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Topic on a Page - Sexual and Reproductive Health

Data Sources:

Health Needs Assessment: Sexual Health (2015)

Public Health England (PHE):

Health Protection Report: latest surveillance reports

National chlamydia screening programme (NCSP) data tables

Sexual and Reproductive Health Profiles

Sexual and reproductive health in England: local and national data guidance

STIs: Surveillance, data, screening and management

Spotlight on sexually transmitted infections in the East Midlands (2016)

Association for Young People's Health:

Key Data on Young People 2017

Supporting Information:

Association for Young People's Health (AYPH):

Sexual health and under-18 conceptions

British Association for Sexual Health and HIV:

Sexual Health and HIV Guidance

British HIV Association:

Guidelines on the use of HIV pre-exposure prophylaxis (PrEP) (2018)

Guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy (2015)

Guidelines for the routine investigation and monitoring or adult HIV-1-positive individuals (2016)

Standards of Care for People Living with HIV (2013)

British Pregnancy Advisory Service:

Abortion in practice a guide for GPs

NAM Aids Map:

HIV prevention briefing papers

National Institute for Care and Health Excellence (NICE):

Guidance: Contraception

Guidance: HIV and Aids

Guidance: Sexual health: General and other

Guidance: Sexually transmitted infections

NHS Evidence:

Contraception

Sexually Transmitted Infections

Sexual and Reproductive Health

Teenage Pregnancy

Public Health England:

Commissioning local HIV sexual and reproductive health services (2018)

Contraceptive services: estimating the return on investment (2018)

HPV vaccination programme for men who have sex with men (MSM) (2018)

Sexual and reproductive health and HIV: applying All Our Health (2018)

Teenage Pregnancy: Evidence Frameworks

The pharmacy offer for sexual health, reproductive health and HIV: a resource for commissioners and providers

Using audit in commissioning sexual health, reproductive health and HIV services

Royal College of Obstetricians and Gynaecologists:

The care of women requesting induced abortion

Best practices in comprehensive abortion care

World Health Organization (WHO):

World Health Organization (WHO)

HIV Guidelines

Sexual Health

Miscellaneous:

Sex Education Forum

Linked Topics:

New Topic (Dec-18)

JSNA Topic: Sexual and Reproductive Health

Background

Sexual and Reproductive Health (SRH) should not just be viewed as an absence of disease; it encompasses the ability of individuals to make informed choices relating to sex and sexuality, free from violence, coercion, stigma and discrimination.

The 2006 World Health Organisation (WHO) defines sexual health as:

'… a state of physical, emotional, mental and social well- being in relation to sexuality, it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violent. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.'

The scope of this chapter covers sexually transmitted infections, human immunodeficiency virus (HIV), contraception and teenage pregnancy.

Sexual and Reproductive Health (SRH) impacts on all people, regardless of age, gender, background or sexual orientation, but some groups of people are known to be disproportionately affected than others (young people, men who have sex with men and intravenous drug users) and there is a clear link between social deprivation and poor sexual health.

Sexually Transmitted Infections
More than 25 diseases can be transmitted through sexual activity, the most common of which are chlamydia, genital herpes, human papilloma virus (HPV), trichomoniasis, gonorrhoea, human, immunodeficiency virus (HIV), syphilis, hepatitis B.

If STIs, including HIV, are not diagnosed and treated early, there is a greater risk of onward transmission to partners, increasing the risk of avoidable ill health and complications. Many STIs have long- term health effects i.e. chlamydia can lead to infertility and HPV is linked to cervical cancer.

Chlamydia is the most commonly diagnosed sexually transmitted infection (STI) in the UK, affecting both men and women and causes ill health, including complications such as pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility in women, conjunctivitis in both genders and epididymitis in men, all of which impact physical and mental health and increase NHS costs. Chlamydia often has no presenting symptoms therefore opportunistic screening using the National Chlamydia Screening Programme, is essential, to reduce prevalence of this avoidable infection.

HIV is associated with serious morbidity and high costs of treatment and care. The most recent estimate suggests there were 101,600 people living with HIV in the UK in 2017. Of these, around 7,800 are undiagnosed so do not know they are HIV positive. Of the 4,363 people diagnosed with HIV in the UK in 2017, 53% were gay or bisexual men. Of the 1,810 heterosexual people diagnosed with HIV in 2017, 38% were black African men and women.

The overall mortality rate for people aged 15-59 who were diagnosed early was, for the first time, equal to that of the general population for the same age group. (Source: Terrence Higgins Trust) In fact, life expectancy of people living with HIV in high-income countries is very close to that of people without HIV. Early diagnosis and one-pill-a-day treatment can suppress the virus and allow the body’s immune function to recover. (World Health Organisation (WHO)

Today, people living with HIV can live much longer, healthier lives (WHO). There is no evidence that individuals who have successfully achieved and maintained viral suppression through ART transmit the virus sexually to their HIV-negative partner(s). This led to the U=U campaign-Undetectable=Untransmissible. (Source: British HIV Association)

The financial impact of poor sexual health is also far reaching. The cost of treatment per annum when HIV is diagnosed early is around £14,000 per case compared to £28,000 for late diagnosis and each case of HIV infection is estimated to represent between £280,000 and £360,000 in lifetime costs (Source: NICE). The value of preventing a single onward transmission of HIV is estimated to be between £500,000 and £1million including health benefits and treatment costs. In other words if a patient infected with HIV transmits the disease to another person that will cost health and social services an extra £500,000 to £1 million per patient for their treatments and social care (Source: Department of Health, 2001).

