Chapter 7 Infectious Diseases and Sexual Health in Southwark Introduction 7.1 The JSNA 2008 did not reflect the problems of infectious diseases and this chapter redresses this gap. Infectious diseases are the illnesses that result when micro-organisms such as bacteria and viruses invade and reproduce in the human body. Worldwide they cause a considerable burden of disease, especially in developing countries. London with its mobile, high density, multi-cultural population and areas of deprivation remains vulnerable to infectious disease. Pooled data from 2004-6 indicates that the average number of years of life lost due to premature deaths caused by infectious diseases was 7.33 years in England and Wales, 16.40 years in London and 20.22 years in Southwark. 1 Tuberculosis Background 7.2. Tuberculosis (TB) is an infectious disease caused by a bacteria belonging to the Mycobacterium tuberculosis group. Every year there are around nine million new cases of TB and nearly two million deaths worldwide. Normally TB causes disease in the lungs, though it can affect almost any part of the body, and only TB in the lungs is infectious. It is spread via the coughing up of infectious droplets and usually requires prolonged close contact with an infectious case. Epidemiology of TB in the United Kingdom 7.3.TB is increasing across the United Kingdom with over 8000 new cases of TB currently reported each year. Most cases occur in major cities, particularly in London which now has 40% of all cases of TB in England. 1 The rate of diagnosis of TB varies across and within Primary Care Trusts (PCTs). Much of the disease occurs in those born abroad in high incidence countries, or among recognised risk groups. In general TB is more common in more deprived areas and vulnerable groups such as the homeless or prison population. It is also strongly associated with HIV infection. Epidemiology of TB in Southwark 7.4. Since 2004 the incidence of TB in Southwark has decreased from 53.8 to 40.8 cases per 100 000 population per year in 2009 1. This leaves Southwark as the borough with the third highest incidence in South East (SE) London but a lower incidence than the London average of 45.3 cases per 100 000. 7.5. In 2007 more cases were seen in men (57%) and in the 20-44 age group. The majority of cases (59%) were from the Black African ethnic group. 1 In the first quarter of 2009 87.5% of cases were in people who were born abroad but many of these will have been in the UK for more than five years. This profile is similar to other London boroughs.
Prevention and Treatment 7.6. Due to the high levels of TB in Southwark all babies born in the borough should receive a BCG vaccine within the first four months of life. 2007-8 figures indicate that only 63.5% of babies born in Southwark have received a BCG vaccine by the time they are one year old. 1 Early detection and treatment also forms part of the prevention efforts for TB as it helps to reduce the number of additional infections from each case. 7.7. TB can be cured with a combination of antibiotics but treatment must be continued for at least six months both to ensure cure and to prevent the development of resistance. There is a national target of 85% treatment completion on which PCTs are now monitored. Latest figures for Southwark indicate that the PCT is failing to meet this target with only 75% of cases completing treatment. 7.8. The rate of resistance to first line drugs decreased slightly from 11% in 2006 to 8% in 2007. No multi-drug resistant cases were reported within the borough during 2007. This compares to an overall rate of drug resistance in SE London of 8%. The lack of completeness of drug sensitivity data is a concern with the results of drug sensitivity testing only being recorded in 42% of all notifications in 2007. 7.9. TB services are provided in local hospitals, where most patients are diagnosed, and in the community by the Three Boroughs Community TB Team. In addition patients can access refugee health, homeless health, drug and alcohol, and HIV services via the Three Boroughs Primary Healthcare Team of which the TB team is a part. Additionally, some patients benefit from pan-london initiatives for example the Find & Treat team (which specialises in returning socially chaotic/marginalised patients who have been lost to follow up back to TB services), and the Mobile X-ray Unit which targets chest x-ray screening for, among others, the homeless and those in prison. 1 Barriers to services 7.10. There are many misconceptions surrounding TB locally. Its associations with HIV and disadvantaged groups have led to it becoming a stigmatised condition which may affect the uptake of services. In addition some communities have little knowledge of or confidence in the NHS or may face language barriers. The length of treatment required also poses another barrier to successful treatment. 7.11. A London wide TB Commissioning Unit is now being established to ensure that services for TB are accessible, appropriate, efficient and effective in treating and managing TB and reducing the degree of spread.
