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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy

Minimising unintended pregnancy and managing sexually transmitted infections (including HIV)

1. Introduction

1.1 This paper highlights the review level evidence and practice based evidence underpinning the recommendations contained in the proposed Sexual Health and Relationships Strategy targeted at managing sexually transmitted infections and reducing unintended pregnancy. This complements the other supporting papers linked to the Strategy and in particular Supporting Papers 5A and 5B which highlight other aspects of clinical service provision.

2. Background

Sexually Transmitted Infections (STIs)

2.1 STIs impact unequally on certain population groups who already face inequalities in relation to their sexuality, ethnicity and gender. However, the number of new diagnoses and repeat diagnoses with STIs is ever increasing and is at record levels (see Supporting Paper 1). This places increasing demands on service provision, resulting in longer waiting times. There is no clear or single explanation for the sharp rise of recent years: evidence does not exist to suggest that changes in sexual behaviour are the only cause - failure to practice safe sex and complacency may be more plausible answers. Whilst most females take the pill or emergency contraception to prevent pregnancy, evidence suggests that they and their partners are not using condoms either at first sexual encounter or long term in a stable relationship (Macdowell 2002). Reddy (2002) found that where young people said they would not seek contraception if parental notification was required, this would not lead to increased condom use among the same young people. This is in spite of condoms being an effective way of preventing STIs (beyond abstinence). Barriers to their use appear to be lack of knowledge, skills for appropriate use, culture issues, gender inequities and in some instances prohibitive cost. Initiatives developed in response to this include C-card schemes for young people, free availability in premises used by gay men and young people.

2.2 Promoting positive sexual health through sexual health promotion is under-recognised and under-valued to date. The proposed Sexual Health and Relationships Strategy attempts to raise the profile of sexual health promotion and for all practitioners involved in sexual and reproductive health care to take a proactive approach to sexual health promotion. The evidence relating to educational or behaviourial interventions in relation to STI prevention tends to be very broad or focus on particular target groups (Grunseit 1997, Kirby 2000, McKay 2000, Peersman et al 1996, Shepherd 2001 and Stephenson 2000). However, the general conclusions drawn from this evidence point to:

• the importance of the provider or individual delivering the intervention (for example, teachers, health promotion specialists, clinical staff and peer educators),

• the setting in which the intervention takes place (formal education settings, community setting and clinical setting) and

• the method used (for example one to one learning/counselling, group learning/counselling and media campaigns).

2.3 For interventions to be effective, these should include the following features:

• the use of theoretical models of behaviour change (McKay 2000),

• the provision of basic accurate information (Kirby 2000). Wong (1995) found that although information is often insufficient by itself to effect behaviour change, it is necessary and important for STI prevention programmes to provide accurate comprehensive information and allay misconceptions before individuals can take actions to change behaviour

• skills development, motivation building and attitude change (Shephard et al 2001)

• specific behavioural skills training including refusal skills and safer sex negotiation as this helps people build their sense of competency (McKay 2000, Kirby 2000)

• detailed understanding of background behaviours, beliefs and risk perceptions of target groups. Kirby identified age, sexual experience and culture being important issues (Kirby 2000) whilst Shephard et al (2001) and Peersman et al (1996) identified gender as a key issue.

• Use of peer educators, particularly for adolescent audiences (McKay 2000) - although Peersman et al (1996) contend that their effectiveness was yet to be demonstrated. Mellanby et al (2001) conclude that it may be more appropriate for adults to deliver factual information with peer-leaders concentrating on the social factors related to health

• Narrow focus on reducing specific risk taking behaviour such emphasis on condom use rather than abstinence (McKay 2000)

• Of appropriate duration, for example to have sufficient time to ensure all components implemented (McKay 2000, Kirby 2000).

2.4 In summary, if an intervention is to be successful, it needs to be tailored to the needs of its specific target group which in turns involves a "needs assessment" in each new setting so that an understanding of what the target group think, believe and need is developed.