Sexual Health
Increased referrals are being made to psycho-sexual counselling (Relate) for erectile dysfunction in young men, related to addiction to internet pornography and chemsex activity, both of which impact on the unrealistic expectations of sexual relationships and body image and which can damage self-esteem, increase the risk of HIV and STIs and ultimately have a negative impact on mental health.

Chemsex
PHE defines chemsex as the planned use of drugs as an integral part of sex (usually immediately prior to, or during sex); specifically the use of methamphetamine, mephedrone, GHB/GBL and less commonly ketamine, particularly among at risk communities. Lincolnshire residents do not appear to be experiencing this risky group behaviour, as most 'Chemsex parties' are held in major cities; however local alcohol, drug addiction and SRH services are seeing clients who require support due to this risky behaviour in other locations and the consequent harm, such as STIs and mental health issues.

Reproductive Health
Reproductive healthcare provides a range of evidence based contraceptive methods to support the reproductive life-cycle, including long acting reversible contraception (LARC):-Intra Uterine Devices and Systems (IUCD/IUSD) and Sub Dermal Implants (SDI). A national drive to increase uptake of LARC is underway; however Lincolnshire is already exceeding the national and regional rates of uptake. Public Health England (PHE) is seeking a greater focus on women's reproductive life cycle and how contraceptive needs change over time.

Termination of pregnancy is an integral part of reproductive healthcare for women. Around 1 in 3 women will have a termination, and each year just fewer than 200,000 women have a termination in England, Wales and Scotland.

Most terminations are carried out because the pregnancy was unintended, and the large majority of procedures are conducted in the first 9 weeks of pregnancy.

Unintended pregnancy is the main reason for seeking termination: around 1 in 3 women will have a termination, (1 in 2 in the under 18 population) and each year just under 200,000 women have a termination in England, Wales and Scotland (Source: NICE).

Most terminations are conducted in the first 9 weeks of pregnancy. National guidance is being developed to reconcile demand with clinical service capacity. This underscores the need for women to have access to the full range of contraception methods in accessible locations across Lincolnshire.

The Teenage Pregnancy Strategy (1998-2010) resulted in the under-18 conception rate reducing to the lowest level for over 40 years. However at a national level, England's rates remain higher than levels in comparison to Western European countries and progress in reducing rates varies considerably across areas of Lincolnshire. Considerable success has been achieved in reducing the under 18s birth rates across Lincolnshire with a reduction of 53.7% since 1998. (Source: Public Health Outcomes Framework)

Providing young people with accessible SRH services has been challenging due to the reduction in youth organisations across the county and changes in the 0-19 children's services model. The County Council has commissioned a team of Relationships and Sex Education (RSE) Advisors to support schools and parents to provide relationship and sex education at appropriate times and with consistent messages. This is in line with the Childrens and Social Work Act 2017 which will embed mandatory RSE and health education within a PHSE framework in 2020.

Context

National Strategies, Policies & Guidance

 

Sexual Health Services
A framework for sexual health improvement in England (2013), published by the Department of Health and Social Care it aims to provide the information, evidence base and support tools to enable those involved in sexual health improvement to work together effectively in order to ensure people have access to high quality services and support.

Integrated Sexual Health Services - A suggested national service specification (2018) published by Public Health England (PHE) and Department of Health and Social Care, this service specification covers the specialist integrated sexual health services that Local Authorities are responsible for commissioning, including testing and treatment for sexually transmitted infections and provision of the full range of contraception.

Making it work: A guide to whole system commissioning for sexual health, reproductive health and HIV (2015). This PHE guide has been developed to support commissioning bodies to ensure the delivery of high quality sexual and reproductive health and HIV services, in line with their responsibilities set out in the Health and Social Care Act 2012.

Sexual Health Commissioning in Local Government: Building strong relationships, meeting local needs (2015). These nine case studies published by the Local Government Association (LGA) showcase local government experiences of commissioning sexual health services since taking over this responsibility in April 2013. They outline the steps taken to collaborate not only within and between Local Authorities but also with NHS England and Clinical Commissioning Groups.

The National Institute for Health and Care Excellent (NICE) have published a number of guidance, advice, NICE Pathways and quality standards relating to sexual health and on sexual health: general and other.

British Association of Sexual Health and HIV: Standards for the management of sexually transmitted infections (STIs) (2014). With increasing numbers of primary and community healthcare providers playing a role, alongside GUM clinics, in the management of STIs, these revised standards bring together the key elements of best practice that people seeking help in relation to STIs are entitled to expect, whichever service they choose to attend. They provide a framework for monitoring performance which covers the core principles of STI care, staff training, clinical assessment and management, diagnostics, information governance, links to other services, clinical governance and the engagement of patients and the public.

Faculty of Sexual and Reproductive Healthcare (FSRH) (Royal College of Obstetricians and Gynaecologists) Standards and Guidelines

Sexual health, reproductive health and HIV services: evaluation resources (2018). These PHE resources are for public health practitioners evaluating interventions in sexual health, reproductive health and HIV services.

Chlamydia
The National Chlamydia Screening Programme aims to:

  • Prevent and control chlamydia through early detection and treatment.
  • Reduce onward transmission through repeat testing after treatment, provision of condoms and partner notification.
  • Prevent the consequences of untreated infection.
  • Ensure all young people under 25 years are informed about chlamydia and have access to services that can reduce the risk of infection.
  • Normalise screening so young people test every year or with a new partner.

