Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 250-259)



John Austin

  250. Could I welcome the witnesses today and could I apologise for the absence of David Hinchliffe, the Chair of the select committee? He is unavoidably away due to a family problem. Could I ask the witnesses to briefly introduce themselves. Tell us your designation and where you are from.
  (Dr Tobin) I am Jean Tobin. I am a consultant in genitourinary medicine at Portsmouth and I am involved in the Portsmouth arm of the Hepartment of Health chlamydia screening pilot.
  (Dr Cassell) I am Jackie Cassell and I represent the British Medical Association. I work at University College, London in research in sexual health.
  (Professor Johnson) I am Anne Johnson. I am involved in infectious disease epidemiology at University College, London, in the Department of Primary Care and Population Sciences. I have worked on HIV epidemiology for a number of years.
  (Dr Fenton) I am Kevin Fenton. I am a consultant epidemiologist at the Communicable Disease Surveillance Centre. I am a senior lecturer at UCL Medical School and I currently head the HIV division on communicable disease.
  (Dr Hughes) I am Gwenda Hughes. I am a consultant scientist at the Communicable Disease Surveillance Centre and head of the section on transmittable infections.

  251. The primary purpose of this session is to examine the trends in the prevalence of sexually transmitted infections and the possible factors underlying those trends. Firstly, a question to Gwenda Hughes and Kevin Fenton. In your written evidence, you outline the recent trends for acute sexually transmitted infections. Could you summarise these and indicate what projections you have made of what will happen in the next few years?
  (Dr Fenton) We have seen substantial changes in the epidemiology of sexually transmitted infections over the last 20 years. In part, a lot of these changes have been mediated by behavioural modifications in the general population. There have also been substantial changes in how individuals access care and how they take up sexual health services. In the early 1970s and towards the early 1980s, we were seeing some decline in STIs. At that time, we were noticing for some infections—for example, gonorrhea—over 60,000 diagnoses each year. At the beginning of the 1980s at the commencement of the global HIV pandemic we noticed substantial declines in the numbers and rates of both bacterial and viral sexually transmitted infections and these declines have continued throughout the 1980s right up to the mid-1990s. These declines were particularly marked across Britain and were observed especially in so-called high risk groups—for example, gay and bisexual men—and this adds credence to the fact that these groups in particular had adopted a variety of behavioural modifications during that time. As such, we saw some of the lowest rates and numbers of sexually transmitted infections by the mid-1990s and we often describe a nadir or a bottoming out of STI incidence at about 1994 to 1996. This was seen across all STIs. Since 1995, however, we have been noticing a gradual, sustained increase in the numbers and rates of both bacterial and viral sexually transmitted infections. Since 1995, we have seen a doubling of rates and numbers of chlamydia, gonorrhea and syphilis. There are a variety of reasons to explain why these infections have all increased. What we also should remember is that, because the infections bottomed out in 1995, the initial rate of increase by the end of 1990 was seeing approximately the same numbers of infections as we have seen at the beginning of the decade as we did at the end of the decade. However, since 2000, we have observed and we continue to observe substantial increases in all sexually transmitted infections. Undoubtedly, sexual behaviour will be a key determinant of the increases in these STIs, but a number of ad hoc studies as well as our surveillance data confirm that people are also attending GUM services more. They are taking advantage of HIV testing and sexual health screening. That may also contribute to the increases in diagnosis that we are observing. We are also aware that people are taking more interest in their sexual health, partly because of the sexual health campaigns throughout the 1990s. Clearly, this will also contribute to increasing diagnoses. Finally, we have been seeing increases in the sensitivity of our diagnostic tests. We are getting better at diagnosing a variety of STIs. For example, genital chlamydial infection. That may also be contributing to the increases in the numbers and rates of STIs which we are observing. A large part of these increases has been mediated by sexual behaviour.

Dr Naysmith

  252. You said screening may have contributed partly to these increases. What kind of screening? Has it contributed to the detection or the increase?
  (Dr Fenton) I am using that term in its widest application, not in terms of the chlamydia screening programmes which are being developed at present. If individuals are going to STI clinics more, they will have a greater opportunity to be screened and tested for STIs.

