Bolton. Rapid Sexual Health Needs Assessment. Bolton

Transcription

1 Bolton Rapid Sexual Health Needs Assessment Bolton July

2 Contents 1. Executive Summary 2. Introduction a. Sexual Health b. Consequences of sexual ill health 3. National and local overview 4. Roles and responsibilities 5. Costs 6. Local Demographics 7. High Risk Groups 8. Sexually Transmitted Infections 9. Reproductive Health 10. Teenage Pregnancy 11. Contraception 12. Commissioned Services Review 13. Feedback from Stakeholders 14. Gaps and Recommendations 15. Conclusions 2

3 1. Executive Summary 1) In 2013, Bolton was ranked 78 (out of 326 local authorities in England; first in the rank has highest rates) for rates of new sexually transmitted infections (STIs) new STIs were diagnosed in residents of Bolton, a rate of per 100,000 residents (compared to per 100,000 in England). 2) 60% of diagnoses of new STIs in Bolton were in young people aged years (compared to 55% in England). 3) In 2013, for cases in men where sexual orientation was known, 8.2% of new STIs in Bolton were among MSM. 4) In 2013, the rate of chlamydia diagnoses per 100,000 young people aged years in Bolton was (compared to per 100,000 in England). 5) In 2013, Bolton was ranked 114 (out of 326 local authorities in England) for the rate of gonorrhoea, which is a marker of high levels of risky sexual activity. The rate of gonorrhea diagnoses per 100,000 in this local authority was 33.0 (compared to 52.9 per 100,000 in England). 6) In 2013, among genitourinary medicine (GUM) clinic patients from Bolton who were eligible to be tested for HIV, 66.2% were tested (compared to 71.0% in England). 7) In 2013, there were 23 new HIV diagnoses in Bolton and the diagnosed HIV prevalence was 1.8 per 1,000 population aged years (compared to 2.1 per 1,000 in England). 8) In Bolton, between 2011 and 2013, 62% (95% CI 45-77) of HIV diagnoses were made at a late stage of infection (CD4 count <350 cells/mm³ within 3 months of diagnosis) compared to 45% (95% CI 44-46) in England. 9) In 2013, in Bolton upper tier local authority, the total abortion rate was 18.1 per 1,000 female population aged years, compared to 16.6 in England. Of those women under 25 years who had an abortion in that year, the proportion of those who had had a previous abortion was 26.4%, while in England the proportion was 26.9%. 10) In 2012, the under 18 conception rate per 1,000 female aged 15 to 17 years in Bolton was 30.3, while in England the rate was ) In 2013, the rate per 1,000 women of long acting reversible contraception (LARC) prescribed in primary care in Bolton was 49.0, compared to 52.7 per 1,000 women in England. (PHE, 2015) 3

4 2. Introduction The aim of this Sexual Health Needs Assessment is to gain an understanding of the current services, local needs and identify gaps in services in order to inform our approach to improving the sexual health of the local population. The findings will be used for planning and monitoring, and will also inform commissioning and service design. It will provide a framework to reduce sexual health inequalities across the general population including vulnerable groups. Sexual health services include the provision of advice and services covering contraception, sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV), relationships and teenage pregnancy and abortion. Sexual ill health and wellbeing is strongly linked to deprivation and health inequalities that lead to an increasing financial burden for the public sector. Sexual health services that are designed to meet the needs of the Bolton population will enable individuals to have personal control, self confidence and so make informed choice that will ensure good sexual health. a. Sexual Health The World Health Organisation (WHO) defines sexual health as: a state of physical, emotional, mental and social well-being, related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. 1 Early diagnosis and treatment of STIs reduces the risk of costly complications and onward transmission. There are also health benefits for those with HIV being diagnosed and commencing early treatment thus minimising the use of National Health Service (NHS) & social care services. Prevention of unintended pregnancies and control over reproductive choices preserves good mental and psychosexual health. Sexually transmitted infections cause unnecessary ill health and deaths which could be avoided through earlier diagnosis and treatment and improved education. Unintended pregnancy also has a significant life changing impact on individuals, particularly amongst teenagers. Termination of unwanted pregnancy can have a lasting physical and psychological impact on the individual leading to further health problems. b. Consequences of sexual ill health include: Sexually transmitted infections including HIV Pelvic inflammatory disease, which can lead to ectopic pregnancy and infertility Exposure to Human Papilloma Virus (HPV) which can lead cervical and other genital cancers. Oral cancer related to unprotected oral sex Hepatitis, chronic liver disease and liver cancer Recurrent genital herpes Poor self-esteem and possible impact on mental well-being Premature labour and delivery 1 4

5 Unintended pregnancies and abortions Poor educational, social and economic opportunities for teenage mothers Increased morbidity of infants born to teenage parents 5