Public Health England have produced a new Chlamydia Pathway and provided workshops to achieve improved outcomes, as evidence suggests these can be positively impacted by greater partner notification and follow up testing after 6 weeks. Guidelines, standards and resources related to chlamydia screening are available from: National Chlamydia Screening Programme

The chlamydia care pathway describes the individual steps which; taken together, represent comprehensive case management for an episode of chlamydia testing, diagnosis and treatment as recommended by the National Chlamydia Screening Programme (NCSP).

Human Immuno-deficiency Virus (HIV)

NHS England Clinical Commissioning Policy: Treatment as Prevention (TasP) in HIV infected adults (2015) guidance for earlier initiation of treatment in HIV infected adults as a strategy for HIV prevention known as ‘Treatment as Prevention’ (TasP) to provide equitable access to a proven method of HIV prevention which is cost effective and will contribute to reducing the HIV epidemic in England.

The NICE guideline HIV testing: increasing uptake among people who may have undiagnosed HIV [NG60] (2016) includes testing, preventing transmission of STIs and late stage diagnosis:

NICE guidance to promote HIV prevention: HIV testing: Increasing the uptake of HIV testing among black Africans [PH33] (2011) and HIV testing: Increasing uptake of in men who have sex with men [PH34] (2011).

NICE Quality standard [QS157] HIV testing: encouraging uptake (2017) which covers interventions to improve the uptake of HIV testing among people who may have undiagnosed HIV.

British HIV Association Standards of care for people living with HIV (2018). These Standards are designed to provide a reference point against which to benchmark the quality of HIV care in the context of the changing needs of patients and the current financial pressures. They provide information to support top quality care and to inform commissioning decisions to meet the growing need for more efficient and cost-effective services.

The British HIV Association (BHIVA), endorses the ‘Undetectable Equals Untransmittable’ (U=U) Consensus Statement produced by the Prevention Access Campaign. The U=U statement is based on evidence from the PARTNER study (published in the Journal of the American Medical Association, 12 July 2016) which reported that the risk of HIV transmission with effective treatment is negligible.

PHE recommends that individuals at risk should test for HIV regularly, including men who have sex with men and black African men and women. PHE Guidance on HIV: testing

WHO Guidelines: Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (2015).

Teenage Pregnancy

PHE Teenage Pregnancy Resource Collection (2018) - Evidence-based frameworks that provide structure for local areas to prevent unplanned teenage pregnancies and support young parents and their children

Good progress but more to do: teenage pregnancy and young parents (2018). Published by the Local Government Association, this report shows that high quality relationships and sex education (RSE), welcoming health services (in the right place, open at the right time) and friendly non-judgmental staff, help young people to delay sex until they are ready and to use contraception effectively.

Relationships Education, RSE and PSHE

Department for Education (DfE) statement on relationships education, relationships and sex education (RSE), and Personal, Social, Health and Economic education (PSHE)

Relationships and sex education House of Commons Research Post Note 2018
This briefing document reviews evidence on the potential outcomes of RSE in schools and how to maximise its effectiveness.

Contraception

All NICE products on contraception: which includes guidance, advice, NICE Pathways and quality standards.

Faculty of Sexual Health and Reproductive Healthcare (FSRH) Emergency Contraception (2017).

Termination of Pregnancy

New guidance for Pregnancy Terminations is in progress and currently due for publication in September 2019

In 2014, the Department of Health issued Guidance in Relation to Requirements of the Abortion Act 1967. This guidance is intended for those involved in the commissioning, providing and management of termination of pregnancy services to help them comply with the Abortion Act 1967. The Care Quality Commission has also published specific requirements for providers of termination of pregnancy services.

Letter from the Chief Medical Officer: Clarification of time limit for termination of pregnancy performed under grounds c and d of the Abortion Act 1967 (see above from the Department of Health)

Sexual Assault and Abuse

For further information on terminations please refer to the JSNA Topic Maternal Health, Pregnancy & First Few Weeks of Life

Strategic direction for sexual assault and abuse services NHS England (2018). This strategic document outlines how services for victims and survivors of sexual assault and abuse, need to evolve between now and 2023. It sets out six core priorities that NHS England will focus on to reduce inequalities experienced.

Public health functions to be exercised by NHS England - service specification: sexual assault referral centres NHS England 2018

For further information relating to this subject please refer to the JSNA Topic Domestic Abuse

Local Strategies & Plans

 

Lincolnshire Integrated Sexual Health (LISH) have adopted the PHE National Chlamydia Screening Programme (NCSP) Pathway Plan.

The local aims of this are to:

  • Maintain and improve communication between all stakeholders
  • Refresh all C-Card and chlamydia promotional resources
  • Deliver accessible training and follow up support to providers
  • Provide outreach work and health promotion activities
  • Shorten the time lag between positive diagnosis and recall for treatment
  • Improve efficiency in partner notification

The Lincolnshire Joint Health and Wellbeing Strategy (JHWS) includes embedding prevention in all pathways across health and care. LISH services have a 'golden thread' of prevention throughout their work streams with a specific sexual health advice, prevention and promotion (SAPP) team that provide C-Card, chlamydia screening with partner notification and outreach work. Clinical staff are dual trained which enables them to support patients to make informed choices that may prevent unwanted pregnancy or the transmission of STIs. All patients attending sexual health appointments are offered an HIV screening test to identify infection and treat early; this prevents HIV transmission and enables open discussion about reducing risky sexual behaviour.