2.5 Fleming and Wasserheit (1999) suggest that STIs, including HIV, are more easily transmitted from men to women than vice versa. Hart et al in their systematic review of the effectiveness of interventions to prevent STIs/HIV in hetereosexual men could only find behavioural and/or social interventions rather than those aimed at reducing morbidity.

2.6 There are no comprehensive statistics on STIs, HIV, teenage births or abortions among black and minority ethnic communities (BME). For births, information is collected on the nationality of the mother but this does not identify the BME community to which they are related. Whilst moves are underway to improve ethnic related information in terms of service uptake and epidemiology, its absence causes problems in understanding the extent of sexual ill health among BME communities and setting targets and indicators that are relevant for such communities. There is some evidence to suggest that some BME populations are more at risk of STIs or teenage pregnancy compared to others but not enough is known - this needs to be addressed in service provision.

HIV

2.7 Much of the report of the HIV Health Promotion Review Group (Scottish Executive 1999) is relevant to sexual health in general and in relation to those at risk of acquiring HIV, for example gay men, men who have sex with men, partners of people with HIV and so on. Some progress has been made, such as antenatal testing and counselling but more progress is required.

2.8 Evidence indicates that the needs of individuals with HIV and their partners are not being addressed as comprehensively as they should be. There is a recognition that HIV carries particular risks and is a global pandemic likely to affect Scotland increasingly: the number of newly diagnosed heterosexual patients (both males and females) has overtaken gay men and injecting drug users for the first time and estimates suggest that nearly half of all such infections are undiagnosed. For some people, treatment is started late mainly due to late presentation and subsequent diagnosis (BHIVA audit, 2002). Two thirds of HIV infected persons who attend a GUM clinic and who are undiagnosed prior to clinic attendance do not undergo named HIV testing at the clinic and thus remain undiagnosed (D Goldberg, 2003). The long term aim should be to undertake increased HIV testing to detect undiagnosed infection at all tiers: as a pre-requisite there should be widespread awareness that negative HIV tests should not be reported to insurance companies.

2.9 Close surveillance of the population groups being newly diagnosed should be used to monitor the movements of newly identified at risk population groups (for example asylum seekers). Evidence indicates secondary prevention interventions involving, for example, individual counselling and testing, one to one peer support, free/subsidised condoms, multiple component motivation and skills education and involving users in service design can be effective when targeted at specific groups (drug users, men in workplace and clinic attendees) at reducing social/behavioural practice (Elwy et al (2002), Ellis and Grey (in press)).

Unintended Pregnancy

2.10 Supporting Paper 1 provides data on conceptions and terminations. The latter is usually used as a proxy for unintended pregnancy, particularly in young people. It is suffice to say that the UK is second only to the US in having the highest rate of pregnancies among young girls aged 19 and less in the world (UNICEF, 2001): this equates to a rate of 30 births per 1000 compared to the lowest rate of 7 per 1000. Whilst parenthood can be a positive and life enhancing experience for some, it may have negative impacts for other young people and their children, some of which are identified in Supporting Paper 2 outlining the wider cultural and social factors influencing sexual health. Adverse health outcomes can include anaemia, urinary tract infections (Konje 1992) and low birthweight babies (Miller et al 1996, Botting et al 1998).

2.11 Whilst much of the evidence on interventions on unintended pregnancy focus on young people, there will be some lessons to be learnt for those outwith their teens. School based sex and relationships education, particularly linked to contraception services, youth development services, community based education and the inclusion of parents in information and prevention programmes have been shown to help in reducing teenage pregnancy (NHSCRD 1997, DiCenso et al 2002, Cheesborough et al 1999, Franklin et al 1997, Grunseit A 1997, Kane and Wellings 1999, Kirby 2001, Peckham et al 1996).

