Category: Sexual health services

New HIV infection in UK in men who have sex with men exceeds heterosexual transmission after many years

Annual report of HIV infections in the United Kingdom in 2001 published by Health Protection Agency (HPA) show that for the first time in  many years newly diagnosed infections were higher in men who have sex with men (MSM) than transmission through heterosexual intercourse.

By the end of 2011, there were an estimated 96,000 (95% credible interval 90,800 – 102,500) people were living with HIV in the UK. Approximately one quarter (22,600, 24% [19%- 28%]) of these were undiagnosed and unaware of their infection. Fig 1

Fig 1. People infected with HIV at the end of 2011

 

This is an increase from the 91,500 people estimated to have been living with HIV by the end of 2010. The estimated prevalence of HIV in 2011 was 1.5 per 1,000 (1.5-1.6) population of all ages, 2.1 per 1,000 (1.9 – 2.3) men and 1.0 per 1,000 (1.0 – 1.1) women.

The rise in new diagnosis in MSM (Fig 2) is particularly worrying as nearly half the patients (47%) are diagnosed late when their immune system is already compromised increasing the chance of a fatal outcome within one year of diagnosis ten fold. These deaths are totally avoidable with the use of anti-viral therapy early in the infection.

 

Fig 2. New cases of HIV by exposure category

 

STIRF: new projects approved

In this year’s funding round we received six applications. After sending them for external peer review by experts, the Scientific Committee approved two projects for funding in 2013 which was submitted to the Trustees.

Project 1: Chlamydia trachomatisis the most common sexually transmitted infection effecting young people in the UK. It infects one in ten of all women aged 15-25 and can cause serious long term complications such as pelvic inflammatory disease and infertility. According to the Health Protection Agency in 2011 in England and Wales 147,594 infections were diagnosed in 15 to 24 year olds.

Recent evidence for emergence of resistance to the commonly used antibotics used in eradicating chlamydia is very worrying. We are delighted to fund Emma Hathorn as part of a multi-centre study to evaluate the incidence of  chlamydia resistance in people attending a clinic for sexually transmitted infections.

Antimicrobial resistance in Chlamydia trachomatis: is it a reality? STIRF-022

 

Project 2: There is increasing focus on involving patients and what they perceive are their actual needs when delivering clinical services in the NHS. This is particularly important in the fast developing field of HIV where new management strategies and new treatments take place within the background of shrinking funding. These clearly call for new ways of delivering these services more efficiently as well as more effectively. It is with this in mind that STIRF decided to fund the nurse-led project by Lucy Land that is taking steps to objectively define these priorities as seen from the HIV-infected patients perspective.

Development of a weighting scale to evaluate the relative importance of items in a validated HIV patient satisfaction questionnaire. STIRF-020

This study aims to refine a questionnaire they developed and validated with the help of HIV-infected patients to find issues that are more important and therefore need to be prioritised in development of HIV services.

Thanks to all the researchers who submitted and to the reviewers who gave their valuable time for free.

Pre-exposure prophylaxis can be a cost effective addition to other preventative options for men who have sex with men

HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by uninfected individuals to prevent HIV infection, has demonstrated effectiveness in preventing acquisition in a high-risk population of men who have sex with men (MSM).

Researchers from the Imperial College London have developed a mathematical model representing the HIV epidemic among MSM and transwomen (male-to-female transgender individuals) in Lima, Peru, to investigate how PrEP can be used cost-effectively to prevent HIV infection in such populations.

The study reported that strategic PrEP intervention could be a cost-effective addition to existing HIV prevention strategies for MSM populations.

However, PrEP will not arrest HIV transmission in isolation because of its incomplete effectiveness and dependence on adherence, and because the high cost of programmes limits the coverage levels that could potentially be attained.

No increase in sexual behaviour in HPV vaccinated teenage girls in US

Since US public health officials began recommending in 2006 that young women be routinely vaccinated against HPV, many parents have hesitated over fears that doing so might give their children license to have sex. Research published on Monday in the journal Pediatrics and reported in the New York Times of October 15 may help ease those fears.

Using a sample of nearly 1,400 girls, the researchers found no evidence that those who were vaccinated beginning around age 11 went on to engage in more sexual activity than girls who were not vaccinated.

“We’re hopeful that once physicians see this, it will give them evidence that they can give to parents,” said Robert A. Bednarczyk, the lead author of the report and a clinical investigator with the Kaiser Permanente Center for Health Research Southeast, in Atlanta. “Hopefully when parents see this, it’ll be reassuring to them and we can start to overcome this barrier.”

