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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy
Sexual Health In Scotland: Attitudes, lifestyles and the changing epidemiology of pregnancy, abortion and sexually transmitted infections
1. INTRODUCTION
1.1
This paper presents a summary of the findings from the Scottish sample of the 1999/2000 NATSAL survey (Macdowell et al 2002), compares these to the results of the 1990/91 NATSAL survey and places this in the context of the changing pattern of pregnancy, abortion and sexually transmitted infections in Scotland. It provides the background against which many of the recommendations within the proposed Sexual Health and Relationships Strategy are placed, both in terms of sex and relationships education and in clinical service proposals.
1.2 The full report of the 1999/2000 NATSAL study can be found at
www.healthscotland.com/hebs . Further details on sexually transmitted infections can be found
www.show.scot.nhs.uk/scieh and
www.show.scot.nhs.uk/isd. The latter website also contains information on conceptions and abortions.
1.3 In reading this paper, the following should be noted:
2001 is the most recent year for complete data reporting by the Information and Statistics Division (ISD) of the Common Services Agency, although some data is available for 2002 and is reported here - more recent epidemiological data has been provided by Scottish Centre for Infections and Environmental Health (SCIEH)
Unless specified, the data in this paper is derived from information provided on attendances at genito-urinary medicine (GUM) clinics in Scotland. This has its limitations. For example it does not include sexually transmitted infections (STIs) treated in other clinical settings - in particular general practice or family planning clinics - some data derived from the Continuous Morbidity Recording (CMR) system is included to provide an insight into the issue of GP consultation
Patients with HIV infection differ from most of those with other STIs in that infectious disease specialists treat the majority.
The NATSAL survey covered males and females aged 16-44 with many results being compared between those aged 16-29 and those aged 30-44
2. ATTITUDES AND LIFESTYLES AS REPORTED IN THE NATSAL SURVEY
Key facts
The median age of first intercourse is 16 for females and males: this is lower than the earlier 1990/91 NATSAL results (18 for females and 17 for males)
Sexual competence (based on variables relating to first intercourse: regret, willingness, autonomy of decision and contraception use) has increased among those aged 16-29, which included an increase in the use of condoms at first intercourse. Sexual competence declined as the age of first intercourse decreased
Men had more sexual partners than women, and were more likely to have more than one sexual partner at the same time
Pregnancy was cited as the most important reason to use contraception, the most popular of which were condoms and the oral contraceptive pill
Women were more likely to have accessed the medical profession for contraceptives than men
A substantial minority believed homosexuality is always or mostly wrong
Whilst sex before marriage was largely accepted, sex outside a regular relationship was not viewed positively across the Scottish population both young and old
Parents were not the main source of information about sexual matters for most young people
Those who reported learning about sex from parents or school were significantly less likely to report first intercourse before the age of 16 and more likely to report condom use when it did occur (whole UK sample)
Educational level, family structure, lack of discussion with parents and in some instances sources of information outside school/parent were associated with poorer sexual health outcomes
2.1
Learning about sex: Supporting
Paper 2 outlining the wider determinants of sexual wellbeing and Supporting
Paper 4 detailing sexual health and relationships education for young people highlight the range of ways individuals learn about sex. In summary, parents, schools, friends and the media were cited as the most common sources of information, although parents were less likely to be consulted compared to other sources. Those who did not cite parents or schools as their main source were less likely to use contraception at first intercourse.
Implications for the proposed Sexual Health and Relationships Strategy
Opportunities to deliver health promotion messages regarding sexual health should be maximised by everyone delivering sexual health education and services
Supporting parents and carers in being an information route on sex and sexual health should be key activity for health promotion and other service providers
Involving parents and carers in school based sex and relationships education is a key partnership in providing young people with accurate information about sex and relationships
2.2 More information on STIs, relationships, and contraception for all ages was a strong theme from respondents. More than half of male respondents wanted more on STIs (compared to 40% of females) whilst just under half of females wished increased information on feelings and relationships. Whilst there was little difference between males and females wanting help in saying "no", more women than men reported regret after their first sexual intercourse.
