Examination of Witnesses (Questions 300-319)|
WEDNESDAY 17 JULY 2002
300. And can also cause warts.
(Dr Hughes) It is less. It is rare for that to be
the case. But they are all transmitted in the same way.
(Dr Tobin) There is a lack of agreement about this,
even between GU medicine physicians. There are some who feel that
they are just a nuisance and only their appearance is a problem.
There is no doubt that some types of wart viruses are related
to cervical cancer, and quite the best way of dealing with that
problem is probably through cervical cytology on the screening
programme that is available. I think it would be unwise to suggest
to people that genital warts are something that could safely be
ignored. They should be seen and some treatment offered. There
are treatments now that patients can use themselves to get rid
of them, so they are not transmitting either the less worrying
types of virus or the more serious types. One has also to bear
in mind that those who have acquired this virus are also at risk
of having acquired other infections so they may be a high-risk
group of patients who we would like to see at least once. It would
be a worrying message to get across to people that genital warts
are perfectly okay and one should not do anything about them.
301. There is also a suggestion that condoms
do not prevent the spread of genital warts. Is that generally
agreed to be true?
(Dr Tobin) The problem is that a lot of people will
not know they have genital warts. There is quite a long incubation
period and so if they have a partner they have been with for a
while, it is very likely that that person has already acquired
the warts if they are going to, and to use condoms then is not
going to be particularly helpful. The teaching at the moment is
that you cut down the risk of transmitting genital warts, though
you will not completely remove the risk, if with a new partner
you use a condom.
302. Moving on to syphilis, the numbers are
relatively low compared to other STIs, but there was a big percentage
increase between 1999 and 2000. Is there anything that causes
particular concern about that? Is syphilis a special case, or
does it follow the epidemiology of the other STIs?
(Dr Fenton) Syphilis is a particularly interesting
STI because, as Anne has said, nearly forty years of effective
prevention and control have driven syphilis almost to extinction
or elimination in Britain. In fact, by the early 1990s we saw
a handful of cases which were acquired in the United Kingdom.
Many cases were imported from high-prevalence countries. Since
1997, however, that has changed dramatically. We have had a number
of outbreaks of infectious syphilis across the country, and these
have occurred in both heterosexuals and homosexual populations.
The biggest outbreaks to date and the most difficult to control
have occurred in gay men. There are outbreaks currently ongoing
in London, Brighton and Manchester. The significance of all of
this is that as with gonorrhoea and other STIs, syphilis is a
relatively good marker of high-risk partner change and resurgence
of unsafe sexual behaviours. A number of studies we have done
in the outbreak sites have confirmed that the disease has been
re-introduced into gay men who are having extra partner change
or who are using venues that facilitate rapid exchange of partners,
and meeting partners with similar high-risk lifestyles. Similarly,
in the heterosexual outbreaks, work in those sites has also shown
that the infection had been located among the commercial sex workers,
among heterosexuals who were practising a variety of esoteric
sexual practices. It is resurgent, and is located in particular
core groups of society. As an indicator of high-risk behaviours,
we need to be aware of them.
303. It does not need to be treated in a different
way; it would be targeted in exactly the same way as for gonorrhoea
and other STIs.
(Dr Fenton) No, it will need both a general approach
to controlling it, which is consistent, but you also need targeted
approaches for syphilis as well because of the high concentration
of high-risk cores.
304. One of the things we have already had a
few hints about is that service is a bit patchy around the country,
but most people, according to the written evidence, suggest that
the service is under very heavy pressure, and that there is a
lack of access. To what extent do you think lack of access and
pressure on the system is attributable to the increase in STIs?
(Dr Fenton) Maybe we had better start off with some
of the work we have done. Every year for the last two or three
years we have been doing a study on access to GUM services, and
that has shown a marked increase in access times to GUM clinics.
