Select Committee on Health Minutes of Evidence

Memorandum by Sigma Research (SH 101)


  1.  Sigma Research is one of the US only social research groups specialising in the policy and practice aspects of HIV and sexual health. Sigma Research is affiliated to the University of Portsmouth and based in South London. During the last seven years, Sigma has undertaken more than 50 research and development projects concerned with the impact of HIV on the sexual and social lives of a variety of populations. Our research includes needs assessments, audits, evaluations and service reviews funded from a range of sources. We have published more than 75 research-into-practice reports, journal articles and book chapters.

  2.  Sigma Research is the main research partner in CHAPS, the Community HIV and AIDS Prevention Strategy co-ordinated by the Terrence Higgins Trust and funded by the Department of Health. The CHAPS partnership undertakes targeted HIV prevention work with gay men and other homosexually-active men. As part of CHAPS, Sigma has been instrumental in producing and disseminating the Making it Count model for local commissioning of gay men's HIV prevention. Making it Count is endorsed in The national strategy for sexual health and HIV as a best practice model for national and local HIV prevention with gay men.

  3.  Since 1997, as part of CHAPS, Sigma Research has undertaken the National Gay Men's Sex Survey (GMSS). Undertaken annually, GMSS is the World's largest on-going HIV prevention needs assessment of gay and other homosexually active men, recruiting over 15,000 men in the latest survey in 2001. Sigma also undertakes the largest on-going national survey of the needs of people with HIV and undertakes survey work with African people with HIV.

  4.  Peter Weatherburn is the Director of Sigma Research and a Senior Research Fellow at the University of Portsmouth. He has worked in HIV and sexual health policy research (continuously) since 1989.


  1.1  Homosexually-active men (HAM) are the group at greatest risk of acquiring HIV infection in the UK. They constitute about 1.6 per cent of the population of England but bear an estimated 56 per cent of the burden of new HIV infections. Approximately 1,400 new HIV infections are reported to the Public Health Laboratory Service (PHLS) per year, giving an HIV incidence on par with gay men in San Francisco and New York. Gay men are 50 times more likely to acquire HIV infection than the rest of the population.

  1.2  Some of the factors contributing to HIV incidence are becoming more common thanks to successful interventions in other areas. The number of men acting on their homosexual desire appears to be increasing, as does the prevalence of HIV due to reduced mortality in people with HIV because of anti-HIV therapy. Men with HIV infection are sexually active for longer and an increase in well-being will be accompanied by an increase in sexual activity.

  1.3  Awareness of the on-going national CHAPS mass media campaigns is remarkably high (averaging about 50 per cent of all gay men in England). Awareness of small media (leaflets) and other HIV-related educational resources is less consistent and more dependent of voluntary sector infra-structure. The geographic availability of other HIV prevention interventions resemble the infamous "postcode lottery"—arising from a lack of voluntary sector infra-structure and from historic and continuing inconsistencies in Health Authority (now Primary Care Trust, PCT) commissioning. Overall, there are more opportunities in the gay population for sexual HIV exposure than ever before. This means that change in incidence is a poor indicator of the worth of current HIV prevention programmes.


  2.1  One of the original stated aims of the strategy was to develop a broader public health understanding of sexual health. However, it was ultimately structured to limit the meaning of sexual health to those aspects addressed by NHS clinical services. Although paragraphs 1.1 and 1.2 suggest the strategy will adopt a broad and inclusive definition of sexual health, this is quickly reduced to concern about infections and unwanted conceptions. In addition, while the proposed approaches to meeting people's HIV and unwanted pregnancy needs are chiefly educational and community-based, the strategy concentrates on describing the funding and infrastructure of clinical diagnostic and treatment interventions.

  2.2  This limiting of sexual health to the absence of infection/conception and the limiting of interventions to clinical NHS providers runs throughout the strategy and causes "blind-spots" and gaps which seriously limit its likely effectiveness. Below, we outline how this might be addressed during the implementation phase, especially in the Health Promotion and Commissioning toolkits that are promised in the strategy's Implementation plan. If the strategy's ambitious targets are to be achieved these toolkits must provide future PCT commissioners and health promoters with a template against which to assess and prioritise local need and deliver services.


  3.1  Health promotion (HIV prevention) is neither art nor a science. It is both far less exact than medical services, and far less mature a discipline. The strategy assumes that "prevention" = "information giving" and "services" = "clinical interventions". These assumptions lead to a belief that any provider of a clinical service is qualified to deliver any non-clinical prevention service. This is not the case and most prevention interventions require specific expertise. These skills and expertise must be acknowledged, valued and fostered if we are to collectively increase our impact on sexual health.