6 3. National and local overview Improving sexual health is a national priority set out in the Healthy Lives, Healthy People White Paper , the Health and Social Care Act , and the Public Health Outcomes Framework (PHOF) The Public Health Outcomes Framework (2012) identifies 3 specific indicators for sexual health: Under 18 conceptions Chlamydia diagnoses in the year old age group Late diagnosis of HIV Nationally, significant progress has been made in improving sexual health including: Access to specialist genito-urinary medicine (GUM) services Teenage pregnancy rates are at their lowest since records began Long-acting methods of contraception (LARC) use has increased Early diagnosis for HIV, with high quality treatment can lead to a near normal life expectancy However, there still remain areas of concern where improvements can be made: Further reducing the number of unwanted pregnancies Rates of syphilis are at their highest since the 1950s Because of antibiotic resistance, gonorrhea is becoming more difficult to treat Late HIV diagnoses A Framework for Sexual Health Improvement in England (DH 2013) 5 In 2013, the Government published the Framework for Sexual Health Improvement in England which aims to: Continue to tackle the stigma, discrimination and prejudice often associated with sexual health matters; Continue to work to reduce the rate of STIs using evidence based preventative interventions and treatment initiatives; Reduce unwanted pregnancies by ensuring that people have access to the full range of contraception, can obtain their chosen method quickly and easily and can take control to plan the number of and spacing between their children; Support women with unwanted pregnancies to make informed decisions about their options as early as possible; Continue to tackle HIV through prevention and increased access to testing to enable early diagnosis and treatment; and

7 Promote integration, quality, value for money and innovation in the development of sexual health interventions and services. The framework states that there is clear evidence that sexual health outcomes can be improved by: Accurate, high-quality and timely information that helps people to make informed decisions about relationships, sex and sexual health; Preventative interventions that build personal resilience and self-esteem and promote healthy choice; Rapid open-access to confidential, comprehensive sexual health services in a range of settings, accessible at convenient times; Early, accurate and effective diagnosis and treatment of STIs, including HIV, combined with the notification of partners who may be at risk; and Joined-up provision that enables seamless patient journeys across a range of sexual health and other services this will include community gynaecology, antenatal and HIV treatment and care services in primary, secondary and community settings. Roles and Responsibilities National Sexual Health Commissioning Structure The Health and Social Care Act (2012) 6 divided responsibilities for the commissioning of sexual and reproductive health services between local authorities, Clinical Commissioning Groups and NHS England. Since April 2013 the national commissioning structure for sexual health services is as follows: Local Authorities commission: comprehensive sexual health services - including most contraceptive services and all prescribing costs, but excluding GP additionally-provided contraception sexually transmitted infections (STI) testing and treatment - chlamydia screening and HIV testing specialist services, including - young people s sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, services in schools, college and pharmacies CCGs commission: most abortion services sterilisation vasectomy 6 7

8 non-sexual-health elements of psychosexual health services gynaecology including any use of contraception for non-contraceptive purposes NHS England commissions: contraception provided as an additional service under the GP contract HIV treatment and care (including drug costs for PEPSE) promotion of opportunistic testing and treatment for STIs and patient-requested testing by GPs sexual health elements of prison health services sexual assault referral centres (SARCS) cervical screening Costs Investment in sexual health services can lead to healthcare savings by preventing unplanned pregnancies, reducing transmission of STIs and treatment. The cost benefit of contraceptives has been estimated at 11 for every 1 spent. 7 In addition, preventing a person from developing HIV can save the NHS over 350,000 (APGG, 2012) 8. In 2013, it was estimated that unintended pregnancies and STIs cost the UK between 84.4 billion and 127 billion. Of the 84.4 billion, 11.4 billion lay with NHS and 73 billion with the wider public sector. 9 Consequently, improving access to contraception and contraceptive services make a saving of between 3.7 and 5.1 billion (Development Economics, 2013) McGuire, Alistair and Hughes, David (1995) The economics of emergency contraception provision Fertility Control Reviews, 4 (2) ISSN

9 Local Demographics The Demographics of Bolton The Metropolitan Borough of Bolton is a Metropolitan Borough of Greater Manchester. The Town of Bolton is 10 miles northwest to the City of Manchester. The Borough is divided into 20 wards each of which elects 3 Councillors. Population Bolton s resident population is estimated to be 280,100. The population is comprised of 141,400 Females (50.5%) and 138,700 males (49.5%). This gender distribution broadly comparable to Greater Manchester, North West and national figures. These figures are based on the mid 2013 population estimates. The primary target group for sexual health services, year olds, comprises 87,700 Males and 88,400 Females. Together year olds comprise approximately 63 % of the population in Bolton. Bolton s latest population structure by age band compared to the England population can be seen below. Bolton has a higher proportion of younger people compared to England but significantly a smaller proportion of year olds. 9

10 The population is projected to increase by an additional 16,000 people over the next 10 years. However this increase is overwhelmingly in the 65+ category where there is a projected increase of 9,100 people. As can be seen below, the other age group categories that show a significant increase over the next decade are the 0-19 category and the category. Nationally Young people aged years have been shown to be one of the groups to have higher rates of new STIs. This pattern is perfectly replicated in Bolton. Also in Bolton, of all those diagnosed in 2013 with a new STI 46% were male and 54% were female. 10