HPV, the most common sexually transmitted virus in the United States, can cause cancers of the cervix, anus and parts of the throat. Federal health officials began recommending in 2006 that girls be vaccinated as early as age 11 and last year made a similar recommendation for preadolescent boys. The idea is to immunize boys and girls before they become sexually active to maximize the vaccine’s protective effects.

Data from the CDC showed that in 2011 nearly a third of children 14 to 19 years old are already infected with HPV. But despite the federal recommendations, vaccination rates around the country remain low, in part because of concerns about side effects as well as fears the vaccine could make adolescents less wary of casual sex. A study by Basu et al from Yale on parental attitudes toward the vaccine found that concern about promiscuity was the single biggest factor in the decision not to vaccinate.

HIV Infection Among Ethnic Minority and Migrant Men Who Have Sex With Men in Britain

A study by Jonathan Elford and colleagues published in in the journal Sexually Transmitted Infection has examined human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) from different ethnic and migrant groups living in Britain.

A diverse national sample of MSM living in Britain was recruited in 2007-8 through Web sites, in sexual health clinics, bars, clubs, and other venues. Men completed an online survey that included questions on HIV testing, HIV status, and sexual behaviour. A sample of just under 12,000 white British men were used as comparison

Results: Nine hundred and ninety-one ethnic minority MSM, 207 men born in Central or Eastern Europe (CEE), 136 men born in South or Central America, and 11,944 white British men were included in the analysis.

Self-reported HIV seropositivity was low for men of South Asian, Chinese, and “other Asian” ethnicity (range, 0.0%–5.8%) and for men born in Central or Eastern Europe (CEE 4.5%) but elevated for men born in South or Central America (18.7%), compared with white British men (13.1%) (P < 0.001).

Interestingly there were no significant differences between these groups in high-risk sexual behavior (P = 0.8). After adjusting for confounding factors in a multivariable model, substantial differences in the odds of HIV infection remained for South Asian and Chinese MSM as well as for migrants from CEE, but not for other groups, compared with white British men; for example, South Asian men, adjusted odds ratio 0.43, 95% confidence interval 0.23, 0.79, P = 0.007.

The authors concluded that despite marked differences in HIV between ethnic minority, key migrant, and white British MSM  there was no significant difference in high-risk sexual behaviour between the groups studied.

Their study highlights the importance of health promotion targeting MSM from all ethnic and migrant groups in Britain.

Sex workers collective show long-term health gains of self-empowerment

A parallel AIDS conference in Kolkota, India gave the rights an update on the success of the VAMP sex-workers colective – now in its 15th year reports, reports Andera Cornwall the Guardian.

They have shown an impressive ability to minimise risk of HIV and other sexually transmitted infections in sex workers.

Founded in 1997, Vamp now has more than 5,000 members. Weekly meetings bring the collective together to tackle a wide range of issues faced by members. Health work and advocacy for sex rights’ human rights are interwoven with Vamp’s everyday work in the densely populated alleyways in the red-light districts of Sangli and other towns in the region.

Vamp’s mission is to change society. Rather than treating sex workers as victims to be rescued or rehabilitated, it demonstrates the power of collective action as a force for women’s empowerment, mobilising sex workers to improve their working conditions, and claim rights and recognition. And they’re yielding results.

The report showed how self-empowerment and education can achieve high rates of safe sex in women at high risk of sexually transmitted infections and HIV. It is yet another reminder to that the most effective way to protect this vulnerable population is to help then self-organise and self-protect rather than to criminalise prostitution.

The latter, as many studies have shown, merely drives women into the hands of criminal gangs, or leads to risk-taking sexual practices and high rates of self-harm.

Development of a questionnaire to measure patients’ satisfaction with HIV Clinics

A STIRF funded project (STIRF-012) has been completed successfully. Professor Jonathan Ross, Consultant in HIV medicine at University Hospital Birmingham and Lucy Land, Reader in Nursing at Birmingham City University have developed a questionnaire that will give patients attending an HIV clinic the opportunity to feedback their experiences of care.

A systematic review of the medical literature provided background information on what factors were important to patients attending a HIV clinic. Current users of the service were then involved in verifying this information and added their views about the issues that were important to them. For example being afforded respect, dignity and autonomy, together with an expectation of expert medical care were considered essential to a good service.

A draft questionnaire was constructed to include questions around these issues as well as others that were relevant and important to patients with HIV. This draft was tested with a group of patients and refined further. The final questionnaire was piloted on 100 clinic patients and showed that the feedback from the questionnaire could provide an accurate reflection of patients’ experiences. In the future, an annual survey using this questionnaire will be conducted and the data will be used to measure the quality of care and inform improvements in HIV clinic services.