2.12 In their evidence review of effective interventions on reducing teenage pregnancy and parenthood, Swann et al (2003) identified the following characteristics of services and interventions:

• Focus on improving contraceptive use and at least one other behaviour likely to prevent pregnancy and/or STI transmission

• Long term services and interventions

• Focus on high risk groups and working through opinion leaders and peer educators

• Services which are accessible, for example in terms of location, staff attitude, opening hours and confidentiality

• Encouraging an open and non judgemental discussion about sex, sexuality and contraception

• Inclusion of personal skills development such as negotiation and refusal skills

• Having a multl agency approach and working with communities

2.13 Evidence also suggests that good antenatal care, parental, psychological, social and educational support may help improve health and educational outcomes for young mums and their children (NHSCRD 1997). There are however, a number of areas where little or no evidence is available to demonstrate effective interventions: these include interventions aimed at those facing the greatest barriers to positive sexual health (for example looked after young people, those excluded from school), young men and the links between deprivation and teenage pregnancy. Supporting Paper 2 gives more detail on these and other areas identified by the proposed Sexual Health and Relationships Strategy.

2.14 Providing pregnant mums and teenage parents with increased opportunities to continue their education can give them the skills to gain future employment: this is a central pillar of the Teenage Pregnancy Strategy south of the border (SEUTP, 1999). Limited access to appropriate childcare does hinder plans for such opportunities although there are some promising practice examples in Scotland (Raymond in HEBS, 2002)

2.15 Fullerton (HEBS, 2002) states that there is currently little reliable UK evidence which identifies interventions to prevent unintended pregnancies among teenagers. Nevertheless, evidence is available to suggest that creative programmes, whether designed to prevent teenage pregnancy or support teenage parents are more holistic in approach and aim to address some of the identified factors associated with risk. This highlights the need for multi-component approaches aimed at preventing pregnancy and/or poor outcomes associated with unintended pregnancy.

3. Measures to Respond to Sexually transmitted infections and Unintended Pregnancy

Contraception Provision

3.1 Accessibility to, and uptake of, the full range of contraceptive methods varies widely throughout Scotland, as does the quality of service provision. Community-based family planning clinics are a source of specialist knowledge whilst general practitioners have tended to remain generalists: there is no mandatory training requirement for general practitioners to update knowledge and skills in relation to contraception once they have qualified. This may result in more referrals than necessary to specialist clinics. In contrast, family planning practitioners must acquire professional specialist qualification and re-accreditation at regular intervals. This has led to a situation where GPs can prescribe contraception but may not have the expertise to fit them and where family planning clinics have the expertise but no funding for the devices. It will be for the Lead Clinician in each NHS Board area to assess services provided against the required competencies to meet agreed clinical standards and to ensure that practitioners address any skills deficit through training programmes (see Supporting Paper 5A).

3.2 Feedback during the Strategy's engagement process indicated that individuals might not know what contraceptive services were available until a consultation was made or knew of the strongly held views of practitioners in relation to contraception and/or the circumstances in which this would be made available. This may result in individuals not seeking contraception. Where service providers do not provide the full range of contraception that might be required by their patients, they must make this known in advance through information leaflets, practice booklets and to helplines such as NHS 24. In addition, individual patients should be referred to alternative accessible services if their requirements cannot be met at first consultation.

3.3 Research carried out in France (Bajos 2003) found that one in three pregnancies was unplanned with half of the women subsequently deciding to have an abortion. Whilst failure to use contraception properly was cited as the main reason for pregnancy, many women reported not knowing why their contraception had not worked. This research demonstrated the mismatch between a women's contraceptive needs, particularly over their life course and the methods they use. A similar response is likely to be found in Scotland. In addition, evidence on contraceptive uptake by young people indicate that young men in particular have low levels of knowledge about reproduction, time limits and safety of contraception (including emergency contraception) and contraceptive service availability (NHSCRD 1997, Graham et al 1996). It is therefore essential that to avoid unplanned pregnancies, men and women should be made aware of all the contraceptive choices available and that professionals acknowledge and take into account all the factors that impact on effective contraceptive use, such as lifestyle, age and type of relationship. The proposed Sexual Health and Relationship Strategy's intent of providing two choices for individuals to access services should help with this disparity in terms of contraception.

Condoms

3.4 The Strategy's Reference Group was pleased to note that many Health Promotion departments provide condoms to a range of access points free of charge - this includes general practices, local drop-in services, services for at risk populations such as LGBT, commercial sex workers, men who have sex with men and local community facilities. However, feedback from the engagement process suggests that this is not consistent across Scotland.