Implications for the proposed Sexual Health and Relationships Strategy
Sex and relationships education should include aspects of STIs as well as emotions and relationships
Further research is required to understand the feelings of regret experienced after intercourse to identify appropriate support to minimise this
2.3
Early heterosexual experiences and sexual partners: Those aged 16-29 reported greater sexual competence compared to those aged 30-44. In other words, they reported less regret following their first intercourse and mutual respect for sexual encounters. Younger respondents were twice as likely to use condoms at first intercourse whilst those aged 30 and over were more likely to report oral or no contraception.
Implications for the proposed Sexual Health and Relationships Strategy
Work is required to ensure that condoms are used consistently over a prolonged period in addition to oral contraception
The cost implications of condom use need to be addressed if increased use is to be encouraged
2.4 In general, men reported having one and half times as many partners as women during their lifetime and those aged under 30 had had more partners in the year prior to the study compared to those aged over 30. Around one in ten males and one in sixteen women had had two or more partners at the same time. Older men were more likely to have had same sex contact than younger men with the opposite being true for women, although this has not changed since the 1990/91 NATSAL study.
Implications for Sexual Health and Relationships Strategy
2.5
Pregnancy and abortion: a quarter of women reported parenthood before18: this is a similar result for the UK as a whole. Younger women were more likely to report early parenthood and more likely to report having had an abortion than older women. More than one in ten women said that they had had an abortion: 2.5% reported this occurring before age 18. This compares to 4% for England and Wales. A very small percentage of men under 29 (0.3%) and none of the older age group reported parenthood prior to age 18.
2.6 Around a third of men and women thought abortion was wrong whilst about one in five viewed it as being rarely or not wrong at all. This is a much higher response compared to England and Wales.
2.7
Ongoing contraception use: especially those under 30 reported the condom and oral contraceptive pill as most popular methods. About one in ten young men used withdrawal as a method of contraception. GPs and family planning clinics were the most preferred sources of professional advice for both men and women: around one in ten aged under 30 stated a preference for a dedicated sexual health service.
2.8 The main reason cited for using contraception was to prevent pregnancy. Only a minority reported the risk of infection as the reason for protection. Data on the number of people using both the condom and contraceptive pill was not collected, despite this being the most effective means of protecting against STI and unintended pregnancy when having intercourse.
2.9 The personal risk of HIV was seen as low: 4% of men and 2% of women. Injecting drug users and people with multiple heterosexual partners were perceived as being at greatest risk of HIV/AIDS. Around one in ten men and women had been tested for HIV with the most common reason for women to cite being pregnancy - routine antenatal HIV screening was introduced in 2003 but was available in some NHS board areas. Respondents perceived that the risk for male homosexuals was dependent on their use of condoms. Around one in four men and one in five women reported changing their sexual behaviour in response to HIV and STIs, particularly young men. The most common change reported was condom use.
Implications for Sexual Health and Relationships Strategy
Information on effective contraceptive methods and the importance of maintaining effective protection once in a relationship should form part of sexual health and relationships education and health promotion activities
Services should reflect the access and other needs of their target audience
National and local mass media communications should work together to raise awareness of the risks of STIs, including HIV and the realistic likelihood of transmission particularly among those embarking on sex with new partners (for example, younger people and the older " newly singles")
2.10
Attitudes to sexual relationships and experiences: A small number of respondents (3%) believed sex outside marriage was wrong. The majority of respondents, and particularly women and young people, considered that sex outside stable relationships as always or mostly wrong. One night stands were more accepted by men than women and younger people are more tolerant of one night stands than those in the older age group (although the gender difference was still visible). This supports the results from the Health Education Population Scotland (HEPS) survey.
3. CONCEPTIONS
3.1 The overall birth rate in Scotland is declining and will continue to decline in the next decade - a situation mirrored in the other UK countries. The provisional data for all and live births to end March 2002 confirms this: in terms of individual NHS Board areas, the Western Isles shows the highest rate with Greater Glasgow recording the lowest rate of births. The number of stillbirths recorded for Scotland as a whole has also steadily reduced: in 1976 about one in every hundred births was recorded as a stillbirth whilst this rate had been halved by 2001. Whilst there are variations across the NHS Board areas, particularly due to small numbers, the overall trend is in decline (see
Graph 1).