11 Ethnicity and Religion The ethnic profile of Bolton shows the largest population is white British representing 79% of the population. This is significantly lower than the North West average which is 87% of the population but broadly in line with the UK average as a whole. The second largest group in Bolton is the Category Asian or Asian British: Indian. This group accounts for approximately 8% of the population. This is significantly higher than both the England and Northwest average for this group. Similarly the proportion of the Category Asian or Asian British: Pakistani is higher than the National and North West average. 11

12 As would be expected the religious breakdown reflects the ethnic breakdown with approximately 63% identifying as Christian which is lower than the North West average but higher than the English average. Similarly approximately 11% identify as Muslim which almost exactly reflects the proportion of the population which comes from both the Asian population in Bolton. Notably there is also a higher proportion of Hindus in Bolton than in both the North West and England as a whole. Although this group only accounts for 2% of the population that is still the equivalent of 5,988 people 12

13 Deprivation and the distribution of STIs There is considerable geographic variation in the distribution of STIs and for Bolton, this is highlighted below. The most deprived areas are located mainly in and around Bolton Town Centre and the South East of the Borough with other pockets of Deprivation in the West of the Borough. Inevitably the areas with the highest rates of STI s are in and around the Town Centre. Bolton falls within the 15% - 6% most deprived local authorities in England in all measures of deprivation and Bolton currently has higher percentage of people living in the most deprived areas Also despite progress Bolton has additional risk factors such as a higher than average % of teenagers living in poverty. Despite progress this has only improved in line with regional and national trends in recent years. 13

14 On a more positive note the current deprivation rankings shows that one of the wider determinants of good sexual health notably year olds not in education, employment of training is currently performing line with the national average, in spite of the current deprivation rankings and % of young people that are living in poverty. Socio-economic deprivation (SED) is a known determinant of poor health outcomes and data from GUM clinics in Bolton show a strong positive correlation between rates of new STIs and the index of multiple deprivation. Bolton follows the national pattern with highest rates of new STIs in the more deprived Lower Super Output Areas. This is demonstrated in the graph below. Rates of new STIs by deprivation category in Bolton GUM diagnoses only):

15 High Risk Groups There are specific behaviours that are associated with increased transmission of STI and HIV, including: age at first sexual intercourse experience number of lifetime partners concurrent partnerships payment for sexual services alcohol substance misuse Nationally, young people aged years, MSM and black Caribbean ethnic groups have been shown to have higher rates of new STIs. Overall, of all those diagnosed in 2013 with a new STI in Bolton, 46% were male and 54% were female (gender was not specified or unknown for 0% of episodes). Young people Young people are also more likely to become re-infected with STIs, contributing to infection persistence and health service workload. In Bolton, an estimated 10% of year old females and 7.8% of year old males presenting with a new STI at a GUM clinic during the five year period from 2009 to 2013 became re-infected with an STI within twelve months. Teenagers may be at risk of reinfection because they lack the skills and confidence to negotiate safer sex. Although there has been a significant reduction in the rate of teenage pregnancy in Bolton, it is still higher than the national average. There is a correlation between educational attainment and current and future health status, including sexual health. Young people between 15 and 24 years old experience the highest rates of new STIs. In Bolton, 60% of diagnoses of new STIs were in young people aged years. The age profile is shown in Figure 1. 15

16 Looked After Children Low levels of self esteem and the wish to be accepted can lead to young people in care giving in to pressure to engage in early or unwanted sexual activity. Looked after children are more at risk of sexual ill health and may be more vulnerable to involvement in unwanted sexual activity, abusive relationships and early parenthood. Interruptions and gaps in education together with changing schools may lead young people in care to miss sex and relationship education Young women in care are more likely to become young mothers than the general population of women aged 16 to 24, and less likely to have the support of their family to help them cope Young men in care are more likely to become young fathers than their peers who are not in care Care leavers who are parents report wide variations in access to sexual health advice before they became pregnant and many fear involvement with services that could help them in case it leads to their child being taken away Young people in care are more at risk of sexual exploitation and abuse through prostitution Men Who Have Sex with Men (MSM) Men who have sex with men (MSM) refer to men who have same sex partners regardless of their sexuality. They are at increased risk of specific STIs including HIV and are reported to have poor mental wellbeing compared to the general population and more likely to use alcohol, drugs and tobacco and engage in risk taking behaviour. STIs diagnoses reported in MSM continued to rise in Gonorrhoea diagnoses increased by 37% in 2012, chlamydia diagnoses by 8%, genital warts diagnoses by 8% and syphilis diagnoses by 5%. Gonorrhoea was the most commonly diagnosed STI among MSM in In Bolton in 2013, for cases in men where sexual orientation was known, 8.2% (n=58) of new STIs were among MSM. In 2010, the proportion of new STIs among MSM was 6.6% (n=41). The significant increase in the number of gonorrhoea cases, the ongoing LGV (Lymphogranuloma Venereum) epidemic in older HIV-positive MSM and the continued increase in new HIV diagnoses among MSM during 2012 suggests strongly that there are high levels of unsafe sex continuing in this population leading to STI and HIV transmission: The number of adult MSM newly diagnosed with HIV each year continues to rise because of increased HIV testing and on-going transmission It is likely the HIV epidemic among MSM is largely due to on-going incidence from men unaware of their infection: of the estimated 41,000 MSM living with HIV in the UK at the end of 2012, nearly one in five was unaware of his infection 16