3.5 Feldblum et al (1995) demonstrated the efficacy of consistent and correct condom use in preventing the spread of HIV and STIs: Weller (2001) found that consistent condom use was associated with an 80% reduction in risk of heterosexual transmission of HIV. Despite this levels of condom use remain low among both the general population and those with high risk behaviours. The findings of the NATSAL study indicated that condoms were used to prevent pregnancy rather than to prevent sexually transmitted infections and in younger age groups (MacDowell 2002). Myer et al (Cochrane Review 2003) in developing their review protocol identified availability and accessibility and being able to use condoms effectively as key factors that act as barriers to prevent condom use during sexual intercourse. Abdool Karim et al (1992) found that the negative attitudes of health care providers might prevent uptake of condoms provided through health facilities, affecting especially young people. Condoms which are sold commercially may be price outwith the pocket of may potential users. The proposed Sexual Health and Relationships Strategy recommends that condoms should be freely available to both males and females. O'Reilly and Piot (1996) highlighted the value of structural interventions such as legislative changes in helping accessibility to condoms in other countries. For example Thailand's "100% condom" program aimed at sex workers has resulted in changes in sexual behaviour and declining incidence in rates of both HIV and STIs (Nelson et al 1996, Celentano et al 1998). Lamptey and Price (1998) demonstrate the value of linking social marketing ventures with condom promotion activities: successful projects have included exchanging coupons for condoms (Witte et al 1999, Dahl et al 1999), distribution to high risk groups such as sex workers (Albert et al 1998) or young people (Alstead et al 1999) or where high risk sexual contacts take place (Egger et al 2000), bars and other places.

3.6 Knowing how to use a condom and its effectiveness in different circumstances is crucial. Gardner et al (1999) suggest that awareness of male condoms as a simple prophylactic device is closely related to knowledge of HIV and AIDs. Albert et al (1995) showed that commercial sex workers who used condoms regularly reported low rates of condom slippage or breakage suggesting that experience and practical knowledge may contribute to more effective condom use, which supports the findings of Peltzer (2000). This has implications for sex and relationships education in schools and sexual health promotion activities across the lifespan.

3.7 Even with access and practical knowledge of condoms, use is very dependent on the participation of both sexual partners. Reduced sensation, latex allergies and perceptions of lack of trust are reported as reasons for non use (Myer et al, 2002). Economic and gender imbalances between men and women, are documented as a major barrier to negotiating condom use, for example by commercial sex workers (Varga 1997).

3.8 Elwy et al (2002) examined interventions aimed at preventing STIs and HIV among heterosexual men but could not identify a single method as being effective in all situations aiming to change behaviours, increase knowledge or measure an intention to change. This supports the view that interventions must be targeted and be context-specific as found by Myer et al (2002), Wang et al (2000) Kim et al (1997) and Kirby et al (1994). Examples of promising practice were highlighted during the Strategy's engagement exercise: these include free access to condoms and advice and provision of nurse-led contraception service under patient group directions at young people's drop in clinics, free emergency contraception through community pharmacies, C-card schemes in Lanarkshire and Lothian and distribution of free condoms to health centres, NHS premises, community facilities and locations used by those most at risk of unplanned pregnancy and STIs. A project in Fife offers free pregnancy testing, free condom supply and counselling on STIs as well as free supply of emergency contraception located in community pharmacies. The suggested benefits identified in the interim findings include improved access to contraception, particularly in more rural areas, potential reduction in teenage pregnancy rate and rates for other age groups (personal communication, Cath Brunton, May 2003). Five per cent of those using the service were under 16: those aged 16 to 20 were the biggest users followed by 21-30 age group. More than half of users expressed satisfaction with their experience of the project. The Right Medicine (Scottish Executive, 2002) foresees this type of activity being developed by other community pharmacies in the future.

