Select Committee on Health Minutes of Evidence

Memorandum by the Department of Health



  1.  The first ever, national strategy for sexual health and HIV was published for consultation on 27 July 2001. The strategy proposes a comprehensive and holistic model for modernising sexual health services in line with the principles set out in the NHS Plan.

2.  The NHS Plan set out the Government's plans to develop a health service for the 21st century, offering fast, high quality and patient centred care. The core principles underpinning the NHS Plan form the basis of the key aims and objectives of the Sexual Health and HIV Strategy. These include providing a comprehensive range of services, shaping services around the needs and preferences of individual patients, responding to the needs of different populations and continuously improving quality services.

3.  Tackling poor sexual health is an important part of broader work to tackle health inequalities. Poor sexual health disproportionately affects disadvantaged communities, and there are inequities in service provision from area to area.

4.  This memorandum presents an analysis of sexual health in England today, and sets out the action the Government is taking to tackle the main problems identified.


Sexually Transmitted Infections and HIV

5.  In the year 2000, there were over 1.1 million visits to Departments of genito-urinary medicine (GUM) in England. The most common conditions diagnosed in Departments of genito urinary medicine (GUM) were chlamydia, non-specific urethritis and wart virus infections. New diagnoses of sexually transmitted infections (STIs) such as gonorrhoea, chlamydia and syphilis are currently showing an upward trendi.

6.  An estimated 33,500 people in the UK were living with HIV at the end of 2000, of whom 72 per cent were aware of their HIV status. About 400 people a year die as a result of their HIV infection. Although there is still no cure, combined therapy has improved the life span of people living with HIV. For the last three years the number of new infections acquired through heterosexual sex has outnumbered those acquired through homosexual sex, and over 80 per cent of heterosexual infections were probably acquired abroad. Sex between men remains the major transmission route for HIV in this countryii.

7.  The average lifetime treatment costs for an HIV positive individual is calculated to be between £135,000 and £181,000iii, and the monetary value of preventing a single onward transmission is estimated to be somewhere between £1/2 and 1 million in terms of individual health benefits and treatment costs.

International comparisons

8.  France, the Netherlands, Sweden and Switzerland all reported increases in gonorrhoea between 1995 and 1999iv particularly among men having sex with men. The same group has also suffered outbreaks of syphilis, for example new diagnoses doubled in Sweden between 1996 and 1999. Between 1995 and 2000, new diagnoses of sexually acquired HIV infections increased by 20 per cent in Western Europe and numbers of people living with HIV are rising by around 3 per cent a year.

9.  Data from the UNAIDS Report on the Global HIV/AIDS epidemic (June 2000) shows that at the end of 1999, the UK had an HIV rate of 0.11 per cent compared to rates of 0.74 per cent in Portugal, 0.58 per cent in Spain and 0.44 per cent in France. This reflects prompt action on a number of fronts: health promotion, needle exchange schemes and other harm minimisation initiatives, screening of blood and clinical interventions, the availability of open-access GUM clinics and careful surveillance and analysis of trends.

Sexual behaviour & knowledge

10.  Studies suggest there has been an increase in risky sexual behaviour, and that there is still ignorance about the possible consequences. The average age at which people start having sex is now 16. Forty years ago it was 21 for women and 20 for menv. In 1999 most people questioned in a national study did not know what chlamydia wasvi.

11.  Further important data have recently been published from the National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) vii, which can be compared with information from a similar survey undertaken in 1990. This showed that between the two surveys there had been an increase in behaviours associated with increased risk of HIV and STI transmission, including increases in numbers of partners and concurrent partnerships. In particular, there were considerably higher rates of new partner acquisition among those younger than 25 years and this is reflected in the substantially higher incidence of STIs in this age group.

12.  Natsal also recorded increases in consistent condom use, which were greatest for men with multiple partners in the last year. Four in five 16 to 24 year olds used a condom at first intercourse and around 90 per cent used some form of contraception. These are significant increases from 1990 when over a third of teenagers reported not using any contraception at first intercourse. However, the increase in numbers of sexual partners may have offset some of the advantages of increased condom use.

13.  A 1999 survey of gay men showed that 58 per cent of those under 20 did not always use a condomviii. A recent study indicated that 44 per cent of HIV positive men had anal sex with a new partner in the last month, of whom 40 per cent reported no or inconsistent condom useix.