  253. Not in the sense of people being screened for other things and you are picking these up?
  (Dr Fenton) That may also contribute to it. Another good example is genital chlamydial infection where the diagnostic technology has improved since the mid-1980s. We have been using a succession of more sensitive tests to diagnose chlamydia and therefore we are getting better at picking up asymptomatic infections.

John Austin

  254. You gave a very clear picture of the trends to date and some of the underlying reasons. Have you made any projections for the near future?
  (Dr Fenton) We have not at the Communicable Disease Surveillance Centre done any specific projections for STIs. We tend to do projections for HIV and AIDS by using a variety of statistical modelling.
  (Dr Hughes) What we have seen is a consistent rise particularly in infections like gonorrhea since about 1995. The evidence that we have from the preliminary data for last year is that that is continuing. It is rising at quite a sharp rate and does not seem to be easing off.

  255. Dr Cassell, you have published a report on STIs. What prompted the BMA to produce that report?
  (Dr Cassell) The Board of Science and Education of the British Medical Association produced the report and that is a standing committee of the BMA, which works at the interface between the profession and the public and government and aims to contribute to public health through education, particular of professionals with a view to educating the public. It produces a variety of reports in response to the concerns of members. For example, at the annual representatives' meeting, debates might be generated on issues of concern in members' working lives. A number of issues of concern were raised over several years in relation to sexual health, particularly the sexual health of young people. As a consequence, the Board of Science and Education decided to produce this report with a view to educating professionals and raising awareness that this is an important health issue in order to help professionals in talking to their patients about risks, being aware that these risks are very real in their working lives and also with a view to improving services at all levels.

Julia Drown

  256. We are expecting in March next year the work of the Sexual Health Services Data Group to report, mentioned at the beginning of the health implementation plan. Could you give us any insight into the work that they are doing and possible recommendations that might come out of that?
  (Dr Hughes) What the group is trying to do is to find out what information do we need to be able to monitor sexual health in the population effectively so that we can develop appropriate intervention strategies and monitor how effective they are once they have been developed. What is likely to happen is that they are going to recommend that there are new standards for data collection across all health services which are providing sexual health services. There will be a minimum amount of information that will be felt to be necessary. That will need to come not just from the specialist services but also from primary care, especially now we have the sexual health strategy where there is a commitment to greater delivery of services in primary care. We are clearly going to need to get information from primary care to be able to monitor how effective that is going to be. What is obvious is that these are quite big changes and that there would need to be considerable training involved and investment in information systems in order for these changes to be realised. They are going to make recommendations in relation to the data that should be collected. They are currently looking at how different strategies could be used to try and get that information. That is still under discussion.

  257. That is about getting better data rather than saying there should be different screening programmes to get the data?
  (Dr Hughes) The remit of that group is to look at getting better quality information in order for us to be able to monitor these programmes.
  (Dr Fenton) Although we do have a very comprehensive STI surveillance system, it does have its limitations. We are very much hoping to get detailed information on inequalities in sexual health and sexual ill health in the population and to target our interventions quite closely to undertake targeted interventions. One of the strategic visions the data group has for STI surveillance is to take along term approach to see what we need to inform STI prevention and control. What do we want to have in seven years' time? What would we like to do in two years' time?

  258. Can you see things that should be happening that we as a Committee might want to recommend should happen that perhaps might not have come out of the data group or other work?
  (Dr Hughes) At the moment, we have broad, reasonable information from genitourinary infection clinics but we have no information from primary care currently. If we are going to address that situation and particularly if we are going to have more services delivered through general practice, we are going to have to monitor that. There is going to need to be some investment put into information systems to be able to collect that information, to train people to gather that information and then to look at how that information might be integrated across all the services.

  259. It is about trying to make sure that, in developing services into primary care, the proper data is picked up?
  (Dr Hughes) That is right.

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