17 85% of MSM report not receiving information about same sex relationships at school In 2012, about 78% of syphilis, 58% of gonorrhoea and 17% of chlamydia diagnoses were reported among MSM Sex Workers Selling sex is not illegal, although related activities such as soliciting, advertising using cards in telephone boxes, and kerb crawling are offences which effectively render sex work illegal. There is no accurate data regarding the number of sex workers in the UK. There is however evidence to suggest that there are some distinct differences between parlour based workers and street sex workers. Jeal et al (2007) i reports the following findings: Parlour sex workers were less likely to have chronic and acute illnesses Street sex workers were more likely to suffer from mental health problems including and depression. 17

18 More street sex workers had a dependency on hard drugs and experienced illnesses such as abscesses, deep vein thrombosis, chest infections and Hepatitis B. Homeless Homeless people are at increased risk of STIs and unwanted pregnancies and can come under pressure to exchange sex for food, shelter, drugs and money. Recent Government statistics reveal that statutory homelessness, and the number of people living in temporary accommodation has risen. The rise in homelessness is taking place against a backdrop to welfare and NHS reforms. Asylum Seekers and Refugees Data relating to the geographical distribution of asylum seekers and refugees for local areas is in the main, not available. Statistics on the location of asylum seekers in the UK are linked to available information of the support that he/she receives therefore the location of those not receiving support may be unknown. Those asylum seekers who are granted refugee status become free as the general population and so cease to exist as a special category and then become invisible to policy makers that can have major implications for health policy. Gateway Protection Programme In partnership with the United Nations Commission for Refugees (UNHCR), in April 2003 the Home Office launched the Gateway Protection Programme to create a legal pathway for refugees to enter the UK. These refugees are identified as being extremely vulnerable, in need of permanent resettlement and protection. The programme focuses on those refugees considered most at risk and are offered indefinite leave to remain. They are assisted to integrate into the UK society through the provision of locally based coordinated support packages. Bolton continues to be part of this programme. Consequently, there are increasing numbers of refugees within the borough. The main sexual health issues affecting asylum seekers and refugees are: 18 Suffering the consequences of sexual violence, torture rape Being pregnant as a result of rape Suffering the consequences of female genital mutilation (FGM) Suffering from HIV/AIDS Fleeing persecution because of sexual orientation and fear of prejudice and harassment in the UK Being involved with the sex industry Being at risk of sexual exploitation

19 Risk taking behaviours Alcohol and Substance Misuse There is an association between alcohol attributable hospital admissions in both males and females and teenage pregnancy. There is evidence that alcohol consumption and being drunk can result in lower inhibitions and poor judgement in relation to sexual activity, vulnerability and risk sexual behaviour, such as not practising safe sex Alcohol consumption by young people leads to an increase likelihood that they will have sex at a younger age, and alcohol misuse is linked to a greater number of sexual partners and more regretted or coerced sex Alcohol increases the risk of sexual aggression, sexual violence and sexual victimisation (Bellis M et al, Contributions of Alcohol Use to Teenage Pregnancy, North West Public Observatory, 2009) 19

20 Sexually Transmitted Infections 2372 new STIs were diagnosed in residents of Bolton in 2013 (1080 in males and 1287 in females), a rate of per 100,000 residents (males and females 913.2) (gender was not specified or unknown for 5 episodes). The number of cases of each new STI diagnosed in Bolton from can be found in Appendix 2. Please see Appendix 3 for diagnoses included in new STIs. It should be noted that if high rates of gonorrhoea and syphilis in a population are seen, this reflects high levels of risky sexual behavior. Reinfection of STIs Reinfection with an STI is a marker of persistent risky behaviour. In Bolton, an estimated 6.3% of women and 6.2% of men presenting with a new STI at a GUM clinic during the five year period from 2009 to 2013 became re-infected with a new STI within twelve months. Nationally, during the same period of time, an estimated 6.9% of women and 8.8% of men presenting with a new STI at a GUM clinic became re-infected with a new STI within twelve months. In Bolton, an estimated 4.7% of women and 2.8% of men diagnosed with gonorrhoea at a GUM clinic between 2009 and 2013 became re-infected with gonorrhoea within twelve months. Nationally, an estimated 3.7% of women and 8.0% of men became re-infected with gonorrhoea within twelve months. Ethnic group and country of birth The proportion of new STIs diagnosed in GUM clinics by ethnic group is shown in the table below. Where recorded, 9.9% of new STIs diagnosed in Bolton were in people born overseas. Number and proportion of new STIs by ethnic group (GUM diagnoses only): 2013 Ethnic Group Number % Other ethnic groups Mixed Not specified Black or Black British Asian or Asian British White Source: Data from Genitourinary Medicine clinics Excludes chlamydia diagnoses made outside GUM 20