HIV Background 7.12. Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immune Deficiency Syndrome (AIDS) where the immune system fails and the person is subject to life-threatening opportunistic infections. Infection with HIV occurs through the exchange of bodily fluids such as blood, semen or breast milk. Since the advent of highly active anti-retroviral therapy HIV has become a treatable medical condition and the majority of those living with the virus remain fit and well on treatment. 7.13. HIV remains an important public health issue both worldwide and in the UK, but especially in London which has 50% of the national caseload. It is associated with serious morbidity, high costs of treatment and care, significant mortality and high number of potential years of life lost. Epidemiology of HIV in Southwark 1 7.14. In 2007 1902 Southwark residents accessed HIV-related care; 1379 males and 524 females. This equated to a prevalence rate of 989 and 389 per 100,000 population respectively for 2007. Compared to 2006, increases were seen in both male (10 per cent rise) and female patients (3 per cent). All of the middle level super output areas within Southwark had a rate 50% or more higher than the UK rate. Lambeth and Southwark account for 40% of all the HIV in London and therefore almost 25% of the HIV in England. 7.15. Most of the people accessing care were aged 35-44 years. By ethnicity, the greatest numbers of patients were white males 921 (67 % of all male patients) and black females - 394 (75 % of all female patients). The highest prevalence rates however were seen in black African females 2,331 per 100,000 population, and black African males 1,270 per 100,000 population, although these rates are provisional for 2007. Between 2006 and 2007 numbers of patients accessing care increased for all ethnicities except black African females (-2%). 7.16. The largest proportion of patients who were resident in Southwark were infected via the route of men who have sex with men (52%). This was the highest prevalence rate seen across the PCTs of SE London for this route and was almost 9 times higher than the UK prevalence rate for mode of infection. Heterosexual infection accounted for 750 Southwark residents receiving care which was 3 times higher than the UK rate and was the highest rate in the PCTs of SE London. Transmission of HIV by intravenous drug use or mother to child transmission remains low. Prevention and Treatment 7.17. Due to the nature of the HIV epidemic in the UK, HIV prevention strategies are generally tailored to the most at risk groups. Interventions can include condom distribution, using the media to promote prevention messages and educational newsletters and booklets. Raising awareness of HIV is an important part of any prevention strategy especially as many people now seem less concerned about the risk of contracting HIV than previously. Due
to the population groups affected HIV remains a stigmatised disease and prevention strategies need to work to counteract this. 7.18.The HPU estimates that around one third of people who are infected with HIV are unaware of their infection. There therefore remains a risk to their health as well as a risk of unwittingly passing the virus on to others. Raising awareness and encouraging increased HIV testing could help to reduce the number of undiagnosed cases of HIV in the community and thereby reduce onward transmission. According to British guidelines, 1 HIV testing should be offered at GUM clinics as part of routine STD screening, regardless of symptoms of disease or risk factors of infection. Increased testing and diagnosis can also help to reduce morbidity and mortality due to HIV by facilitating earlier access to treatment. 7.19. HIV services are provided at a number of sites in south east London. There are three tertiary centres nearby (Guy s King s and St Thomas Hospitals) as well as well as several sexual health clinics, the Three Boroughs Community HIV Team and services provided by the voluntary sector. 7.20. Of the patients with HIV in Southwark, 28 per cent attended King s College Hospital, 28 per cent attended Guy s and St Thomas Hospital and 2% attended another SE London hospital. Forty two percent were treated in outside the SE London sector but only a very small number went to a clinic outside London. Sexual Health Issues 7.21. Sexually transmitted infections, HIV and unintended pregnancy can have short and long-term consequences both for the individual and the community. Inequalities exist in the distribution of sexually transmitted infections, termination of pregnancy and teenage conceptions. Sexual illhealth disproportionately affects young people, men who have sex with men and people from black and minority ethnic minority groups. Impact on morbidity 7.22. Chlamydia infection, the most common STI diagnosed in the UK, can lead to pelvic inflammatory disease, which may increase the risk of ectopic pregnancy and infertility. Some sexually transmitted infections can pass from mother to baby in utero and during birth. Persistent infection with certain types of the Human papillomavirus (HPV) is found in over 99% of women with cervical cancer and the infection is also implicated in other genital cancers. 1 Other HPV types cause genital warts. Incidence of sexually transmitted infections 7.23. The number of sexually transmitted infections diagnosed in Genitourinary Medicine (GUM) clinics in South-East London has decreased in the period 2003-2007 though a slight rise was seen in 2007 (fig 7.1.). This data does not include infections diagnosed in primary care and community reproductive and sexual health clinics, does not include place of residence, and therefore should be treated with caution. The most commons STI
diagnosed was Chlamydia, followed by warts. 1 Rates of STIs are relatively high in South east London, however estimating rates is problematic due to the lack of data on total infections. Figure 7.1: Diagnosis of STIs, South-east London Genito-urinary Medicine Clinics 2003-2007 7.24. The majority of infections were diagnosed in people aged 16-24 years of age (Fig 7.2). Sixty-six percent of infections were diagnosed in men. This may reflect the demographic make-up of clinic attendees however rather than a true difference in the incidence of STIs by sex. Figure 7.2. Diagnosis of STIs, South-east London Genito-urinary Medicine Clinics by age group 2003-2007 Unintended pregnancy and termination of pregnancy (TOP) 7.26. Evidence suggests that almost 50% of pregnancies are unintended. Nationally around 22% of pregnancies end in abortion. There is considerable national variation in the rates of termination of pregnancy, with risk factors including deprivation, ethnicity, younger age, education, access to contraception and local policy.