The U=U message brings hope of minimising the impact of HIV and the future eradication of HIV and is an important way to help reduce the stigma experienced by people living with HIV, whose sexual partners may fear infection unnecessarily. This will form part of a new approach within LISH and Positive Health

Better Births Strategy and Implementation Plan for Lincolnshire 2017-2020/21 Local co-designed services are being developed and a strong partnership is being forged to bring SRH services closer to where women prefer to receive pregnancy care. LISH is offering SRH clinics in four Maternity Hubs and plans to utilise Children's Centres (48 in Lincolnshire).

What is the picture in Lincolnshire?

What the data is telling us

Sexual Transmitted Infections

In Lincolnshire, the crude rate for all newly sexually transmitted infections (STI) diagnosis rate per 100,000 population, was 509 per 100,000 population in 2017. This is significantly below the national (743 new STI diagnosis per 100,000 population) and regional levels (621 new STI diagnosis per 100,000 population). Further investigation is required to identify potential causes and find solutions that can be implemented.

The overall attendance at LISH Sexual Health Clinics in 2017-18 was16, 603 GUM attendees (10,925 new)

In 2017, of the people in Lincolnshire that were diagnosed with STIs; 59% had chlamydia, 16% had genital warts, 9% had genital herpes, 6% had gonorrhoea, less than 1% had syphilis and 8% had other STIs. These figures are rounded down, therefore the total equals 99% (Source: PHE-Fingertips)

At District Council level, Lincoln City (1,067 per 100,000 population) had the highest rate of newly diagnosed STIs in Lincolnshire in 2017, and the 2nd highest district in the East Midlands region. In contrast, the lowest new STI diagnostic rates in Lincolnshire can be found in South Holland (384 per 100,000 population) and East Lindsey (397 per 100,000 population).

The STI testing rate (excluding chlamydia aged less than 25) was 9,411 per 100,000 population in Lincolnshire in 2017, which is worse than national (16,739 per 100,000 population) and regional levels (13,468 per 100,000 population). The STI testing rate and new STI diagnoses rates are closely linked.

The new STI diagnoses rate (excluding chlamydia in under 25 year olds) per 100,000 population aged 15 to 64 was 445 in Lincolnshire in 2017, better than the regional (599 per 100,000 population) level, national levels are not compared.

The STI testing positivity rate (excluding chlamydia in under 25 year olds) in Lincolnshire was 4.7% in 2017. Once again Lincoln district (5.8%) has the highest STI positivity rate as well as the new STI diagnostic rate per 100,000 (aged 15-64 years) (731 per 100,000), in comparison to South Holland district which has a 4.6% testing positivity rate and a diagnostic rate of 271 per 100,000 population.

Syphilis, Gonorrhoea, Herpes and Genital Warts

Syphilis
Syphilis is an important public health issue for men who have sex with men (MSM) among whom the incidence of the disease has increased over the past decade. In 2017 the rate of syphilis diagnosis per 100,000 population in Lincolnshire was 6.4 per 100,000 population for people accessing specialist and non-specialist sexual health services. This is similar to regional levels (6.2 per 100,000), while remaining below national levels (12.5 per 100,000 population). Locally Lincoln City (20.5 per 100,000) is significantly above regional levels and has the highest rate of syphilis diagnoses in the East Midlands region, compared to East Lindsey district (1.4 per 100,000 population) which has one of the lowest rates for syphilis diagnoses in the East Midlands region.

Gonorrhoea
Gonorrhoea causes avoidable sexual and reproductive ill-health and is used as a marker for rates of unsafe sexual activity as well as being more likely than chlamydia to result in physical symptoms. The gonorrhoea diagnostic rate per 100,000 population in Lincolnshire was 30.5 per 100,000 population in 2017, thus performing better than the regional (48.0 per 100,000 population) and national rates (64.9 per 100,000 population).

Locally, Lincoln City (73.9 per 100,000 population) has the highest gonorrhoea diagnostic rate in Lincolnshire, indicating high levels of risky sexual activity; this is in comparison to South Holland (22.7 per 100,000), East Lindsey (23.8 per 100,000 population) and South Kesteven (18.5 per 100,000 population), who are amongst the districts performing better than the national average and with the lowest gonorrhoea diagnostic rates regionally.

Genital Herpes
Genital herpes is the most common ulcerative sexually transmitted infection seen in England. Infections are frequently due to herpes simplex virus (HSV) type 2, although HSV-1 infection can also be seen. Recurrent infections are common with patients requiring several treatment episodes. The genital herpes diagnosis rate per 100,000 was 46.7 per 100,000 population in Lincolnshire in 2017, performing better than both national (56.7 per 100,000 population) and regional levels (49.4 per 100,000).

Locally, Lincoln City has the highest diagnosis rate (76.0 per 100,000 population) compared to South Holland (29.2 per 100,000 population) which has the lowest rate in the region.

Genital Warts
Whilst genital warts are the second most commonly diagnosed STI in the UK caused by infection with specific subtypes of human papillomavirus (HPV); recurrent infections are also common with patients returning for treatment. In 2017 in Lincolnshire the genital warts diagnostic rate per 100,000 population was 81.4 per 100,000 population, performing better than national levels (103.9 per 100,000 population).

Lincoln City (161.2 per 100,000) had the highest rate both regionally and in Lincolnshire, compared to South Holland (57.3 per 100,000) which was the lowest district within the region.