3.2 In terms of pregnancies among females aged between 13-19 years, the rate per 1000 women has changed very little in recent years: the 2001 rate of 43.3 per 1000 females is the same as that recorded for 2000. However, this masks a significant decline in the rates for those aged 13-15 years which peaked in 1996 at 9.5 per 1000 falling to 7.6 per 1000 in 2001. The equivalent rate of those aged 16-19 years was recorded as 71 per 1000 females.
Graph 2 gives the pregnancy rate for those aged 13 to 19 years over the period 1991 and 2001.
3.3 The picture across NHS Boards is also mixed. The latest data for 2001 identifies Borders as having the lowest rate of teenage pregnancy in females aged13-15 whilst Grampian has the lowest rate for those aged 16-19. By contrast the highest pregnancy rates for both age groups were seen in Ayrshire and Arran and Tayside NHS Boards. Dundee City Council had the highest pregnancy rate in those under 19, 63.1 per 1000 women aged 13-19.
Graph 3 shows the outcome of teenage pregnancy by age group at conception between 1991 and 2001.
3.4 The number of therapeutic abortions has changed very little in recent years. In 2002, the rate per 1,000 women aged 15-44 is 10.8, compared to 11.4 during 1998. Terminations by medical methods (49.8% in 2002) and performed at earlier gestational period (65.5% at less than 10 weeks in 2002) have been the most significant developments over the last ten years. There is also an increasing trend of terminations being performed on women aged 30 and over: 28% in 2002 compared to 22.4% in 1991. In 2002, Tayside and Lothian NHS Boards recorded the highest rate of terminations per 1,000 women aged 15-44 with Dumfries & Galloway and the Island Boards (Orkney, Shetland and Western Isles) having the lowest rates.
Graph 4 gives the rate of abortions by mother's age between 1968 and 2002.
3.5 Among 13-15 year olds, the delivery and abortion rates have remained fairly constant: 3.6 deliveries per 1000 and 4.0 abortions per 1000 females. In the older age group the abortion rate is much lower than the delivery rate, averaging 27 per 1000 women. However, since 1991, the proportion of teenage pregnancies proceeding to full term has changed, particularly in this older age group: in 2001 almost 42% of pregnancies miscarried or aborted. The proportion of pregnancies in those aged 15 and under failing to reach full term has remained fairly constant at around 52%.
3.6
In terms of births in areas of deprivation, there are 4-5 times the proportion of births to mothers aged under 20 in the more deprived groups compared to the least deprived over the period 1976 to 2002. This is in spite of total number of births in this age group nearly halved over this period. In the 20-24 age group the ratio of babies born in the least deprived areas to the number born in quintile five is approximately one to two, but this starts to reverse in the age group 25-29, and for the age groups 30-34 and 35-39, the ratio is two to one with little change in this proportion over the time period. Much the same sort of pattern is seen when all births are examined rather than just first births. This leads to the conclusion that delaying reproduction and having smaller families is a factor for all society.
Graph 5 shows the age distribution of first births by deprivation in 2002: this shows that women in the most deprived areas tend to have children about 12 years earlier than those in the least deprived areas.