21 Rates per 100,000 population of new STIs in Bolton and England: Diagnoses Rate: 2012 Rate: 2013 % change 2012 to 2013* Rank within England 2013** Rate in England residents: 2013 New STIs Chlamydia Gonorrhoea Syphilis Genital Warts Genital Herpes ± Rates are calculated using 2012 ONS population estimates * % change not provided where rate per 100,000 population in 2012 was 0.0 ** Out of 326 local authorities, 1st rank has the highest rates. Rank within England has been based on alphabetical order of local authority name where rate for local authority was 0.0 per 100,000 population Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive Nucleic Acid Amplification Tests (NAATs) and additional screening of extra-genital sites in MSM Any decrease in genital warts diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination ± Any increase in genital herpes diagnoses may be due to the use of more sensitive NAATs Data Source: The Genitourinary Medicine Clinic Activity Dataset v2 (GUMCAD) and chlamydia test and diagnosis data are sourced from the Chlamydia Testing Activity Dataset (CTAD). 21

22 Period England Greater Manchester Bolton Indicator Syphilis diagnosis rate / 100, Gonorrhoea diagnosis rate / 100, Chlamydia detection rate / 100,000 aged (PHOF indicator 3.02) <1,9001,900 to 2,300 2,300 Chlamydia proportion aged screened Genital warts diagnosis rate / 100,000 Genital herpes diagnosis rate / 100,000 All new STI diagnoses (exc Chlamydia aged <25) / 100,000 STI testing rate (exc Chlamydia aged < 25) / 100,000 STI testing positivity (exc Chlamydia aged <25) % Sexually Transmitted Infections indicators in Bolton, 2013 Source of data: PHE, 2014 In Bolton, between 2009 and 2013 there has been a reduction in the diagnosis rates of syphilis and genital herpes. Both are below the England, North West and Greater Manchester average. In 2013 the chlamydia diagnosis rate for Bolton was 2,603 which is above the recommended diagnostic rate of 2,300 per 100,000 and exceeds the national and Greater Manchester averages. The HIV prevalence rate in 2013 is higher than the North West average but lower than the National and Greater Manchester average. However, whilst the HIV late diagnosis rate has reduced since , in 2013 it is significantly higher than the national and Greater Manchester averages. 22

23 Gonorrhoea Reducing gonorrhoea transmission, and ensuring treatment resistant strains of gonorrhoea do not persist and spread remains a public health priority. The Gonorrhoea Resistance Action Plan for England and Wales (April 2013) makes recommendations on ensuring prompt diagnosis, prescribing guideline adherence, identifying and managing potential treatment failures effectively, and reducing transmission 70 Gonorrhoea diagnosis rate / 100, Bolton Greater Manchester North West England Chlamydia Genital chlamydia infection is the most commonly diagnosed bacterial sexually transmitted infection in the UK. Prevalence is highest in sexually active women aged and men aged If left untreated the infection can have serious long-term consequences including pelvic inflammatory disease, ectopic pregnancy, and tubal factor infertility. Those infected with chlamydia are often asymptomatic therefore opportunistic screening of young people aged between 15 and 24 years is considered the best approach for detecting and treating this infection. The National Chlamydia Screening Programme (NCSP) in England was established in The programme aims to prevent and control chlamydia through early detection and treatment of asymptomatic infection, thereby reducing onward transmission and the consequences of untreated infection. The NCSP recommends that all areas aim for at least 2,300 chlamydia diagnoses per 100,000 people aged years Chlamydia proportion aged screened in Greater Manchester MCD,

24 HIV Owing to the introduction of effective antiretroviral therapy (ART) in the mid 1990s, HIV infection has transformed from a fatal to a chronic life-long infection. As a result there are increasing numbers of people living with diagnosed HIV. In 2013 it was estimated that 107,800 people were living with HIV in the UK which is a 5.1% increase from Sexual health data from PHE revealed that out of the ten Greater Manchester Metropolitan County Districts (GM MCD), the highest HIV diagnosed prevalence rates in people aged years were in Manchester (5.8) and Salford (4). In 2013 the diagnosed prevalence rate in Bolton was 1.77 per 1,000 of the population which is a slight increase from 2010 (1.54). The rate still remains below the National and Greater Manchester rate. 24

25 People living with diagnosed HIV In 2013, 314 adult residents (aged 15 years and older) in Bolton received HIV-related care: 198 males and 116 females. Among these, 49.4% were white, 44.9% black African and 0.6% black Caribbean. With regards to exposure, 33.4% probably acquired their infection through sex between men and 60.8% through sex between men and women (Table 6). Number of adults living with diagnosed HIV by ethnicity and exposure group in Bolton: 2009 and 201 Ethnicity 2009 % % 2013 White Black Caribbean Black African Other Not known Probable route of infection Sex between men Sex between men and women Injecting drug use Other/Not known Total Source: The Survey of Prevalent HIV Infections Diagnosed (SOPHID) 25