Chlamydia
Caused by the chlamydia trachomatis bacterium, chlamydia is the most commonly diagnosed sexually transmitted infection in the UK, affecting both men and women. Over 1.3 million chlamydia tests were carried out and 126,826 diagnoses were made nationally in 2017, equivalent to a detection rate of 1,882 per 100,000 population and accounting for 30.8% of all new STIs diagnoses rates per 100,000 for people aged 15-24 years. (Source: PHE). Between 2016 and 2017 there was an 8% decline in the number of chlamydia tests, continuing the trend of the previous year; most of this decrease in testing took place in sexual and reproductive health (SRH) services, where chlamydia testing has fallen by 61% since 2015, likely reflecting a reduction in service provision. There were 2,361 fewer chlamydia diagnoses made among 15 to 24 year olds in 2017 than in 2016, a reduction of 2%

Lincolnshire's chlamydia detection rate per 100,000 population for 15-24 year olds (Target: 2,048 per 100,000 population 15-24 year olds) was below the national expected chlamydia detection rate of at least 2,300 per 100,000 population in this age group, recommended for Local Authorities in 2017. However, Lincolnshire still performed above the national (1,882 per 100,000 population) and regional levels (1,848 per 100,000 population).

Locally, Lincoln City (2,569 per 100,000 population 15-24 years old) was significantly above the regional and national detection rate target, being the third best district to detect chlamydia regionally, whilst Boston (1,256 per 100,000 population 15-24 years old) had the lowest detection rate in Lincolnshire in 2017.

Overall in 2017 in Lincolnshire, more chlamydia cases were detected in females (2,809 per 100,000) than in males (1,306 per 100,000) for the population aged 15-24 years old.

Of the total population aged 15-24 years old that attended Lincolnshire GUM & Non-GUM services in 2017; 21.7% were tested for chlamydia in 2017 and 9.4%, had a positive test result. (Source: PHE STI & HIV Portal).

The number of young people screened across the county has increased considerably since the inception of the Lincolnshire Chlamydia Screening programme in 2008. The following information is taken from data collated by Public Health England published on the Sexual and Reproductive Health Profile:

In Lincolnshire 18,365 chlamydia screens were carried out in 2017, equating to 21.7% of the target population of 15-24 year olds which is better than the national (19.3%) and regional levels (17.4%).

While chlamydia infections are more commonly found amongst young adults aged less than 25 years, women and men aged 25 years and over are also at risk of chlamydia. In Lincolnshire in 2017 the chlamydia diagnostic rate in over 25s was 92 per 100,000 population aged 25+, lower than the national (189 per 100,000 population aged 25+) and regional rates (150 per 100,000 aged 25+). Locally; Lincoln City (184 per 100,000 population aged 25+) has one of the highest rates regionally, whilst East Lindsey (68 per 100,000 population aged 25+) has one of the lowest.

Human Immuno-deficiency Virus (HIV)
The HIV diagnosed prevalence rate per 1000 among persons aged 15 to 59 years, was 0.76 per 1,000 in 2017, which was better than the national average and does not exceed the 2 in 1,000 HIV diagnosis prevalence for population aged 15 to 59 years in 2017. It is evident that knowledge of HIV status increases survival rates, improves quality of life and reduces the risk of HIV transmission.

In Lincolnshire the new diagnosis rate of HIV for people aged 15 and over was 4.6 per 100,000 population in people aged 15 and over, which is better than the national (8.7 per 100,000 population aged 15+) and regional levels (6.5 per 100,000 population aged 15+). Whilst the numbers may be small, there is a major impact on physical and mental health, social welfare and the rising costs of ART (Anti- Retroviral Therapy).

Lincoln City (10.9 per 100,000 aged 15+) had the highest rate of newly diagnosed HIV cases, compared to West Lindsey (1.3 per 100,000 population aged 15+) with the lowest rate.

People with HIV with a late diagnosis have a tenfold increased risk of dying within a year of diagnosis. In Lincolnshire the Public Health Outcomes Framework (PHOF) indicator 3.04 (HIV late diagnosis- CD4 cell count <350 cells/mm3) rate was 43.1% in 2017, similar to national levels (41.1%), but below regional levels (46.3%) and above the national aim to reduce late HIV diagnosis to below 25%. This indicates that most cases are diagnosed reasonably early, but some improvement is still required.

However, HIV testing coverage in Lincolnshire (67.7%), which measures the percentage of people tested for HIV, is better than the regional levels of 63.5% in 2017. National levels are not compared here. HIV testing is integral to the treatment and management of HIV.

Despite the 2017 HIV testing coverage being 63% amongst women attending specialist sexual health services in Lincolnshire, the county performs above regional (54.5%) levels. However, Lincolnshire remains below the HIV testing coverage expectation for males attending specialist sexual health services (73.1%), performing worse than regional (77%) levels.

At a district level West Lindsey performs worse than the national level (54.5%) for both females (51.9%) and males (68.9%) and has the lowest HIV testing coverage, compared to South Holland (females 71.26% and males 80.7%) which had the highest percentage of HIV testing coverage.

For MSM, the MSM HIV testing coverage for Lincolnshire (90.2%) in 2017, performing at similar rates to regional levels (87.5%). MSM HIV testing coverage is highest in North Kesteven (94.7%) and South Kesteven (94.3%) and lowest in East Lindsey (81.3%), all performing similar to regional levels.