Teenage pregnancy and unintended pregnancy

  14.  Sexual health is not just about disease. Ignorance and risky behaviour can also have profound social consequences. Planning parenthood, understanding contraception and the age of first intercourse can all have an important impact on individuals and communities. Teenage birth rates in the United Kingdom are the highest in Western Europe. Conception rates in England have now started to fall, the rate for under 18s and for under 16s having dropped by over 6 per cent between 1998 and 2000. This is encouraging, but the work being undertaken to implement the Teenage Pregnancy Strategy, such as improvements to Sex and Relationship Education and services for young people, will need to be sustained if the goal of a 50 per cent. reduction in rates by 2010 is to be achieved.

15.  In 2001 there were nearly 176,000 abortions performed in England and Wales. Following a pill scare in 1995, abortion rates increased until 1998, but now appear to be stabilising. Abortion rates are highest for women in their early twenties and late teens.

16.  It is estimated that the prevention of unplanned pregnancy by NHS contraception services saves the NHS over £2.5 billion a year.


17.  Sexual ill health is not equally distributed among the population. The highest burden is borne by women, gay men, teenagers, young adults and black and ethnic minoritiesx, xi. The rates of gonorrhoea in some inner city black and minority ethnic groups are ten or eleven times higher than in whitesxii. HIV infection also has an unequal impact on some ethnic and other minority groups. Britain's African communities have been particularly badly affected by HIV/AIDS, with high rates among both adults and childrenxiii. There is some evidence to suggest that chlamydia infection rates are associated with levels of deprivation.

18.  There is a strong link between social deprivation and STIs, abortions and teenage conceptions. Unintended pregnancies increase the risk of poor social, economic and health prospects for both mother and child. The risk of becoming a teenage mother is almost 10 times higher for a girl whose family is in social class V (unskilled manual), than those in social class I (professional).


Development of the Strategy

19.  In May 2000 it was announced that the HIV/AIDS and sexual health strategies had been integrated into a single programme. The aim of combining the two strategies was to develop more coherent health promotion messages and more effective service interventions for sexual health, including HIV/AIDS.

20.  A new process for developing the combined strategies was established, building on existing structures and work to date, and bringing in additional expertise as required. An Integrated Strategy Steering Group was established (membership attached) together with various sub-groups and working groups to look at specific issues.

21.  A wide range of stakeholders was also involved in the development of the strategy. A written consultation with health professionals working in the field was undertaken and meetings held with the Royal Colleges, professional organisations and other key players. There were specific consultations held with young people, black and ethnic minority groups and gay men and lesbian women.

Publication of the Strategy

22.  The Strategy was launched for consultation on 28 July 2001. It was backed by investment of £47.5 million to support a range of initiatives set out in the strategy. The main aims of the Strategy are to:

    —  reduce the transmission of HIV and STIs;

    —  reduce the prevalence of undiagnosed HIV and STIs;

    —  reduce unintended pregnancy rates;

    —  improve health and social care for people living with HIV; and

    —  reduce the stigma associated with HIV and STIs.

  23.  The Strategy proposes to achieve these aims by:

    —  providing clear information so that people can take informed decisions about preventing STIs, including HIV;

    —  developing a new information campaign for the general population;

    —  producing a sound evidence base for effective local HIV/STI prevention;

    —  developing managed networks for HIV and sexual health services, with a broader role for those working in primary care settings and with providers collaborating to plan services jointly so that they deliver a more comprehensive service to patients;

    —  evaluating the benefits of more integrated sexual health services, including pilots of one-stop clinics, primary care youth services and primary care teams with a special interest in sexual health;

    —  beginning a programme of screening for chlamydia for targeted groups in 2002;

    —  stressing the importance of open access to GUM services and, over time, improving access for urgent appointments;

    —  ensuring a range of contraceptive services are provided for those that need them;

    —  addressing the disparities that exist in abortion services across the country;

    —  increasing the offer of testing for HIV to ensure earlier access to treatment for those infected and limiting further transmission of the virus;

    —  increasing the offer of hepatitis B vaccine;

    —  setting standards for the treatment of STIs and for the treatment, support and social care of people living with HIV;

    —  setting priorities for future research to improve the evidence base of good practice in sexual health and HIV; and

    —  addressing the training and development needs of the workforce across the whole range of sexual health and HIV services.


  24.  The consultation period on the Strategy ran from 27 July to 21 December 2001. The Strategy was circulated widely across the NHS, voluntary organisations, Royal Colleges and social services.