26 Late Diagnosis Late diagnosis is the most important predictor of HIV-related morbidity and short-term mortality. It is a critical component of the Public Health Outcomes Framework and monitoring is essential to evaluate the success of expanded HIV testing.people diagnosed late have a tenfold increased risk of dying within a year of diagnosis. The rate of late HIV diagnosis rate in Bolton remains high and is continuing to rise.in Bolton, between 2011 and 2013, 62% (95% CI 45-77) of HIV diagnoses were made at a late stage of infection (CD4 count <350 cells/mm³ within 3 months of diagnosis) compared to 45% (95% CI 44-46) in England. 50% (95% CI 25-75) of men who have sex with men (MSM) and 73% (95% CI 50-89) of heterosexuals were diagnosed late. New cases of HIV In UK, reported cases of HIV infections as at 2012 was 128,805 where 6,364 were newly diagnosed. In the North West, 9,742 cases of HIV infections were recorded with 772 new HIV and AIDS cases. In England, of those diagnosed with HIV infection in 2013, 80% had residence information available through linkage with The Survey of Prevalent HIV Infections Diagnosed (SOPHID). Where residence information was available in 2013, 23 adult residents of Bolton were newly diagnosed with HIV. Among those who acquired their HIV through sex, 10 new HIV diagnoses were among MSM, 6 among heterosexual men and 6 among heterosexual women. The graph below shows the percentage of new cases of HIV and AIDs in the GMMCD and the route of infection. The predominant route of infection for new cases of HIV was MSM. 26

27 New HIV and AIDS cases by infection routes HIV testing Since 2009 in Bolton HIV testing uptake in MSM in Bolton has been higher than the National, North West and Greater Manchester averages but there has been a slight fall in In areas where HIV prevalence exceeds 2 in 1,000 of the population, the British HIV Association (BHIVA) guidelines recommend that a test should be offered In 2013, a HIV test was offered at 72.7% of eligible attendances at GUM clinics among residents of Bolton and, where offered, a HIV test was done in 79.7% of these attendances. Nationally, a HIV test was offered at 79.4% of eligible attendances at GUM clinics and, where offered, a HIV test was done in 80.0% of these attendances. In order to increase the uptake of HIV screening in all groups Greater Manchester commissioners are considering the introduction of point of care testing across the area. Point of care testing (also called rapid HIV test), detects HIV antibodies in the blood. This test gives a result in a few minutes, eliminating the stress of waiting a week for results. This is an indicative result and those tested as positive will need a further blood test using a specimen that needs to be sent to a laboratory. 27

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29 Period England Greater Manchester Bolton Reproductive Health The Public Health White Paper Healthy Lives, Healthy People: Our Strategy for Public Health in England highlights a commitment to work towards an integrated model of service delivery to allow easy access to confidential, non-judgemental sexual health services (including for sexually transmitted infections (STIs), contraception, abortion, health promotion and prevention). Reproductive health includes access to abortion services, contraception including long acting and emergency and cervical screening. Increasing access, choice and knowledge of all methods of contraception, including long-acting reversible contraception (LARC) methods and emergency hormonal contraception, for women of all ages and their partners can reduce unwanted pregnancies. Contraception should be available through general practice and a range of contraceptive, sexual health and young people s services. Contraception should be provided free from any prescription charges. Local authorities are mandated to commission open access contraception advice and treatment services that meet the needs of their local population. LARC methods are more effective at preventing pregnancy than other hormonal methods and condoms. There is also evidence LARC methods fitted by the abortion provider can reduce repeat abortions. For those women seeking an abortion, access to services at all gestations up to 24 weeks should be easily available and accessible Indicator Abortions under 10 weeks as (Percentage of all NHSfunded abortions performed under 10 weeks gestation) Under 25s repeat abortions (Percentage of abortions in women aged under 25 years who have had a previous abortion in any year) Total Abortions / GP prescribed LARC rate / Under 18s conception rate / 1,000 (PHOF indicator 2.04) Under 18s conceptions leading to abortion (%) Under 18s births rate / 1,

30 Period England Greater Manchester Bolton Indicator Pelvic inflammatory disease (PID) admissions rate / 100, / Ectopic pregnancy admissions rate / 100, / Cervical cancer registrations rate / 100, Abortion The total abortion rate, access to NHS funded abortions at less than 10 weeks gestation, and under and over 25 years repeat abortion rates are indicators of lack of access to good quality contraception services and advice, as well as problems with individual use of contraceptive method. The National Survey of Sexual Attitudes and Lifestyles (NATSAL 2010) found that 16.2% of pregnancies in the year before the study interview were unplanned. This survey found that: pregnancies among 16 to 19 year olds accounted for 7.5% of the total number of pregnancies, but 21.2% of the total number were unplanned. the highest numbers of unplanned pregnancies occur in the 20 to 34 year age group. Unplanned pregnancies can end in abortion or a maternity. Many unplanned pregnancies that continue will become wanted. However, unplanned pregnancy can cause financial, housing and relationship pressures and have impacts on existing children. Restricting access to contraceptive provision by age can therefore be counterproductive and ultimately increase costs. In 2013, in Bolton upper tier local authority: the total abortion rate per 1,000 female population aged years was 18.1, while in England the rate was The rank (out of 146) within England for the total abortion rate (1st has the highest rate) was 49. among women under 25 years who had an abortion in that year, the proportion of those who had had a previous abortion was 26.4%, while in England the proportion was 26.9%. The rank (out of 129) within England for the repeat abortion under 25 years (1st has the highest rate) was