The Joint United Nations Programme on HIV/AIDS (The UNAIDS) 90:90:90 ambition sets out a global target for 90% of people living with HIV to have their status known, 90% of those diagnosed to receive treatment and 90% of those treated to be virally suppressed. This national target has recently been achieved as a result of comprehensive HIV testing programmes tailored to the needs of its target population. (Source: PHE HIV Testing in England: 2017 Report).

In Lincolnshire the percentage of people that take up HIV testing was 77.6 % in 2017, performing similarly to regional levels (71.9%). National levels are not compared.

Locally, South Holland district (84.9%) has the highest uptake of HIV testing in Lincolnshire performing better than regional levels, compared to West Lindsey district (74.5%) with the lowest percentage of test uptake in Lincolnshire.

Furthermore, there is evidence that 100% of all clients who attend Lincolnshire’s sexual health clinics are offered HIV testing, however not all patients accept this offer.

HIV testing uptake for women in Lincolnshire was 74.7% in 2017, which is above regional levels (62.9%). South Holland (81.6%) is the most successful district for HIV testing uptake for females, compared to North Kesteven (70.5%) which has the lowest proportion of HIV testing uptake.

HIV testing uptake for males in Lincolnshire (80.7%) is higher than female uptake, however performance is worse than the regional (84.9%) levels. For males the district with the highest HIV testing uptake is South Holland (88.3%) compared to Lincoln (78.1%), West Lindsey (79%) and East Lindsey (78.4%), who perform below regional levels.

The highest HIV testing uptake percentage for 2017 in Lincolnshire was for MSM at 94.5%, reflecting the similar regional (94.9.1%) level. Locally, North Kesteven (97.1%) had the highest percentage uptake amongst the districts, compared to East Lindsey (88.2%) with the lowest percentage uptake.

Positive Health have supported 277 people during 2017-18, including 96 carers and were supporting 164 people living with HIV.

LISH have approximately 300 HIV positive patients and work closely with Positive Health. It should be noted that each provider tailors their work to meet the needs of their target populations and aim to provide discrete, non-judgmental and accessible services. Due to the strong prevalence for anonymity, patients choose where they wish to be seen, with some travelling to out of county, non-contracted providers.

Reproductive Health
In Lincolnshire the total of long acting reversible contraception (LARC) prescribed by GPs and Sexual Reproductive Health Services (SRHS) (excluding injections) was 60.1 per 1,000 population in 2016, above national (46.4 per 1,000) and regional (53.3 per 1,000) levels. Of those total LARCs, 46.5 per 1,000 were prescribed by GPs and only 13.6 per 1,000 population were prescribed by the SRH service, both excluding injections.

The percentage of women aged under 25 choosing long acting reversible contraceptives (LARC) excluding injections as their main method of contraception at SRHS in Lincolnshire was 37.2% in 2016, significantly above national (20.6%) and regional (28.3%) levels. Furthermore the percentage of women aged 25 and over choosing long acting reversible contraceptives (LARC) excluding injections as their main method of contraception at LISH was 53%, also performing significantly above national (35.7%) and regional (42.4%) levels.

The percentage of women who choose injections at SRHS as their main method of contraception in Lincolnshire was 8.5% in 2016; this is below national (9.8%) and regional (9.4%) levels.

Another contraceptive method is the user-dependent method, in Lincolnshire the percentage of women choosing user-dependent methods as their main contraception at SRHS in 2016 was 46%, again below national (62.1%) and regional (55.3%) levels.

While the percentage of woman choosing hormonal short-acting contraceptives at SRHS was 34.2% in Lincolnshire in 2016, lower than national (46.9%) and regional (41.7%) levels.

The above indicators are merely to inform, but not to be used to compare against each other as the as the intention is to encourage choice rather than to promote any form of contraception over another.

LISH Reproductive health services saw 5,049 contraceptive attendees in 2017-1018.

Teenage Pregnancy and Termination of Pregnancy
Despite the intensive work which took place nationally during the Teenage Pregnancy Strategy (1999-2010); England still has a higher rate of teenage pregnancy compared to other Western European countries. In Lincolnshire the rate of under-18 conceptions in 2016 was 20.5 per 1,000 females, which is similar to the national rate of 18.8 per 1,000 females and the East Midlands average of 19.4 per 1,000 females.

Locally, Boston (29.8 per 1,000 females), East Lindsey (28.7 per 1,000 females) and Lincoln (26.7 per 1,000 females) performed worse than the national and regional rates in 2016 for under 18 conceptions, whilst North Kesteven (11.8 per 1,000 females) performed better than national and regional levels.

The level for under 16s conception rate per 1000 females (3.4) is similar to the national (3.0) and regional (3.3) level in 2016.

In Lincolnshire the under 18s birth rate in 2016 (5.4 per 1,000 females aged 15-17) is similar to the national average (5.6 per 1,000 females aged 15-17) and regional average (6.1 per 1,000 females aged 15-17). Locally, East Lindsey (10.3 per 1,000 females aged 15-17) had the highest under 18s birth rate in 2016; whilst North Kesteven had the lowest (value has been supressed).

In 2016 under 18 conceptions leading to abortion in Lincolnshire (44.2%) are lower than national levels (51.8%) and similar to regional levels (47.1%). Locally North Kesteven district (79.2%) had the highest percentage of under 18s conceptions leading to abortion in Lincolnshire, above the regional and national averages, whilst West Lindsey (25.9%) had the lowest percentage of under 18 conceptions leading to abortion in Lincolnshire.

Lincolnshire's under 18s abortions per 1,000 females aged 15-17 rates were similar to national (8.4 per 1,000 females aged 15-17) and regional levels (7.8 per 1,000 females aged 15-17) in 2017. No district data is available for this indicator.