7.27. Southwark has around twice the rate of terminations for all age groups as compared to England and Wales (Fig 7.3). It should be noted that services are used by women who are resident elsewhere. The majority of abortions are performed at less than 10 weeks gestation. Thirty-five percent of women under the age of 25 years seeking abortion in Southwark have had a previous abortion as compared to the national figure of 24%. 1 Nationally women seeking repeat abortion are more likely to come from certain ethnic minority groups. 1 Fig 7.3. Termination or pregnancy rate in Southwark compared with national and other areas 90 80 70 Rate per 1,000 60 50 40 30 20 10 E&W Surrey Glouc. Southwark Lambeth 0 Under 18 18-19 20-24 25-29 30-34 35+ Age group Evidence of effectiveness 7.28. NICE has issued evidence based guidance on effective generic health promotion interventions to change attitudes and behaviour and interventions for community engagement. 7.29.The provision of contraceptive services has been shown to be costeffective. In addition, long-acting reversible contraceptives (LARCs) have been found to be more cost effective than the combined oral contraceptive pill, and increasing the uptake of LARC methods will reduce the numbers of unintended pregnancy. 1 7.30. NICE have also issued evidence based guidance on reducing STIs in the clinical setting. They state that PCTs should ensure that sexual health services, including contraceptive and abortion services, are in place to meet local needs and that these services should have arrangements in place for the notification, testing, treatment and follow-up of partners of people who have an STI (partner notification). 7.31. They recommend that those at higher risk of contracting STIs are identified opportunistically, that structured discussion using the theory of behaviour change should be used and partner notification should be carried out when an STI has been identified. 1 Southwark Actions 7.32. The Southwark Sexual Health and HIV Strategy 2006-2009 set out measures to develop an integrated continuum of services across health promotion, sexual health and HIV services. In terms of service provision the
availability of sexual health services has been improved through the Sexual Health Modernisation Initiative (2003-2008) has increased capacity and accessibility across a range of providers, with a greater focus on providing services in the community. 7.33. Particular emphasis has been placed on providing tailored health promotion and sexual health services to under-served and high-risk groups including young people, men who have sex with men and some ethnic minority groups. The Southwark Sexual Health & HIV Strategy (2006-2010) will be refreshed in collaboration with the Lambeth Sexual health Strategy in January 2010. This will take stock of the significant progress made by local sexual health services and review how services can be further developed to ensure high risk group have improved access to high quality services. Provision of sexual and reproductive health services (RSH) 7.34. NHS Southwark aims to provide a wide range of integrated sexual and reproductive health services. Two sexual health clinics in Camberwell and at the Artesian Health Centre were opened in 2007. Other RSH clinics are located at the Walworth Road Clinic and the Brook Clinic for under 25 s. Services in some GP practices have also been expanded. More specialized Genito-urinary Medicine (GUM) services are available at Guy s Hospital and Kings College Hospital. All local GUM providers met the government s target to offer an appointment to patients within 48 hours. Total attendances across all providers of sexual health services in Lambeth and Southwark has increased from 146,105 in 2006-07, to 154,995 in 08/09. This is an average year on year increase of 3%. 7.35. Emergency hormonal contraception (EHC) can be used up to 72 hours following unprotected sexual intercourse to prevent pregnancy. EHC is provided free to under 30 s in Southwark and is available at all RSH clinics, GUM clinics and at most pharmacies. The provision of the oral contraceptive pill from pharmacy is being piloted at one Pharmacy in Southwark as part of a National pilot 7.36. In order to reduce the number of repeat terminations, TOP providers are commissioned to provide a full and extensive contraceptive discussion to all clients, and 30% should leave one of the more recommended methods.
Recommendations A system to ensure the provision of BCG vaccination to new born babies in Southwark within the first four months of their life should be implemented. Continue to work to meeting the TB treatment completion rate of 85% as a matter of urgency. The prevalence of cases of HIV in Southwark is large and growing partly due to new infections and improving detection but particularly due to success of treatment where those with HIV now have long term good prospects of survival. Patients should be offered and encouraged to accept HIV testing in a wider range of settings than is currently the case. Given the current prevalence of HIV in Southwark consideration should be given to offering an HIV test to all men and women aged 15 to 59 registering in general practice and to all general medical admissions. 1 All doctors, nurses and midwives should be able to obtain informed consent for an HIV test in the same way that they currently do for any other medical investigation. HIV services and interventions to promote sexual health should be strengthened and expanded to better meet the needs of those with high risk of HIV acquisition within the UK, especially black African heterosexuals and men who have sex with men. Investment in resources and services will need to keep pace with the increasing numbers of HIV-infected persons requiring care. The pilot work currently being undertaken to expand HIV testing, especially in Lambeth should be rolled out in Southwark as part of the offer of a comprehensive sexual health service to all residents The proportion of women having repeat abortions in Southwark needs to be further addressed. Use research being undertaken locally and regionally to inform a strategy to reduce repeat abortions