25.  The extended consultation period provided an opportunity for the Department of Health and other groups to organise a number of consultation events to supplement the written exercise. The Department of Health held six events in Warrington, London (two separate events), Bristol, York and Birmingham. These events were attended by a wide spectrum of health professionals and others from the field.

26.  In addition we commissioned the Terrence Higgins Trust, Brook, the African HIV Policy Network and others to organise more targeted events. Other organisations such as the fpa and the National AIDS Trust also held events. The Royal College of General Practitioners held an event for GPs. Canvassing a wide range of constituencies was important and has helped us in developing implementation plans.

Summary of responses to the Strategy

27.  We received over 400 detailed and thoughtful written submissions of very high quality. The large majority of people involved in the consultation welcomed publication of the Strategy. Many felt that the development of a strategic approach to improve sexual health is long overdue.

28.  There was strong consensus around our analysis of the problem, in particular the rising trend of infections, the link between sexual ill health, poverty and social exclusion, and varying standards of service provision. There was also a large degree of support for the main interventions proposed, in particular the development of service standards to ensure consistent quality of care regardless of the point of access.

29.  Many respondents were concerned about exactly how in practice the Strategy would be implemented, particularly following the mainstreaming of HIV funding. There were also strong views that improving clinical services—while important—would not of itself be sufficient. Implementation of the Strategy will require partnership working with other government departments, local government and the voluntary sector in order to succeed. There are limits to what a single organisation can achieve, particularly in seeking to change the behaviour of individuals.

30.  Given the overall support for the aims, principles and interventions proposed in the Strategy, we do not propose at this stage to revise the Strategy itself. We are developing a response to the consultation and a detailed implementation action plan which will be published shortly. The Strategy taken together with the consultation response and implementation plan set out in this document will provide an overall framework for action.

Action taken during 2001-02

31.  During 2001-02, alongside the consultation exercise and events, we invested £5.5 million to prepare for implementation of the Strategy as detailed below:

    —  We provided funding for every local area to undertake a baseline service mapping exercise, and identify gaps and weaknesses in existing services. These reports will be analysed and a summary report published in the autumn. (£1.6 million)

    —  We have started to develop the information campaign, including undertaking research on what works. We also supported the World AIDS Day HIV prejudice campaign. (£0.8 million)

    —  We have funded a study to investigate the incidence and re-infection rates of genital chlamydial infection in young women attending public health care settings in Portsmouth and Wirral. This will help to inform the design of the chlamydia screening programme, particularly screening intervals. (£0.6 million)

    —  We have funded a range of national and local interventions aimed at reducing the recent resurgence of syphilis in England. These include an awareness campaign for groups most at risk of syphilis, reviewing and updating of national enhanced laboratory surveillance for syphilis and improving outbreak management skills. We have also funded local interventions in London, Manchester and Brighton, which complement national initiatives, but are more targeted, appropriate and sensitive to local circumstances. We have also provided more doses of hepatitis B vaccine to GUM clinics. (£1 million)

    —  We provided funding to 16 further areas to start or expand schemes for pharmacy availability of emergency hormonal contraception under a patient group direction. (£0.75 million)

    —  We have taken forward other national initiatives, in particular the development of basic sexual health skills training for health professionals and introduction of a more efficient abortion data processing system. (£0.75 million)


    32.  Our implementation action plan, to be published shortly, will set out in detail how we will work both through the NHS and in partnership with other Government Departments and the voluntary sector to tackle sexual ill-health. This is a long-term programme. We will need to both improve and modernise services, and also seek to change individuals' behaviour drawing on the best evidence on what works in achieving this. This will form an important part of our work to improve public health, tackle health inequalities and communicable diseases, and deliver the NHS Plan. The main strands of the implementation plan are summarised below.

    33.  The Implementation Action Plan will build on the arrangements already in place at national and local level to implement the Teenage Pregnancy Strategy, working in partnership with a wide range of organisations from the statutory and voluntary sector. The Plan will also link to implementation of the Infectious Diseases Strategy Getting Ahead of the Curve which identifies control of HIV transmission as a key priority.

    Framework for delivery

      34.  Primary Care Trusts (PCTs) will play a central role in implementing the strategy. PCTs have a unique perspective across community, hospital and primary care and across both the NHS and local authorities. They also have a very clear relationship both with frontline staff and with patients. PCTs have been given new powers and control over resources to shape and commission services. These new powers will enable commissioning to be more responsive to local need and the views of service users.