Trends

Sexual Transmitted Diseases
All new STI diagnosis rates per 100,000 population in Lincolnshire have remained below national levels since 2012.

For the population aged under 25 the new STI diagnoses (exc. chlamydia) per 100,000 population in Lincolnshire have performed better than national levels since 2012.

The STI testing rate (excluding chlamydia aged <25) / 100,000 in Lincolnshire has steadily increased since 2012, but consistently performs worse than the national rate.

The STI testing positivity (exc. chlamydia aged <25) % has performed worse than the national level from 2012 to 2014, but has been at a similar level to the national levels since 2015, where it has remained to date.

Chlamydia
The chlamydia detection rate per 100,000 aged 15- 24 (PHOF indicator 3.02) in Lincolnshire has not achieved the detection rate target of at least 2,300 per 100,000 population aged 15 -24 since 2012, for either male or females, but has steadily increased since 2016, performing similarly to national levels in 2017.

The proportion of the population aged 15 to 24 screened for chlamydia in specialist, non-specialist sexual health services (SHSs) has reduced by 15.7% since 2012, performing better than national levels since 2013.

The chlamydia diagnostic rate / 100,000 has been lower than national levels since 2012 and since 2016 began to start moving towards national levels. The chlamydia diagnostic rates per 100,000 for people aged 25 and over rose between 2014 and 2016, remaining below national levels, reducing by 15.6% from 2016 to 2017.

Syphilis, Gonorrhoea, Herpes and Genital Warts
The syphilis diagnostic rate per 100,000 population in Lincolnshire has performed better than national levels since 2012.

The gonorrhoea diagnostic rate per 100,000 population in Lincolnshire has increased by 89% from 2012- 2017, performing better than national levels since 2012.

The genital warts diagnostic rate per 100,000 population in Lincolnshire has also performed better than national levels since 2012, reflected in a reduction of incidence of 24.5% between 2012 and 2017.

The genital herpes diagnosis rate per 100,000 population in Lincolnshire has performed better than the national level since 2012, despite moving closer to the national level in 2017.

HIV – Prevention of Transmission
The percentage of HIV testing coverage in Lincolnshire performed better than the national level for the first time in 2017 since 2009. A similar picture can be seen for MSM HIV testing coverage which has also risen since 2009, remaining similar to national levels in 2017. However, HIV testing coverage for men in Lincolnshire has performed worse than the national average since 2009, starting to move closer towards national levels in 2017, whilst the percentage of HIV testing coverage for women has performed better than the national levels since 2015.

The percentage of population taking up HIV testing performed worse than the national levels from 2009 to 2015, but remained similar to national levels from 2016 to 2017; showing improvement in the uptake of HIV testing in Lincolnshire.

The percentage of MSM taking up HIV testing remained similar to national levels between 2009 and 2017, showing a steady increase of MSM taking up HIV testing. The percentage of men taking up HIV testing however perform worse than the national level from 2009 to 2017; despite the rise in the numbers of men taking up HIV testing in Lincolnshire. On the other hand the percentage of women taking up HIV testing has been better than the national level from 2015 to 2017; with an overall increase of HIV testing uptake amongst women in Lincolnshire.

The new HIV diagnosis rate (per 100,000 aged 15+) showing Lincolnshire has performed better than national levels from 2011 to 2017.

Overall the HIV diagnosed prevalence rate (per 1,000 aged 15 -59) of 1.76 has risen since 2011 and performs better than national levels. It remains below the recommended target for Local Authority and NHS bodies (UK National Guidelines for HIV Testing 2008):- (HIV prevalence exceeds 2 in 1,000 population aged 15 to 59 years) in primary care.

The percentage of population that had an HIV late diagnosis remained similar to national levels from 2015 to 2016 (Lincolnshire: 22%; England: 41.1%), but has not achieved the national target to reduce late HIV diagnosis to below 25%.

Reproductive Health
The Lincolnshire total rate of prescribed LARC (excluding Injections) per 1,000 population has been higher than the national level since 2014. GP prescribed LARC (excluding Injections) have also remained higher than national levels at a similar rate since 2011, indicating no significant change, compared to SRHS prescribing LARC (excluding Injections) which have performed below national levels since 2014.

The proportion of under 25s who chose LARC (exc. Injections) at SRH Services (%) remained similar to national rates from 2014 to 2015 in Lincolnshire, but dropped below the national level in 2016. However, the proportion of over 25s who chose LARC (excluding Injections) has exceeded national levels since 2016.

The proportion of women who chose injections at SRH Services in Lincolnshire, has remained similar to national levels since 2014, dropping below national levels in 2016, whilst the proportion of women who chose user-dependent methods at SRH Services was lower than national levels from 2014 to 2016.

Women who chose hormonal short-acting contraceptives at SRH services were also significantly below national levels.

Teenage Pregnancy and Termination of Pregnancy
The Office for National Statistics (ONS) teenage pregnancy- perception vs. reality report has collected teenage pregnancy data since 1969. Since the launch of the government's teenage pregnancy strategy in 1999 teenage pregnancy rates show a decline and have further fallen for both under 16s and under 18s conception rates. According to the conception statistics for England and Wales the under 16 conception rate per 1,000 women aged 13-15 reduced by 57.8% from 1998 to 2015.

In Lincolnshire the under 16s conception rate per 1000 females has remained similar to national levels since 2009, decreasing by 58.6% from 2009 to 2016.