Implications for the proposed Sexual Health and Relationships Strategy
Direct comparisons cannot be made with pregnancy rates in other UK countries as their data does not include miscarriages
More appropriate service options are required to respond to the increasing number of abortions in older women
Further research is required to ascertain the reasons behind the increasing termination rates in those aged 16-19
4. SEXUALLY TRANSMITTED INFECTIONS
Key Facts
New diagnoses of sexually transmitted infections have risen continually in the last 10 years
Diagnoses of chlamydia have more than doubled since 1995
New cases of genital herpes increased by 11.4% between 1998/1999 and 1999/2000: recurrence rates rose by 12%
Numbers of new cases of gonorrhoea dropped between 1984 and 1994 but have increased in last three years
Although cases of syphilis are rare, a series of outbreaks throughout UK (including Glasgow) in 2002 are causing concern
The most frequently reported STI in 1999/2000 was genital warts
The number of young people, gay and bisexual men, and some minority ethnic populations diagnosed with sexually transmitted infections is disproportionately higher compared to the general population
Improvements in HIV treatments have resulted in a greater number of people living with HIV requiring long term treatment
Gay men are at highest risk of acquiring HIV
Rising number of HIV infections being acquired through links with Africa and other high prevalence countries (for example Eastern Europe and Far East)
The number of injecting drug users who acquire HIV is steadily declining
Glasgow overtook Lothian in recording the highest number of new HIV diagnoses in 2001
Access to specialist sexual health services is becoming increasingly limited - the median time to first appointment in 2002 was 12 days for men and 14 days for women
9% of Scottish men and 13% of Scottish women reported having had an STIs in the 1999/2000 NATSAL survey: one in sixteen young women reported having been tested for chlamydia (compared to 1 in 77 young men)
Sexually Transmitted Infections: recent changes
4.1 An increase in the transmission and diagnosis of sexually transmitted infections signposts changes in high-risk sexual behaviour. STIs can have a significant impact on the short and long term health of both men and women. The capacity to bear children may be impaired and poor health outcomes such as pelvic inflammatory disease, ectopic pregnancy, cervical cancer and death may be a subsequent result. Health promotion and prevention activities, linked to the early diagnosis and treatment of STIs, can help prevent such complications.
Trends in Diagnoses
4.2 Diagnoses of acute bacterial STIs in GUM clinics have more than doubled in recent years and continue to rise each year. Between 1980 and 2000 all STIs for both men and women increased by almost 18%. Specifically:
First occurrence of genital warts increased from 4700 to 5433, recurrence rates increased from 1781 to 2382 between 1994 to 2000;
Chlamydia increased by 16% between 2001 and 2002 for all ages and 62% increase on that recorded for 2000
Genital herpes increased by almost 30% between 1992 and 2001
Gonorrhoea in males increased by 219% between 1992-94 and 2001-02
Graphs
6,
7 and
8 show trends in chlamydia, genital warts and genital warts between 1992 and 2000.
4.3 A number of NHS Boards have introduced screening and testing for these STIs following the publication of SIGN Guideline 42 which may partly explain the increased detection rate. However, due to the acute symptomatic nature of gonorrhoea and syphilis in particular, it is more likely that these new cases are associated with an increase in higher risk sexual behaviour.
4.4 As it is not possible to determine whether infections in men are occurring among those who have sex with women or those who have sex with other men. Analysing STIs in women can give a picture of the extent of infection among the heterosexual population. Moreover chlamydia infection rates are likely to under-report the true extent of infection given its often asymptomatic nature: increases are more likely to be due to changes in screening practice. However, the opposite is more likely for herpes simplex and gonorrhoea.
4.5 Between the early and late 1990s almost all of the increase in herpes simplex incidence occurred among females: the annual number of cases among males has hardly altered between 1992 and 2002 (SCIEH weekly report 2003, 37; 166-171). In 2002, Highland and Lothian report the highest incidence.
4.6 Not all STIs (such as chlamydia) have recognisable and/or long-term symptoms, which mean that they often go unrecognised. As part of its ongoing activities, the Healthy Respect demonstration project in Lothian tested a cohort of male army recruits and found that almost one in ten tested positive for chlamydia: similar results are being found from work targeted at young women. Many of those being diagnosed were unaware of their infection and therefore at risk of developing chlamydia related complications as well as potentially passing the infection on to current and future partners. In 2002, 71% of all chlamydia diagnoses were attributable to women: the highest incidences being seen in Lothian and Dumfries and Galloway whilst Lothian and Highland recorded the highest male incidences. Some of this increase will partly reflect local screening policies.
4.7 Among the heterosexual population, there has been relatively little change in the incidence of syphilis and gonorrhoea infections. Since 1990 there has been between 5 and 20 diagnoses of syphilis each year. Unlike genital herpes simplex and genital chlamydia infections, the majority of cases of gonorrhoea are male. Between 1992-94 and 2000-2002, there has been a 219% increase in diagnoses among males, due largely to transmission among men who have sex with men. Whilst the incidence of gonorrhoea among women across Scotland has remained static between 2000 and 2002, there are potentially significant regional variations are emerging. Lothian and Argyll & Clyde are on the increase whilst numbers in Lanarkshire and Highland are decreasing.