The last study was approximately over ten days for a routine appointment
for services, and clearly this will have implications for disease
transmission on a number of fronts. We know that if individuals
are initially symptomatic of an STI, delayed access to services
may result in a number of things. First of all, they may have
a resolution of their symptoms and therefore believe that they
are no longer infectious, and therefore not attend services. A
very good example of that is having syphilis: you may have a chancre
or a sore for a few weeks and that resolves spontaneously. The
other difficulty with delayed access to services is that there
are a number of studies that have shown that the presence of a
vaginal discharge or a penile discharge does not necessarily inhibit
someone from being sexually active. Studies from the United States
and from Britain show 30 per cent of individuals, despite being
symptomatic, also continue to have sexual intercourse. If you
increase the delay in the length of time for them to have access
to services, it will increase the probability of transmission
and infection in the community.
305. You talked about the possibility of someone
having a chancre and it resolving before they got a chance to
see an expert, and you then suggested they might think it has
gone away, and they have not got an infection at all. Is there
evidence of that happening?
(Dr Fenton) Classically, it is describing syphilis,
because of the disappearance of the primary chancre. In the outbreak
sites we have seen cases of people who are presenting with secondary
syphilis, that is a generalised form of the disease. When asked
about an ulcer or a cut on the penis or vagina, they would say,
"absolutely, I saw that four weeks ago and it went away on
its own". It is simply the rationalisation of symptoms by
patients before attending services. The real issue around delayed
access to services is the probability of onward transmission of
that disease during that interval period that it takes for them
to arrive at the clinic and be given a diagnosis.
306. What about the recommendation for the number
of consultants per head of population? The Royal College recommends
about 1:113,000; and yet we have a couple of examples here: South
Buckinghamshire Trust has a ratio of one consultant for a population
of 300,000. That is nearly a third under-doctored. Is that common
in the service?
(Dr Tobin) Yes, it is very common. I can think of
many examples. In my own area there has been one only recently.
We had a population of 600,000 and two consultants. We now have
another half time consultant, so we have done well. I think one
has to look at the issues within GU medicine, especially if we
are going to have screening campaigns that will involve more providing
more consultants, and we need more properly trained doctors in
other grades.But we also have to look at the resources we already
have, which may be some of our nurses. Many clinics have coped
by training their nurses to a very high level, where they are
able to manage a substantial amount of the workload. In my own
area, that is the only way we have been able to keep our waiting-lists
down. I think one has to look at being able to offer patients
both an appointment and a walk-in service. A walk-in service by
itself, while preferred by patients, can be very inefficient as
a way of spreading the workload across clinic times. We have got
round that by having nurses perform triage for us, like in A&E.
Staffing on all fronts has to be very seriously considered, especially
when one is looking for more education and training for them.
307. When I visited my GUM clinic in Bristol,
I discovered there were lots of doctors employed on contracts,
doctors who elsewhere might have been moving up the training scale,
consultant scale, and they were claiming that they were not getting
proper training and being supported. Would that be something that
(Dr Tobin) We have had many doctors who have helped
us out in GU medicine. We have our specialist registrars of course,
and we will hit a problem with them in the next year or so, when
many of them will have completed their training and there are
not going to be enough consultant posts open for them to apply
for. We have a trained workforce waiting for jobs to be created,
as it were. We also have a lot of clinical assistants who work
in GU medicine.
308. That is probably what I am referring to.
(Dr Tobin) Many of them work outside and have other
interests, like general practice, and do not wish to move up the
scale. I am sure there are some isolated cases where people have
not been able to progress, but I have not personally any experience
309. Can I go back to the view that sexual ill
health, rather like wealth in our society, is not evenly distributed
amongst the population. In the south-east of London, where I am
particularly concerned with the issues relating to my own area,
the occasion of sexual health is disproportionate in certain groups,
as we have seen, and there is evidence to support that at least
statistically. In my own area of south-east London, the Caribbean
population is well established. It is not a new population and
has been there for three generations; and yet there seems to be
a disproportionate occurrence in that group. I separate the Caribbean
from the African population, which has a different profile and
different background. It is by no means restricted to those two
groups, but the evidence presented to us, and the evidence I have
as a constituency MP, is that there are particular problems there
with STI with teenage pregnancy. What work has been done by any
or all of you to try to establish why there should be this discrepancy?
