps.org.uk Tel: About this Response The response was jointly led on behalf of the Society by: Dr Alexander Margetts CPsychol, Division of Clinical Psychology and Chair of the Faculty for HIV and Sexual Health With contributions from: Dr Gayle Brewer CPsychol AFBPsS, Division of Academics, Researchers & Teachers Dr Ailish Cleghorn CPsychol, Division of Clinical Psychology Dr Victoria Ross CPsychol, Division of Clinical Psychology Dr Sarah Zetler CPsychol AFBPsS, Division of Clinical Psychology We hope you find our comments useful. Alison Clarke Chair, BPS Professional Practice Board 1

2 response to the British HIV Association Comments on the Guideline: General Overall, The Society welcomes this comprehensive and well-written document. However having reviewed this, we believe that the psychological factors associated with people living with HIV (PLWH) has been somewhat neglected. Given the significant psychological impact of managing long term conditions on selfmanagement, it is therefore necessary to highlight this in our feedback in order to ensure greater psychological understanding and that appropriate services are offered to meet clinical need and maximise health outcomes. We have outlined comments on specific sections below. Given the scope of the document, it was perhaps inevitable that the specifics of who should play a role in supporting psychological well-being related to sexual and reproductive health, and how this should be delivered, were missing. Indeed the document specifically stated on page 53 Detailed guidance on the management of specific sexual difficulties is beyond the scope of this guidance. However it did suggest that service develop pathways for psychological support for patients to explore their sexual choices and/or develop confidence about methods to reduce sexual risk. It may be helpful if another guidance document has been developed to address this pathway, that it is referenced here. It may also be important that such pathways would involve access to staff who are appropriately trained in psychological perspectives and approaches and who work within appropriate governance/supervision structures. The Society welcomes the fact that issues of domestic abuse (intimate partner violence) and female genital mutilation were mentioned in the document, along with the importance of sensitive routine enquiry. The tone and language used were felt to be appropriately optimistic and respectful of how people may identify themselves. Chemsex Chemsex was alluded to very briefly under sexually transmitted infections, and in erectile dysfunction. Given the recent important qualitative and quantitative literature on the topic (Bourne et al., 2015; Hegazi et al. 2017; Project Neptune; Pufall et al. 2016), and high rates found amongst HIV+ MSM, and potential negative physical, mental and social health consequences, we believe that this should incorporate a substantial topic, similar to IPV and FGM. The Society would be happy to assist with this if required. Preconception advice and conception p11 Some links to psychological services were made, for example, a suggestion regarding provision of reproductive counselling. It may be helpful to outline where such input could be accessed (i.e. the role of a specific nurse, specialist clinic etc.) 2

3 Pre-pregnancy Health - p 13 Women living with HIV are especially vulnerable to experiencing significant emotional distress during pregnancy (Brandt et al., 2009); the majority of pregnant women with HIV will experience psychological distress (Bernatsky, Souza & John 2007). Pregnancy is characterised by a period of significant adjustment spanning emotional, physiological and social aspects of life where PLWH are further presented with a unique set of physiological and pharmacological challenges. Pregnancy offers a unique window of opportunity where women are particularly motivated to engage in health behaviour change. With this in mind, clear pathways should be in place to monitor, detect and treat mental health difficulties as well as to promote general wellbeing in line with NICE guidelines (2016). Contraception and HIV Acquisition, Transmission and Disease Progression p 40 Although frequency of high risk sexual behaviours reduce following diagnosis of HIV, they continue to be common amongst some groups (Marks et al, 2007). Psychological interventions including Cognitive Behavioural Therapy have shown to be effective in reducing high risk sexual behaviours (Birchard, 2015) and therefore reducing public health risk. Furthermore, NICE guidelines (2014) indicate that behaviour change support should be available individuals living with long term conditions should have access to appropriate psychological support. Interpartner violence p47 The section addressing IPV could include greater recognition of the role of psychological abuse and controlling behaviour (e.g. gas lighting ), particularly with regards to reproductive decisions, treatment adherence etc. There could be greater recognition of the complexity of issues surrounding IPV and those factors which influence the decision to terminate an abusive relationship or return to a relationship with an abusive partner. Sexual Dysfunction and HIV p51 The Society welcomes that, alongside guided self-help, timely integrated medical and psychological assessment and treatment is important, as well as an acknowledgement of Nice guidelines, suggesting recognition of the importance of governance structures. We welcome that in assessment of sexual dysfunction, the importance of assessing the bio-psych-social context within which the problem occurs was highlighted. Sexual difficulties in PLWH are common and often due to combination of psychological and physiological factors (Miller & Green 2002). Assessment should include full sexual history including emotional difficulties related to HIV and other factors. A recent review and meta-analysis has highlighted the effectiveness of psychological interventions in treatment of sexual dysfunction (Melnick, Soares & Nasello 2010; Fruhauf et al., 2013). There appeared to be to a large discrepancy between the amount of space devoted to men and women s sexual problems (3 pages vs 1 page). If comparable searches have been conducted it would be worth reflecting upon this disparity and commenting on considerations as to why this is and how this inequality might be addressed. Transgender Individuals p56 Disproportionate levels of HIV are found in transgender women (Sevelius, Carrico & 3