Implications for the proposed Sexual Health and Relationships Strategy
Increasing diagnoses of sexually transmitted infections reflect the increasing numbers attending GUM and family planning clinics, an increased prevalence of STIs in the wider community and increased testing following the SIGN guideline. These increasing demands place additional pressures on the preventive activities of specialist services (eg partner notification and counselling/support). This can mean that the holistic approach to sexual health may be lost.
Those at Greatest Risk
4.8 There are a number of groups within the population who, due to the risks they take in relation to their sexual behaviour, are particularly susceptible to infection and re-infection with STIs.
4.9
Young people, particularly teenage females. More than 52% of chlamydia cases diagnosed in 2002 were among young people aged under 25 (65% if extended to age 30). Of particular concern is the 66% increase in the diagnosis of women aged under 16 between 2001 and 2002. At a local NHS Board level, increases in chlamydia diagnoses greater than 50% were recorded in Ayrshire and Arran and Argyll and Clyde. In 2002 54% of infections from genital herpes simplex were for people aged under 30 years. In the same year, 67% of episodes of gonorrhoea infection among females occurred in those under 25 years: the corresponding rate for males was 35%.
4.10 The high number of cases detected in young people may be partly due to the SIGN guideline recommendation of testing this age group. There may be equally worrying trends in males and other age groups which are as yet undiagnosed.
4.11
Men who have sex with men. In 2002 there was an alarming increase in both infectious syphilis and rectal gonorrhoea among men who have sex with men: 79% of syphilis diagnoses (31 of 39) were reported for this group. The number of diagnoses in the previous two years for men who have sex with men was eight and less than five respectively.
4.12 There is a, though not as dramatic as syphilis, increase in gonorrhoea among men who have sex with men (as indicated through diagnoses of rectal infection among men). The majority of those infected lived in Glasgow and Lothian NHS Board areas: syphilis was found more in Glasgow and gonorrhoea more in Lothian. Thirty out of the 31 men diagnosed declared a total of 253 sexual contacts in the 3 months prior to diagnosis: only 18% of these contacts were subsequently traced successfully for treatment which highlights the extent of unprotected sexual intercourse amongst population and the huge potential for onward transmission. Significantly almost one third of these men were diagnosed as HIV positive.
4.13
Ethnic minority groups. Evidence from other parts of the UK has shown that bacterial STIs, particularly gonorrhoea is particularly high among the black Caribbean population. It is not yet known whether this is similarly the case in Scotland.
Implications for the proposed Sexual Health and Relationships Strategy
There is a lack of information about STIs and unintended pregnancy among black and minority ethnic groups. This masks the need for increased services (for example translation/communications, more same sex staff). Further work is needed to ascertain the extent of sexual ill health among BME communities and ways of promoting sexual wellbeing relevant for BME communities
4.14 Although risk taking in sexual behaviour is a key factor in STI transmission, other determinants may limit attempts to prevent the spread of disease. For example, high levels of asymptomatic transmission, ineffective partner notification measures, poor access to specialist sexual health services, psychosocial factors preventing individuals seeking treatment. It therefore follows that interventions targeted at preventing STIs should take account of an individual's behaviour as well as ability to access and use services appropriate to needs.
Implications for the proposed Sexual Health and Relationships Strategy
Inequalities in service provision are exacerbated in both rural and urban areas but for different reasons: high disease prevalence and increasing demand are particular factors faced by services in urban areas whilst poor access and overstretched staff compound the problems faced by rural services. Those in greatest need often have the poorest access to sexual health services, from primary care through to specialist services or may perceive their access to be poor or not appropriate to their needs, for example young people or men who have sex with men. This means that there is no single solution to meeting the sexual health agenda in Scotland.