31 among women aged 25 and over who had an abortion in that year, the proportion of those who had had a previous abortion was 43%, while in England the proportion was 45.3%. The rank (out of 146) within England for the repeat abortion carried out by women aged 25 and over (1st has the highest rate) was 92. among NHS funded abortions, the proportion of those under 10 weeks gestation was 82.8%, while in England the proportion was 79.4%. The earlier abortions are performed the lower the risk of complications. Prompt access to abortion, enabling provision earlier in pregnancy, is also costeffective and an indicator of service quality and increases choices around procedure. Teenage pregnancies Most teenage pregnancies are unplanned and around half end in an abortion. As well as it being an avoidable experience for the young woman, abortions represent an avoidable cost to the NHS. And while for some young women having a child when young can represent a positive turning point in their lives, for many more teenagers bringing up a child is extremely difficult and often results in poor outcomes for both the teenage parent and the child, in terms of the baby s health, the mother s emotional health and well-being and the likelihood of both the parent and child living in long-term poverty. Research evidence, particularly from longitudinal studies, shows that teenage pregnancy is associated with poorer outcomes for both young parents and their children. Teenage mothers are less likely to finish their education, are more likely to bring up their child alone and in poverty and have a higher risk of poor mental health than older mothers. Infant mortality rates for babies born to teenage mothers are around 60% higher than for babies born to older mothers. The children of teenage mothers have an increased risk of living in poverty and poor quality housing and are more likely to have accidents and behavioural problems. The rate of conceptions in under 18 year olds is an indicator in the Public Health Outcome Framework. In 2012, in Bolton: the under 18 conception rate per 1,000 female aged 15 to 17 years was 30.3, while in England the rate was The rank (out of 324) within England for the under 18 conception rate (1st has the highest rate) was 102. Between 1998 and 2012, Bolton achieved a 39.6% reduction in the under 18 conception rate, compared to a 40.5% reduction in England. among the under 18 conceptions, the proportion of those leading to abortion was 47.2%, while in England the proportion was 49.1%. The rank (out of 311) within England for the under 18 conceptions leading to abortion (1st has the highest percentage) was

32 Contraception The Department of Health s A Framework for Sexual Health Improvement in England indicated that up to 50% of pregnancies are unplanned. The government and the Faculty of Sexual and Reproductive Healthcare both highlight the importance of knowledge, access and choice for all women and men to all methods of contraception to aid in the reduction of unwanted pregnancies. Good contraception services have shown to lower rates of teenage conceptions, which is one of the indicators in the Public Health Outcomes Framework. Contraception is widely available in the UK from a number of sources, and is provided free by the NHS for women and men of all ages. Contraception is available free of charge from: general practices, sexual and reproductive health (SRH) services, young person s clinics, NHS walk-in centres (emergency contraception only), some GUM clinics (emergency contraception and male condoms) and some pharmacists under a Patient Group Direction (emergency contraception). Condoms are not prescribable on the NHS, and are therefore not available from prescription data from GPs. Condoms can also be purchased from pharmacies, supermarkets, and other retailers. Emergency hormonal contraception can also be bought over the counter at some pharmacies and private clinics. Data on contraception is currently only collected from SRH services and some young person s clinics through the Sexual and Reproductive Health Activity Dataset (SRHAD) and from NHS prescription forms within primary care (see below section). Data from other providers are not available. Prescribing data on contraception provision NHS Prescription Services, which is part of the NHS Business Services Authority (NHSBSA), uses NHS prescription forms to calculate how much pharmacists, GPs who dispense and appliance contractors should be paid as reimbursement and remuneration for medicines and medical devic e s dispersed to patients within primary care settings in England. This data is known as the Prescribing Analysis and CosT (PACT) data and is available to authorised users at Primary Care 32

33 Organisations/Area Teams/Trusts and National users. PACT data contains items that have been prescribed and dispensed, items that were not dispensed i.e. prescriptions that were not collected are not included in the data. Please note data presented here is only from PACT, contraception prescribed or bought outside of PACT are not included (e.g. data from community sexual and reproductive health services, pharmacies and young people services etc.)the different methods of contraception prescribed within a primary care setting are presented in the table below. Care should be taken when interpreting this information as the total number of prescriptions is not representative of the number of women who have received each contraceptive method. Long acting reversible contraception (LARCs) methods such as contraceptive injections, implants, intrauterine system (IUS) or intrauterine device (IUD) are more effective as they do not depend on daily concordance. They are also considered to be more cost effective than User Dependent Methods (UDM), and their increased uptake could further help to reduce unintended pregnancy (NICE Clinical Guideline CG30 All currently available LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use. Number of types of contraception and percentage of total contraception prescribed within a primary care setting: 2013 Choice Centre Method Centre LA (n) LA (%) PHE PHE (%) Engla nd England (%) IU Device LARCs IU System Injectable Contracep tive Implant TOTAL LARCs Oral Contra ceptive s* UDM Contracep tive Patch