(Dr Fenton) I can speak from the perspective of work
with black and ethnic minorities. This has been an area of interest
to us at University College London. We have done a range of studies
both within the community with NGO clinics, as well as in the
second national survey of Natsal where we have seen funding from
the Department of Health to look at ethnic variations in STIs.
There is a multiplicity of factors that come into play. Clearly,
there are issues around sexual behaviour, and ways in which sexual
behaviour will facilitate the transmission of STIs; but rather
than the numbers of partners, we need to look at sexual mixing
patterns in the general population. There have been a number of
studies done in south London, which have shown that sexual behaviour
among many minority communities or micro communities is highly
assaultive. In other words, we are much more likely to have sex
or sexual relationships with individuals who look like ourselves;
we choose our partners from within our own ethnic groups and social
class, et cetera. That is in a community which is poorly
accessed by health services, or poorly engaging with health services,
which facilitates transmission of infection in that group. It
may lead to very high rates of disease. There are also cultural
factors which influence the transmission of disease, and these
factors may influence people's confidence in the health services.
We know from a number of studies that black and ethnic minorities
often feel disenfranchised by health services, NHS services, and
they will choose not to attend these services for a variety of
reasons. There are cultural factors that influence how people
deal with the symptoms of STIs and the importance that they place
on those symptoms. A multiplicity of facts is operating, particularly
with the black and ethnic minority communities. You did mention
other groups that also have high rates of STIsthat gay
and bisexual men, for example, have a disproportionate effect
with HIV, and we have seen a dramatic increase of STIs in this
group. Again, we are looking at patterns of sexual mixing and
a resurgence of high-risk sexual behaviour in this group, which
is driving those. The final group we are particularly concerned
about is young people. We know from our sexual behaviour studies
that young people are having sex earlier; they have more opportunities
for multiple partnerships. They are much more likely to have chaotic
relationships when they begin their sexual career, moving from
one partner to another and having overlapping partnerships. These
behaviours are going to increase the risk of STI. Sexual mixing
is also an issue for young people. Young girls are more likely
to have sex with slightly older men, who may be at increased risk
of acquiring STI. In each of these groups there are different
driving factors and therefore different control measures are necessary.
(Professor Johnson) We have talked a lot about the
increased risk in the general population, but another area of
concern from the research we have been carrying out each year,
in the form of a survey of gay venues in London, involving 2,000
gay men each year, is that since 1995 every year we see a year-on-year
increase in the level of risk behaviour in these men surveyed.
We are seeing the re-emergence of unprotected anal intercourse
at higher levels each year. There is a real public health challenge
here because while in this country it is fair to say we have seen
a tremendous response, both from government and from the voluntary
sector to try and control the epidemicand we have done
well. Nevertheless, there are new challenges; it is a moving target.
We have now got effective anti-retroviral therapies, which are
marvellous: people are living longer, they are less sick; they
are back in the workplace and have a better quality of life. But
they have another effect, which is that as people live longer,
there are more people living with HIV in this country. At a population
level, that means the prevalence of HIV infection in these communities
is rising because people are living longer. That, combined with
increased risk behaviours in these groups, and increased sexually
transmitted diseases, creates the impetus for further new HIV
infections, which we know are happening, and creates another anxiety,
which we all have, which is transmission of anti-retroviral-resistant
infections; in other words, anti-retroviral treatments select
out resistant viruses. What does that mean in strategic terms?
It means that we need to work with people who are HIV-infected
and work with those who treat them, to help people have a lifelong
strategy to prevent them passing on HIV. All of us in our own
lives now have difficulties in maintaining our health goals. It
means investing, probably at the level of GUM services, to help
those who we know are infected to prevent transmission of the
infection. That is a classic infectious disease control programme.