Trends in HIV infections
4.15 A range of influences affect the incidence and transmission of HIV infection within the population: these include changes in sexual behaviour, the uptake of HIV testing and subsequent treatment, service use, patterns of injecting drug use, mother to child transmission and individuals importing infection from areas of high prevalence.
4.16 Despite advances in treatment, HIV is still an avoidable communicable disease, it involves high treatment and care costs, results in significant and long term morbidity and ultimately death. It may also take a long time before symptoms emerge and diagnosis is made.
4.17 It is estimated that around one third of HIV infected people have not yet had their diagnosis confirmed: up to March 2003 around 3634 HIV diagnoses had been made with between 750 and 1500 estimated to be undiagnosed.
4.18 The introduction of highly active anti-retroviral therapies has had a significant impact on HIV diagnosis and on AIDs-related deaths. This has also shows been a fall in number of AIDs cases up to 2000 mainly as a result of early diagnosis and improved treatment: the upward trend shown in 2001 and 2002 may represent problems of side effects, compliance, resistant strains and late presentation especially among those from abroad and will require careful monitoring to ascertain whether this can be reversed.
Implications for the proposed Sexual Health and Relationships Strategy
Responding to the increasing need for anti-retroviral medication for HIV might jeopardise the funding for other HIV/STI prevention measures
The ringfenced allocation of HIV monies to NHS Boards should be reviewed to assess its effectiveness in meeting the increasing costs of HIV treatment and care
Those at greatest risk
4.19 Men who have sex with men are the group at highest risk of acquiring HIV in the UK and this picture is no different in Scotland. Figure x shows the data for the period 1990 to 2002: in this last year the number of new HIV diagnoses increased, around 18% having acquired their infection abroad. It is not known whether this increase is due to increased testing, an overall increase among men who have sex with men or due to an increase in imported HIV acquired infections. Until 2001 it looked as if there was a declining incidence among this group: this will only be confirmed through an analysis of data from further years although an increase in HIV would be in line with similar increases in gonorrhoea and syphilis among this population.
4.20 The prevalence of HIV infections in other population groups is varied. Since 1987 a declining trend in HIV diagnosis among injecting drug users has been offset by increases among heterosexual men and women, especially those who have acquired their HIV abroad (around 9% prevalence). In 2002, this increased by 76% and for the first time since testing began, the number of new diagnoses in the Glasgow NHS Board area superseded Lothian. Nevertheless HIV is still relatively uncommon among the general heterosexual population in Scotland (around 0.1% prevalence).
Implications for the proposed Sexual Health and Relationships Strategy
The increasing number of HIV infections acquired abroad means that services must be responsive to the different needs of the populations served, including needs related to culture, language and sexual orientation.
4.21 Whilst there are low numbers of infections being reported among the indigenous Scottish population and injecting drug users, the risks are greater than ever. With the Scottish HIV-infected population increasing by at least 100-200 per year, and with increasing high-risk behaviour, the potential of exposure to HIV through unprotected sexual intercourse is increasing. Moreover, as the sharing of injecting equipment remains high among drug users, they are also at increased risk of acquiring HIV and hepatitis C virus through this route.
Implications for the proposed Sexual Health and Relationships Strategy
Timeous and accurate recording and reporting of disease patterns among populations at risk is essential at both national and local levels
Needle exchange programmes should be sustained so that the potential for blood borne virus transmission among IDUs and their partners can be minimised
4.22 Mother to child HIV transmission can be dramatically reduced by treating the mother, caesarean section and the avoidance of breastfeeding (from one in four to less than one in fifty). Since April 2003 all NHS Boards have introduced the offer of HIV testing as part of routine antenatal screening programmes. Whilst the number of children becoming infected with HIV is small in Scotland, the capacity of services to respond to the needs of such children and their families should not be underestimated.
4.23 In 2002, the prevalence of HIV among pregnant women was 5.8 per 10,000 which is almost double the rate recorded in the mid to late 1990s. Considerable increases in the prevalence among pregnant women in Tayside and Greater Glasgow NHS Board areas were recorded. The reasons for this increase are not clear: it may reflect the overall increase in imported HIV infections as data over the last three years reflects an increase in this patient group. Monitoring of future infections will help confirm/reject these suspicions.