34 Other± TOTAL UDM TOTAL CONTR ACEPTI ON Excludes Norethisterone Enantate under LARC numbers but included under total contraception. Number of individual DMPA doses prescribed reported, divided by 4.3 (estimated that to supply one woman with DMPA for one year requires 4.3 injections) for adjusted numerator (same as Sexual Health Profiles) method adopted based on that undertaken for the London Sexual Health Needs Assessment mapping exercise 2008). *Includes combined pill and progesterone only pill ±Includes vaginal ring, cap/diaphragm and spermicides Source: NHS Prescription Services' Prescribing Database 34

35 The rate of LARCs prescribed in a primary care setting between 2011 and 2013 is shown below. In 2013, Bolton is ranked 228 out of 326 local authorities in England for the rate of GP prescribed LARCs, with a rate of 49.0 per 1,000 women aged 15 to 44 years, compared to 52.7 in England. The number of LARCs reported is not indicative of concordance as data on LARC removals are not available. Discontinuation is an important driver of relative cost effectiveness between LARC methods.

36 Commissioned Service Provision Current sexual health provision The Integrated Sexual Health Services currently commissioned by Bolton Local Authority are provided by Bolton Foundation Trust. The current contract runs until March This service provides level 1, level 2 and level 3 contraception for adults and sexual health services for all ages (as defined within the National Strategy for Sexual Health and HIV). For under 19s, the Local Authority commissions a Young People s Sexual Health Service The Parallel. In addition to this, the Local Authority commissioned Brook to offer a College Drop-In clinic service. This service has also been integrated into the new 5-19 Children and Young People s Health and Wellbeing Service. Bolton also commissions a range of services as part of Greater Manchester collaborative commissioning arrangements. These services include Chlamydia Screening as part of the National Chlamydia Screening Programme, and targeted HIV prevention and support. A number of pharmacies and General Practitioners across the area provide access to chlamydia testing and treatment, emergency hormonal contraception and long acting contraception through additional contracting arrangements. The Local Authority also commissions enhanced services with pharmacies and General Practitioners across the borough to provide emergency hormonal contraception (EHC), long acting contraception and chlamydia testing and treatment. Integrated Sexual and Reproductive Health Clinical Services Provider Bolton Foundation Trust Eligibility criteria Referral route Contracted outcomes All age GP referral/self-referral All Age Service Provide an integrated sexual and reproductive clinical service across Bolton Provide level 1, level 2 and 3 contraception and sexual health services (as defined within the National Strategy for Sexual Health and HIV). Provide an integrated contraception and sexual health service for adults aged 18 years and over and ensure it adheres to the following principles: Ensure services are patient-centred, easily accessible to all communities, confidential and user-friendly with a focus on prevention of sexual ill health and promotion of sexual well-being and contribute to the wider determinants of health. Service Overview: Bolton Foundation Trust was commissioned by Bolton Local Authority to provide an integrated sexual and reproductive health clinical service for all ages. The contract for this service ends in March

37 Using both national and local evidence, the Integrated Sexual Health Service Specification was created, based on a model that will enable an overall reduction in the number of unintended pregnancies and increased diagnosis of sexually transmitted infections. In order for the service to be accessible, appointment clinics and drop-in clinics including weekends are provided. All general clinics are integrated, genito-urinary and reproductive health in addition to Family Planning clinics, HIV, genito-dermatology and Sexual Dysfunction specialist clinics. The Foundation Trust also works with partners to target more vulnerable groups. A social worker is based at the hospital base to advise, support and signpost those infected by HIV. Young People s Services Provider Eligibility criteria Referral route Contracted outcomes Service overview: Bolton Foundation Trust Young people, 19 years and under Self-referral Young People s Service Provide a contraception and sexual health service for young people Ensure seamless access for patients requiring contraception and STI testing and treatment services Provide centre-based clinics and clinical education outreach activities Ensure that there are strong links and pathways with other providers of contraception and sexual health services, particularly where more specialist help is required, i.e. Tier 3 services. Adhere to all the quality standards required, including the application of Fraser Guidelines as appropriate. Contribute to the reduction of teenage conceptions Contribute to the reduction of unintended conceptions and repeat terminations of pregnancy Contribute to the effective delivery of the national Chlamydia screening programme Maximise the sexual health of young people To develop increasingly user-focused sexual health services To create more co-ordinated and sustainable sexual health The Parallel is a Young People s Sexual Health Service commissioned by Bolton Local Authority. It is a health and wellbeing serviced designed by and for young people under 19 years. The service provides drop-in and appointment sessions from its base in the town centre. The nurses work alongside the school nursing team offering an enhanced service through providing health drop-ins and sex and relationship education within Bolton secondary schools. The aim of this service is to support young people s clinical services in order to reduce teenage conceptions and increase uptake of chlamydia screening. The team provides accessible, highquality sexual health services in a variety of settings and is part of the local Condom (C-Card) scheme. 37