4 Johnson 2010). Emerging studies suggest that medication adherence is poor in this population and often associated with marked psychological difficulty (Sevelius, Carrico & Johnson 2010). Despite this, multiple barriers to care exist which include lack of knowledge, fear of discrimination, healthcare disparities and stigma (Sevelius, Keatley & Mock 2011). As such, access to parallel care services between psychological services and sexual health should be provided. As evidence of good practice, Grampian Health board offer a self-referral psychology service embedded within a sexual health services available for PLWH and MSM who are at high risk of contracting HIV. This service can be accessed by various routes but often individuals are sign posted by sexual health professionals following diagnosis, presenting for appointments/failing to and repeated STI testing etc. This is an opportunity to provide holistic care and promote positive health behaviour change. Editorial points It was noted that there were a number of spelling and grammatical errors in the document, such as Pg 7 line 8: use of commoner rather than more common. It was also noted that the document was sometimes difficult to read due to heavy use of long abbreviations i.e. MSM (men who have sex with men). A table with a list of abbreviations may be useful in helping the reader to navigate the document. References Bernatsky, S., Souza, R., & De Jong, K. (2007). Mental health in HIV-positive pregnant women: Results from Angola. AIDS care, 19(5), Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., & Weatherburn, P. (2015). Illicit drug use in sexual settings ( chemsex ) and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study. Sex Transm Infect, sextrans Brandt, R. (2009). The mental health of people living with HIV/AIDS in Africa: a systematic review. African Journal of AIDS Research, 8(2), Carvalho, F. T., Gonçalves, T. R., Faria, E. R., Shoveller, J. A., Piccinini, C. A., Ramos, M. C., & Medeiros, L. R. (2011). Behavioral interventions to promote condom use among women living with HIV. The Cochrane Library. CBT for compulsive sexual behaviour, a guide for professionals, by Thaddeus Birchard Richard Newbury. Sexual and Relationship Therapy, 31(1), 2016 Frühauf, S., Gerger, H., Schmidt, H. M., Munder, T., & Barth, J. (2013). Efficacy of psychological interventions for sexual dysfunction: a systematic review and metaanalysis. Archives of Sexual Behavior, 42(6), Hegazi, A., Lee, M. J., Whittaker, W., Green, S., Simms, R., Cutts, R.,... & Pakianathan, M. R. (2017). Chemsex and the city: sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International journal of STD & AIDS, 28(4), Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R. S. (2005). Meta-analysis of 4

5 high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. JAIDS Journal of Acquired Immune Deficiency Syndromes, 39(4), Melnik, T., Soares, B., & Nasello, A. G. (2007). Psychosocial interventions for erectile dysfunction. The Cochrane Library. National Institute for Health and Clinical Excellence (2014) Behaviour Change: Individual Approaches NICE guideline (PH49) National Institute for Health and Clinical Excellence (2016) Antenatal and Postnatal mental health NICE guideline (QS115) Pufall, E., Kall, M., Shahmanesh, M., Nardone, A., Gilson, R., & Delpech, V. (2016, February). Chemsex and high-risk sexual behaviours in HIV-positive men who have sex with men. In Conference on retroviruses and opportunistic infections (p. abstract 913). Sevelius, J. M., Keatley, J., & Gutierrez-Mock, L. (2011). HIV/AIDS programming in the United States: considerations affecting transgender women and girls. Women's Health Issues, 21(6), S278-S282. Sevelius, J. M., Carrico, A., & Johnson, M. O. (2010). Antiretroviral therapy adherence among transgender women living with HIV. Journal of the Association of Nurses in AIDS Care, 21(3), End. 5