Defining HIV prevention as a discrete and highly specialised activity

  3.2  By adopting an inclusive approach to sexual health, the strategy fails to state unequivocally what constitutes HIV prevention and who should be concerned with it as a specific endeavour. Throughout the strategy, HIV prevention is confused with information provision. In turn, information-provision is confused with the methods used to achieve it (most notably outreach). Greater uptake of HIV testing is also championed as a panacea for preventing HIV infections on the basis of very little evidence and without ever articulating the process whereby it might serve to reduce the number of new infections.

  3.3  The health promotion toolkit needs to define HIV prevention and its purpose, scope and rationale. It also needs to specify key target populations and outline acceptable methods to increasing access to, and the quality, of HIV prevention and other sexual health interventions. That the specialism of non-clinical HIV/STI prevention be recognised, valued, and included in the levels of interventions, rather than described separately.

Financing and prioritising HIV prevention in wider sexual health provision

  3.4  It is widely recognised that the long-established ring-fence around HIV prevention funds has not prevented their misuse. When these funds have been used to address HIV prevention needs, they have often failed to address those populations most likely to acquire HIV infection in the future: namely gay men and Africans.

  3.5  The strategy eliminates the ring-fenced HIV prevention allocation and trusts that current changes in the NHS will improve HIV prevention services. In addition HIV prevention is "mainstreamed" with other sexual health services administered by PCTs out of their main financial allocations. It is our view that this can only exacerbate historic inefficiency and under-investment in HIV prevention, as well as existing inequalities in HIV infection, by:

    —  removing the very limited financial accountability that exists;

    —  substantially reducing the likely national spend on HIV prevention; and

    —  increasing already substantial competition for funds by placing HIV prevention in direct competition with other, less stigmatised, concerns such as unwanted pregnancy.

  3.6  There is a real and pressing danger that HIV prevention will be lost within broader moral and financial imperatives of PCTs.

Targeting groups at substantial HIV prevention need

  3.7  The strategy provides an opportunity for historically mis-allocated HIV funds to be further diverted away from those who will become HIV infected. Hence, it is feasible that the strategy will foster HIV incidence, not reduce it.

  3.8  The cessation of ring-fenced funding and the transfer of commissioning responsibility to PCTs has the potential to affect adversely the targeting and effectiveness of HIV prevention. The strategy conflates the causes of morbidity (sexually transmitted infections including HIV and "unwanted" conceptions) in one section, the conflated groups experiencing them in another, and finally puts all these needs in competition with each other and all other health needs for very finite funds. Because of the lack of expertise and/or prejudice amongst PCTs, "young people" will come to mean "heterosexual young women" who may become pregnant rather than "young gay men" who may get HIV.


  4.1  It was not helpful in this complex strategy, which will be implemented over very many years, to state specific research priorities or areas. These will inevitably change as the epidemic develops, as research is undertaken and published and as interventions become more focussed in areas of practice. The listing of potential research priorities was also at odds with the very welcome statement that the research agenda should be "identified by consultation".


  5.1  The Health Promotion and Commissioning toolkits announced in the Implementation action plan are urgently needed. They need to address fundamental flaws in the strategy that mean the current target of reducing new HIV infections by 25 per cent seems unlikely to be met.

  They should:

    —   Stress that while HIV prevention activity is probably best provided by specialists with health promotion experience, it is also a function of all sexual health services including primary care and specialist out-patient services (such as HIV and GUM clinics). Specialist training needs arise from this recommendation and will need to be addressed.

    —  Stress unequivocally that targeted HIV prevention activity is a necessary and vital part of every local sexual health strategy.

    —  Stress that HIV prevention is very cost effective even where it is only partially successful, given the costs associated with the treatment and care of people with HIV.

    —  Separate the targets of the strategy (rates of unwanted pregnancy, and the incidence of HIV, chlamydia, HPV, NSU, HPV, gonorrhoea and syphilis) from the priority groups that they affect. This involves stating specific priority target groups for each of the targets.

    —  State unequivocally that local HIV prevention activity should be guided by national patterns of HIV incidence and what is known of the existence of priority groups in local communities. Thus, as a general rule, interventions targeting gay men and African communities should take precedence over interventions targeting groups who are easier to access but at little risk of HIV such as "the general public".

  5.2  Finally, recognising that research priorities will change constantly, the Department of Health should set-up a forum where researchers, key policy and intervention practitioners, Departmental officials and key research funders meet on an on-going basis to develop and refine research priorities.

July 2002

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