Termination of Pregnancy (medically or surgically induced abortion)

3.9 Although one of the aims of the proposed Strategy is to reduce unintended pregnancies, it would be naïve to think that such pregnancies would never happen or that termination of pregnancy would be unnecessary. Feedback from the engagement exercise indicated that teminations currently account for more than 25% of gynaecological workload: around one in four women who have had an abortion will have a second one. Young people are particularly likely to make mistakes with contraception and pregnancy rates among young women are a cause for concern. In a study of unplanned pregnancies, Pearson (Pearson et al 1995) found that 80% of young people used contraception at the time of conception whilst a GP based study suggested that more young people who conceive do consult for contraception before that became pregnant (Churchill et al, 2000). Unwanted pregnancies among women aged between 20 and 30 years represent a quantatively much larger problem as demonstrated in the rate of abortions for this age group. Supporting Paper 1 sets out the statistical data relating to abortions.

3.10 Tabberer et al (2000) explored the factors influencing a young woman's decision on whether or not to continue with a pregnancy. Few families had discussed abortion, no mention was made in school sex and relationship education (SRE), few sources of impartial advice and counselling particularly in the 7 to 14 week gestation period were available and the context in which the pregnancy occurred was important, for example as a result of a one night stand, or already having a child. These need to be addressed by those involved in SRE and by service providers. Consideration should also be given to the development of a target aimed at minimising repeat abortions. Early indications from research in Lothian suggests a range of factors that predispose women to have more than one abortion, for example low income, singleton, influence of partners and peers. Followup at 16 weeks gestation found no significant difference between the two cohorts. (personal communication, Anna Glasier)

3.11 There needs to be a safe a, consistent and supportive environment to respond to the needs of women requiring such services. Services should assess their current provision against the guidance produced by the Royal College of Obstetricians and Gynaecologists on the Care of Women requesting induced abortion (RCOG, 2001). If this guidance was included in clinical service standards, the quality and consistency of abortion services would be improved.

3.12 Recent audits indicate that women do not appear to have problems accessing abortion services, although feedback from the engagement exercise suggests that there may been hidden access issues - for example, a reluctance by health practitioners to refer women for termination might mean that services are accessed at too late a stage for intervention. Lack of anonymity in more rural areas was also cited as a potential barrier. Whilst acknowledging the inconsistencies regarding gestation limits across Scotland and the restrictions placed on potential service expansion by legal requirements, the Reference Group considered that women should not have to wait longer 3 weeks to access termination services from initial consultation. This will help reduce the risk of potential complications.

3.13 The way abortion services are provided also poses problems. Hospital gynaecology services are combined with obstetric services with the result that the labour ward requirements tend to be given priority. This can often result in a conveyor-belt approach with little time or effort devoted to preventing repeat abortions. Follow up consultations and support post abortion also appears to be problematic: it is estimated that around one in two women will not attend their follow up consultation (personal communication, Anna Glasier). To address this, the proposed Sexual Health & Relationships Strategy recommends that before being discharged from hospital, women who have had an abortion should have their contraception needs addressed and initial supplies provided.

Partner Notification (also known as Contact Tracing)

3.14 Failure to treat partners may be a common cause of "treatment failure" of chlamydia infection (Gibson and Mindel 2001). International evidence indicates that partner notification is effective as a means of newly detecting infections and that provider referral generally ensures that more partners are notified and medically evaluated than self referral (Macke and Maher 1999, Mathews et al 2001). Oxman (1994) concluded that partner notification was more effective for HIV/AIDs than for STIs. However, all these studies suggest that offering patients a choice might be the most appropriate practice to follow.

3.15 Mathews' systematic review (Cochrane Review 2001) also found that when used in conjunction with prompt laboratory testing and treatment and use of sexual health advisers, partner notification can help:

• Interrupt disease transmission and eliminate symptomatic infection, both of which can have long term health implications

• Identify individuals with asymptomatic infections

• Identify individuals with new HIV infection

• Promote risk reduction strategies for avoiding sexually transmitted infections

3.16 In addition, there was moderately strong evidence that the number of partners presenting for medical evaluation was best achieved through providers leading the referral process rather than patients taking responsibility. Limited success was achieved through nurse-led health education supported by lay counsellors (Mathews et al 2001).

