Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 300-319)



  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.

Sandra Gidley

  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.

Dr Maysmith

  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 is common?
  (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 of that.

Jim Dowd

  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 STIs—that 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 epidemic—and 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 board—gay men and African communities—those who have become infected by whatever route—access 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 it—is that right—and therefore that complicates the issue? It is easy to be gay in London than anywhere else in the country—one knows that—we 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 community—I hesitate to use the pejorative term—but 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 the world.
  (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 convergence—there 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 and STIs.

  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 life—it 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 inevitability—it was just a question of "when", but because of improved treatment and therapies, that is not now the case.
  (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.

Andy Burnham

  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 of Health.

  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 survey—a 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 behaviours—although 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 change—and 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.

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