The research had been submitted for publication

Dramatic drop in health spending according to OECD

Growth in health spending slowed or fell in real terms in 2010 in almost all OECD countries, reversing a long-term trend of rapid increases, according to OECD Health Data 2012.

In real terms average health spending has declined by over 6% compared to the start of the millenium.

Overall health spending grew by nearly 5% per year in real terms in OECD countries over the period 2000-2009, but this was followed by zero growth in 2010. Preliminary figures for a limited number of countries suggest little or no growth in 2011. The halt in total health spending in 2010 was driven by a fall of 0.5% in public spending for health, following an increase of over 5% per year in 2008 and 2009.

While government health spending tended to be maintained at the start of the economic crisis, cuts in spending really began to take effect in 2010. This was particularly the case in the European countries hardest hit by the recession.

UK gonorrhoea rates increase by 25%

Although overall rates of sexually transmitted infections rose by 2%, there has been an increase of 25% in new infections by gonorrhoea reported to the UK Health Protection Agency (HPA) – the second increase in two years running. Gonorrhoea rates increased from 16,835 to 20,965.

Other significant increases in sexually transmitted infections were in infectious syphilis (10%; 2,650 to 2,915) and genital herpes (5%; 29,794 to 31,154).

In contrast there was only a 1% rise in genital warts, perhaps reflecting the effectiveness of the vaccination programme. Diagnoses of genital warts cases in women aged 15-19 actually fell by 14% (11,251 to 9,700).

The greatest increase in sexually transmitted infections was in men who have sex with men and in heterosexual men and women aged 15-24. The high rates of infection reported in girls aged 15-19 is particularly worrying.

According to Professor Cathy Ison, director of sexually transmitted bacterial reference laboratory, the appearance of resistant strains for which no single antibiotic is effective is particularly worrying. This opens the prospect of having to use combination therapy in the future.

Research on effective behavioural change therefore remains a top priority.

Measuring Quality in Sexual health Services

There are a number of reasons why providers of sexual health services might wish to measure quality. Advances in technology, economic uncertainty and increased media coverage of medical errors have created a focus on improving quality in healthcare by those commissioning services, and central guidance in many healthcare systems encourages providers to make services more patient centred. The need to improve quality is also driven by funding mechanisms which often reflect the number of patients attracted to a service and increasingly include a penalty for failing to meet minimum quality standards.

Quality encompasses patient safety, patient experience and the effectiveness of care.  It is multidimensional and its interpretation may vary between commissioners, providers and patients.  Despite this apparent heterogeneity, four key components of quality can be defined: accessibility, acceptability, effectiveness and efficiency.

Accessibility defines how easy it is for patients to get to, and be seen at, a sexual health service. The majority of sexual health patients self-refer, and therefore ease of access is an essential factor when choosing whether to attend a clinic or making a choice between different clinics. Measuring the accessibility of a service can be achieved by formally reviewing clinic location, transport links and parking facilities, although these may not be easily amenable to change. Physical factors, including disabled access, should be easier to change, with the aim of complying with local legislation. Providers have the potentially greatest influence over organisational issues, for example, the percentage of patients seen outside working hours.

Acceptability relates to whether the services provided are perceived to be satisfactory by the patient. Acceptability is also an outcome or consequence of care that may influence subsequent consulting behaviour and health-related decision making.  In either case, evaluation of the opinions of both users and providers is needed.

Effectiveness is whether a service delivers care correctly when assessing the patient’s problem, undertaking appropriate investigations and giving the correct treatment. This encompasses clinic systems to deliver care, individual patient management, and ensuring patient safety.

The limited availability of healthcare resources (including funding, technology and labour) requires them to be used in the most efficient way to maximise outcome. A number of techniques have been developed to measure efficiency in healthcare, for example, cost-effectiveness analyses (the change in cost against change in outcome for a specific disease) and quality-adjusted life years (used in cost utility analyses to calculate the ratio of cost to number of years of life gained for a particular health intervention).  New technology and changes in working practices offer the greatest opportunities to improve efficiency, but require an assessment of associated costs and benefits, which may be both financial and non-financial, for example, improved patient satisfaction, greater diagnostic sensitivity.

A shift in focus from volume to quality of care is increasingly driving change in sexual health services.  However, if measuring quality is to translate into improvement in patient care, a number of key practical questions still remain to be answered, including:

Which bundle of measurements best discriminates between good and poor quality?

How can quality data be most effectively used to effect change and improve outcomes?

See: How to assess quality in your sexual health services. Emma Hathorn, Lucy Land , and Jonathan Ross.  Sex Transm Infect 2011;87:508-510 doi:10.1136/sextrans-2011-050107