    35.  We have asked PCTs to identify a sexual health and HIV lead to drive forward implementation at local level. We are encouraging PCTs to collaborate in commissioning consortia in order to make best use of existing expertise in sexual health and HIV commissioning. A key element of the implementation plan is the development of a Sexual Health and HIV Commissioning Toolkit to support PCTs in this new role.

    36.  We will carefully monitor levels of investment following the mainstreaming of HIV budgets. This will include revised arrangements for monitoring under the AIDS Control Act. Strategic Health Authorities will be responsible for performance managing implementation.

    Better prevention

    37.  We are working towards launching a national information campaign in the autumn. The campaign will highlight the risks of unprotected sex, and will target young adults in particular. This will build on the success of the teenage pregnancy media campaign which has secured recognition of 78 per cent with its target audience, and good understanding of the key messages. We are also taking forward more targeted campaign work, including promoting HIV testing among high risk groups.

    38.  The Health Development Agency is undertaking a review of the evidence base for local HIV and STI prevention. The main findings will be disseminated to local areas by the autumn, supported by a regional seminar programme. We are also developing a health promotion toolkit to support implementation.

    Better services

    39.  We will work with professional bodies and service users to develop and publish a set of recommended service standards. Work on updated standards for HIV treatment is already underway in partnership with the BMA Foundation for AIDS and other key partners. The updated standards will be published later this year. We will also disseminate details of effective managed service networks to upport implementation of the standards.

    40.  The national chlamydia screening programme will start to be introduced in 10 sites, selected from those areas which have expressed an interest. The programme will build on the learning from the successful pilots in Portsmouth and the Wirral. This will be an opportunistic screening programme which will primarily target women who access services, but will also promote greater uptake of testing among men.

    41.  We will start to address variations in abortion services, working towards a maximum waiting time of 3 weeks by 2005. We will also develop the role of health advisors within GUM services, informed by the recommendations from the Health Advisors Working Party, and will work towards shorter waiting times for urgent appointments. We are extending the availability of hepatitis B vaccine, and have recently notified GUM services of the arrangements for this.

    42.  We will develop three models for One Stop Shop sexual health services providing advice, contraceptive and GUM services on a single site. The models will cover youth services, specialist primary care teams and specialist services which meet the needs of all age groups.

    Better support for people living with HIV

      43.  We will commission a report on the support needs of adults living with HIV, and develop services standards. This will include access to good quality sexual health advice and supporting adherence to drug regimes. We will also develop service standards to meet the support needs of children living with HIV. We are reviewing the administration of AIDS Support Grant, with the aims of minimising bureaucracy and ensuring the needs of people living with HIV are met.

    44.  Drawing on consultation responses, we will develop a more detailed action plan to tackle stigma and discrimination working in partnership with other Government Departments.

    Supporting change

    45.  We are undertaking a mapping exercise of current availability of basic sexual health skills training and other professional training to inform a national sexual health training strategy. The strategy will encompass the training needs of doctors, nurses (including family planning specialists and school nurses), midwives, health visitors, health advisors, youth and social workers and other relevant professionals, and will link to the work on teacher training already underway as part of the Teenage Pregnancy Strategy.

    46.  The content of the joint Medical Research Council and Department of Health research programme is being reviewed to ensure that it effectively supports implementation of the Sexual Health and HIV Strategy. New projects to support the Strategy will be commissioned from 2003. Further annual reviews will be undertaken by the Medical Research Council on an annual basis, informed by progress on systematic reviews of the literature in relevant subject areas.


    47.  This is an ambitious and wide-ranging Strategy which sets out a long-term programme working towards safer sexual behaviour, modernised services and better sexual health for the whole population. Improving sexual health and changing behaviour is not something that can be brought about by the Department of Health and NHS services alone: other government departments, local government and the voluntary sector have a crucial role to play too.

    48.  Devolving new powers and resources to Primary Care Trusts provides an important new opportunity to make the commissioning of sexual health services much more responsive to local needs. Service users will be involved at both national and local level in redesigning services around their needs. This work will build on existing models of excellence in GUM, health promotion and reproductive health services which are highly responsive to users' needs and concerns, and have made such a major contribution to controlling the HIV epidemic in this country. By supporting local implementation and building a broad partnership to drive forward the Strategy, we can succeed in reversing the upward trend of infections, tackling inequalities and modernising sexual health and HIV services.

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Prepared 14 August 2002