GUM Activity
4.24 In year 1999/2000, attendances at GUM clinics by all age groups increased by 5% over the previous year: attendances by women increased fourfold compared to males. Attendances by 15-19 year olds increased by just over 10% and accounted for almost 13% of all attendances: more than twice as many young females attended compared to young males: by contrast attendances in those aged under 15 dropped. The over 35 age group comprised almost a quarter of all attendances with twice as many males attending as females.
Graph 9 shows the age distribution of patients seen at GUM clinics in 1999/2000.
4.25 The availability and accessibility of GUM clinics affects the number of patients attending from different NHS Board areas. Some NHS Board areas have very limited access to GUM services (for example island or remote rural areas); some patients prefer to use services in other areas to assure anonymity. Some patients may prefer to see their GP if there is a long way to go to attend a GUM clinic although some GPs may not provide these services. Differences in the rates for each NHS Board will also reflect actual underlying differences in local disease patterns -
Graph 10 shows the STI and Non STI rate for local populations aged 15 to 64 years in 1999/2000.
4.26 In 1999/2000 Grampian, Lanarkshire and Tayside GUM services experienced the greatest increases in new attendances whilst those with no full time GUM service had the lower rates (Borders, Dumfries & Galloway and island areas).
4.27 Patients attending GUM clinics attend from a variety of conditions, not all of which are STIs. The types of infection diagnosed and treated at GUM clinics have changed in recent years. As shown above these reflect changing sexual behaviour, treatment effectiveness and expansion of clinical expertise within GUM departments. In particular the latter includes the management of patients diagnosed with HIV and AIDs and partner notification. In relation to partner notification, the number of cases diagnosed following initial contact has increased for both chlamydia and gonorrhoea.
Tables 1 - 3 show the contact, incidence and prevalence rates by gender and age group for year ending March 2000.
4.28 General practitioners may also treat STIs. Using the CMR system the following can be seen:
Genital herpes: the pattern mirrors that of GUM clinics with comparable age structure and higher incidence in females. A significant proportion is likely to be referred or encouraged to attend GUM clinics
Genital warts: the data suggest that a number of patients consult their GPs more than once with this condition, indicating that many are treated within general practice
Chlamydia and Gonorrhoea: there is a low rate of chlamydia diagnoses compared to gonorrhoea. This may reflect the recording requirements of having a diagnosis on consultation and it takes several days to diagnosis chlamydia. Those with chlamydia might be classified with gonorrhoea until verified by the laboratory results.
5. Conclusion: Measures to respond to the impact on existing sexual health service provision
5.1 Recent increases in high risk sexual behaviour, rising STIs and HIV diagnoses, linked with sexual health promotion and the ability to self refer to some services has led to increased service uptake but often without the necessary additional resources. There is some evidence that access to services is inconsistent, service provision is variable and at times unco-ordinated with some staff providing a service for which they are inadequately prepared/resourced.
5.2 Poor access to services reduces the effectiveness of preventing and managing STIs. People at increased risk tend not to seek timely treatment and may continue to spread their infection. Early and effective treatment of disease should be the primary goal of STI control.
5.3 The proposed tiered service approach (as set out in Supporting
Paper 5A) is intended to help improve access to services at the most appropriate point for the individual in need. This must, however, be supported through adequate resourcing, professional skills development and data surveillance. The proposed Sexual Health and Relationship Strategy recommends the following range of actions to support the detection and management of sexually transmitted infections:
Knowledge about sexual behaviours and sexual health through school based sex and relationships education, lifelong learning and mass communications
Population based screening for all women under 25 and targeted screening for males
Increased HIV testing within GUM services
Targeted interventions for population groups facing the greatest barriers to sexual ill-health
Sustaining and improving HIV and STI surveillance
Development of professional standards
Development of competency based programmes to equip a range of staff to provide sexual health services
In addition, the proposed Sexual Health and Relationships Strategy recommends enhancing current population surveys to include specific sexual health aspects so that the views and attitudes of the general population can be tracked alongside data on service uptake and delivery.
September 2003
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