3.17 The engagement exercise revealed that partner notification varied throughout Scotland, both in terms of consistency and standards of practice pursued. Although it is the primary remit of sexual health advisors working in GUM departments, in some areas family planning nurses may take the lead. The recent review of SIGN guideline on chlamydia indicated that a significant number of practice nurses were involved in simple partner notification with support from named sexual health advisors.

3.18 To achieve consistency in partner notification, the Society of Sexual Health Advisors have produced guidelines for use by secondary and primary care staff. There is however a current problem with the determination of the action taken by an individual following contact tracing due to the lack of data tracking across different service providers. The proposed Sexual Health and Relationships Strategy proposes that further work should be undertaken on a range of data collection issues, including the determination of partner notification outcome.

4. Clinical Service Targets for STIs

4.1 Chlamydia is the commonest treatable STI with the biggest potential in terms of health gain if diagnosis and treatment were optimised. It is largely asymptomatic but if left untreated can have severe long term consequences for women such as pelvic inflammatory disease (PID), ectopic pregnancy and infertility. Even with the limited available data on prevalence, chlamydia is higher than gonorrhoea and syphilis in all NHS Board areas in Scotland.

4.2 Testing is also possible in a range of different settings, for example primary care, family planning, GUM services, specialist voluntary sector services as well as other hospital based services, such as obstetrics and gynaecology and urology. Evaluation of the Healthy Respect pilot of chlamydia postal testing kits will identify whether this is a useful alternative for access to testing, particularly for young people and for rural areas.

4.3 For more general practices to undertake such testing and subsequently make accurate diagnoses, they will need access to microscopy. However, some practices might not wish to pursue this. As a alternative, the Sexual Health and Relationships Strategy proposes the piloting of an STI diagnostic kit to diagnosis chlamydia, gonorrhoea and trichomonas: this would involve laboratories undertaking microscopy of urethral discharge from men or vaginal discharge from women with samples being sent on a glass slide in a plastic container. Piloting of this kit in one urban and one rural practice should enable evaluation of acceptability by patient, referrer and laboratory services as well as identifying any potential cost savings associated with a one-stop test.

4.4 Evidence clearly shows that screening asymptomatic women can reduce chlamydia infection and the incidence of PID. However, such targeting only fosters gender inequalities and reinforces the abrogation of men's responsibility for sexual and reproductive health care, (Duncan and Hart 1999). SIGN Guideline 42 recommends testing of asymptomatic "high risk" men (more restricted compared to its recommendations for women). Duncan et al (2001) identified the need for better information about chlamydia infection so that anxiety can be allayed following a positive diagnosis and treatment followed up following partner notification. These issues need to be addressed as part of any national roll out of the suggested targets set out in Box 1.

4.5 A recent study suggested that a 3% prevalence could be taken as indicative of cost-effectiveness of screening, if age was used as a selection factor and DNA based tests were used in urine samples. If this was adopted, it would mean that a target of testing everyone up to the age of 30 should be set (Honey et al 2002). However, the proposed Sexual Health and Relationships Strategy suggests a more pragmatic stepped approach in accordance with what is achievable in terms of current resources as set out in Boxes 1 and 2. This builds on the intention of SIGN Guideline 42 but allows resources to develop capacity in an incremental manner and in response to local population needs. This approach should also allow individual Boards and Community Health Partnerships to identify target groups for testing once a clearer picture is shown of local prevalence rates and to identify locations where additional testing could be achieved.

Box 1: Interim national clinical service targets for chlamydia

4.6 Given the increasing trends associated with HIV and gonorrhoea, particularly among at risk groups, it is important that there is little delay in the time between diagnosis and treatment. A similar incremental approach to that for chlamydia is proposed so that improvements can be made in responses for both diagnosis and treatment.

Box 2: Interim national clinical service targets for other diagnoses and treatment other than chlamydia

5. CONCLUSION

This paper sets out some of the issues relating to unintended pregnancy and sexually transmitted infections and highlights a potential way forward to help improve service responses. These support the developments proposed in the Sexual Health and Relationships Strategy and in its other background papers.

September 2003

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