Following that is the question of what we are going to do about
the relatively high level of undiagnosed HIV infection in the
community, and how we can ensure that people across the boardgay
men and African communitiesthose who have become infected
by whatever routeaccess the new treatments available and,
for example, prevent mothers from passing on infection to their
unborn babies and so on. That does mean that we need to think
carefully about having good programmes to ensure that people are
screened and diagnosed for HIV in an appropriate environment;
that they can access treatment and that part of the treatment
strategy is a lifelong strategy for preventing passing on infection.
310. The more diverse the community, the more
susceptible it is to having that representation within itis
that rightand therefore that complicates the issue? It
is easy to be gay in London than anywhere else in the countryone
knows thatwe meet people from all over the country who
go there because it is easier to be like that there. The more
diverse a community is, the more it is at risk from having one
of the factors that you have outlined present within it; so where
there is a more stable communityI hesitate to use the pejorative
termbut in a different part of the country where the population
turnover of social change is much less, they are much less likely
to place the multiplicity of risk you have outlined across the
whole field of STI.
(Professor Johnson) That is true. That is why we see
the highest rate of STIs and HIV in large metropolitan areas where
there is that kind of diversity; and that would be true throughout
(Dr Fenton) Having said that, the second national
survey has shown that the change in the last decade was quite
marked outside of London as well. The change is occurring not
only in the city and metropolitan areas.
311. In circumstances where there are more variables.
We have seen a submission stating that until a few years ago STI
and HIV were almost two separate groups; but there has been some
convergencethere are now more reported occurrences of an
overlap between the two. Is that your experience, and can you
offer any explanation as to why that should be so?
(Dr Fenton) It is absolutely correct. Our surveillance
systems among HIV positive individuals show an increasing proportion
of HIV positive, particularly homosexual men who are attending
GUM clinics with an STI diagnosis. The evidence from the recent
outbreaks of infections has confirmed this as well. In London,
currently, of the 300 cases of infectious syphilis diagnosed in
gay men in the last year, 48 per cent of them were HIV positive.
In Manchester, of the 200 men who acquired infectious syphilis
over the last two years, 38 per cent are HIV positive; so we are
beginning to see an overlap between the transition networks for
STIs and HIV. In a sense, it is not surprising because people
are likely to have acquired HIV in part because of their high-risk
sexual lifestyles, and therefore if they are continuing that behavioural
mode, then that would also put them at risk of other STDs. We
are seeing the phenomenon of an increasing overlap between HIV
312. Can I now ask you a completely loaded question?
We have a population now that has lived with HIV and have accepted
that as a fact of lifeit is no longer a threat.
(Professor Johnson) I do not know whether or not there
is new evidence on that, but that issue is often raised. It goes
back to what you said earlier, that there was a lot of information
about this around ten years ago, and we do not hear it
313. In the early days there was a public perception
of inevitabilityit was just a question of "when",
but because of improved treatment and therapies, that is not now
(Professor Johnson) Those things have certainly changed
people; they have a very different expectation of life if they
have HIV, and that is a public good. The question is, as we move
through this epidemic, knowing that we are still seeing quite
a lot of new infection in this country, are we really tailoring
our prevention messages to fit in with current reality, and are
we continuing to invest in it? Anecdotally, people ask, "is
this still a problem?" We may not be getting the message
across in a way that is current to current realities, and that
means that prevention messages need to be as up-to-date with the
epidemiology as vaccines are up-to-date with the technology.
314. I would like to direct a few questions
about the Natsal survey. I found it very interesting, when I saw
the contrast between the first survey in 1992 and the follow-up
survey ten years later. Did you carry out both?
(Professor Johnson) I was involved in both. They were
carried out by
315. For the Department of Health?
(Professor Johnson) The first survey was funded by
the Wellcome Trust and the second survey was a grant awarded by
the Medical Research Council with funding from the Department
316. You cannot help but think that the 2000
survey paints a very different picture of sexual activity amongst
particularly young people. Things seem to have moved dramatically
in that time. For women, the age of first sex went from 21 years
to 16 years; and for men 17 years to 16 years. The number of lifetime
partners increased fairly dramatically for both men and women.
Numbers of people having concurrent sexual relationships has gone
up, and the proportion of men and women having anal sex. In all
areas it just seems that there is a dramatic change in what people
are doing. To what extent is that caused by differences in methodology
that were used? How comparable are the two surveys? Can we trust
them as being totally comparable?
(Professor Johnson) Can I comment on one point of
fact? You said that the age of first intercourse had declined
from 21 to 16 over ten years; it is actually from 21 to 16 over
50 years because we have seen a steep decline that has been going
on through the course of the century. In 1990, some of the people
we asked were 60 when we asked when they had first intercourse,
so we were going right back over 50 years.
317. So they are not directly comparable.
(Professor Johnson) In 1990 we were asking people
aged 16 to 59, so the 59-year olds would have been born in 1930;
so the oldest people in the first survey were born in 1930. The
second survey asked people aged 16 to 44 and was carried out in
2000. The oldest people in the 2000 survey were born in 1955.
The comparisons in The Lancet paper compared those aged
16 to 44 in the 1990 survey with those aged 16 to 44 in the 2000
survey; so they were the same ages at the time of the survey,
but they would have been born at different times. The question
is: are they comparable? They are comparable in the sense that
both surveys were undertaken using similar probability sample
surveys; that is, we aim to end up with a random sample of the
population. They were the same in that for the questions on which
we have made comparisons, identical wordings were used. They are
different to the extent that the second survey used computer-assisted
interviewing, and the first survey used pen and paper interviews.
In the first survey, we would have handed the respondent a booklet
in which they would have marked down the answers, privately in
their own time, but in their home, with an interviewer present
but not in view of what they were writing; and the answers were
put in a sealed envelope before being handed back to the interviewer.
On the second survey, the questions were on a laptop computer,
which was handed to the respondent, who tapped in the answers,
using the number pad, in the same way that you would get money
out of the bank. That second method we know, from a randomised
experiment that we did in the feasibility stage, results in people
completing the surveya greater completeness of data because
they do not skip questions. We could not establish that they were
more honest, in that we did not find different rates of reporting
sensitive behavioursalthough there is evidence of that
from other studies elsewhere. So we have reason to believe that
the methodology might improve people's willingness to report.
318. But it might be marginal.
(Professor Johnson) Yes. I think perhaps a more important
way in which people have been made more wiling to report is that
attitudes to sex have changed very substantially in the last decade.
People are much more accepting of homosexual behaviour and much
more tolerant. They are more tolerant of casual sex and so on.
In our own lifetimes we can think back to 1990. We talk about
things in a different way in 2000 than we did in 1990. On the
basis of that and the scientific evidence of the liberalisation
of attitudes, it would suggest to me that people may feel more
willing to report stigmatised behaviours than they were ten years
ago. We believe that the changes we observe are partly a result
of true changeand the evidence to back that up is the rising
STD rates and the other triangulation to other forms of survey
work suggesting the same trend. We believe that the magnitude
of the change is over-estimated in a sense because of the methodological
differences and the changing attitudes. However, I think the results
now should be giving us a more accurate picture of true behaviours
than ten years ago.
319. The answer is that probably society has
changed, but possibly not quite so dramatically as people may
suggest. As you say, there is a different culture. Has the rise
of clubbing, more prevalence of drug-taking, or anything like
that induced more risk-taking in terms of trends of what young
people do out of school hours?
(Professor Johnson) I cannot give you chapter and
verse on the extent to which these things have influenced the
behaviours, partly because we did not have that level of detail
in the first survey. We do have data for the second survey, which
looks at where people meet their partners and how long it is between
first meeting someone and having first intercourse with them.
That data is not fully analysed yet, but it is a very important
area of the points at which people might take risks.