The Under-18s conception rate per 1000 females has also remained similar to national levels since 2007 and has fallen by 53.7% since 1998. Since 2010 some areas of Lincolnshire have exceeded the National Teenage Pregnancy Strategy's original goal of a 50% reduction, whilst other areas continue to have higher levels of under-18 conceptions. There is a strong correlation between wards with high under-18 conception rates and high levels of multiple- deprivation

The under-18s birth rates across Lincolnshire show a reduction of 62% since 2009, consistent with the national downward trend.

Recent trends for under-18s abortions per 1,000 females aged 15-17 remained similar to national levels from 2016 to 2017, showing a reduction in trend.

Key Inequalities

Sexual Health and Reproductive Health

There are several equality strands that have the potential to impact on sexual health. These include age, socio-economic status and sexual orientation.

Age
The effective uptake of sexual health services by young people is influenced by various factors including their awareness and knowledge of the services that are available. Schools remain inconsistent in their provision of sexual health information but parents often solely rely on this source to provide their children with information relevant to the promotion of sexual health.

Inequalities persist in the provision of sexual health information for young people; the impact of STIs therefore remains greatest in young people under the age of 25 years. Between 2014/15 and 2015/16, there was a drop in contacts with sexual health services. This reduction in contacts was highest in younger age groups (under 25s), which underscores the need for continued efforts to engage with young people and provide accessible digital services and relevant information

More mature women who are experiencing relationship breakdown and divorce are noted to be increasing sexual activity and may require more targeted information about RSH.

Within the older MSM community, Lincolnshire RSH services note an increase in co-morbidity and substance misuse which have significant impacts upon mental health.

Socio-economic deprivation
There is evidence that a consistent association exists between socioeconomic disadvantage and higher risk of chlamydia infection. For example, individuals from families with lower disposable income or whose mothers had fewer educational qualifications were more likely to have chlamydia infections (Source: DECIPHer). This association may reflect a number of factors including social variation in engagement with Chlamydia control programmes (Source: Crichton et al, 2015). There is limited research evidence available locally to demonstrate that areas with higher levels of deprivation tend to have higher rates of sexually transmitted infections.

Sexual Orientation
HIV infection in the UK disproportionately affects Men who have Sex with Men (MSM). These groups have a higher risk of poor sexual health and experience stigma and discrimination, which can influence their ability to access services. LGBT+ service users generally have a good rapport with LISH and Positive Health, and SRH staff are very aware of the need to consider all screening requirements for transgender clients. There is a greater focus in Lincoln for drop in clinics offering Point of Care Testing (POCT) which needs to be offered more widely across the county.

Other Inequalities
In addition to the above, Lincolnshire is recognised as a sparsely populated and rural county with poor transport links. This can affect the ability of people to access services and ongoing treatment. For further information please refer to the JSNA Access to Transport topic.

In Lincolnshire during 2015/2016, 7% of the resident female population aged between 13 -54 had at least one contact with sexual health clinics, but only 1% of men in the same age group made a contact, which indicates a need to improve equality of access.

In Lincolnshire; Eastern European communities, young people with Special Educational Needs and Disability (SEND), young people who are “Not in School, Education or Training” (NEETS) and Men who have Sex with Men (MSM) population represent a large proportion of unmet need. Pockets of deprivation in South Holland, South Kesteven and Boston equate to lower uptake of sexual health service offers in these areas. The RSE team are supporting special needs and disability (SEND) schools to adapt teaching around RSH and LISH to become autism friendly.

Eastern European individuals may have unmet health needs, partly due to work patterns and locations within a rural county, cultural beliefs and language barriers. Outreach by LISH and the provision of rapid access clinics-(FlyBy) alongside postal testing are helping to improve uptake. Greater assessment of need and barriers is required for better access to vulnerable groups and the Eastern European community.

There are about 30 Public Sex Environments sites (PSE) across Lincolnshire, mainly used by MSM and male and female sex workers. Local knowledge suggests there is a growing 'swingers' community (couples who want to have multiple casual sexual relationships, sharing partners or arranging group sex). LISH Genitourinary Medicine (GUM) Consultants and Sexual Health Practitioners have identified that these groups of sexually active people are more likely to practice unsafe sex and outreach work is the optimal method of engagement to promote safer sexual activity as individuals require complete anonymity.

Teenage Pregnancy and Termination of Pregnancy
Teenage pregnancy should be considered within the context of healthy relationships and having aspirations for the future, as well as positive sexual health. Raised aspirations and skills in resilience have a direct influence in reducing the full range of poor outcomes for young people, including teenage pregnancy (Source: Teenage Pregnancy Strategy: Beyond 2010).

The majority of under-18 conceptions are unplanned and almost 50% end in termination. There is a strong correlation between young people who take risks with sexual health who also take wider risks including drug taking and high levels of alcohol consumption. It is often under the influence of alcohol and/or drugs that conceptions take place.

National research shows that children born to teenage mothers have higher rates of infant mortality and are at increased risk of low birth weight which impacts on the child's long term health. Young mothers are also less likely to breastfeed than older mothers. Babies of young parents have a higher rate of hospital admissions within the first year of life than babies born to older parents.

Teenage mothers are three times more likely to experience poor emotional health and wellbeing and are more likely to suffer from postnatal depression and experience poor mental health for up to 3 years after the birth. In addition, 2 in 3 teenage mothers experience relationship breakdown during pregnancy or the 3 years after birth.

Teenage parents and their children are at an increased risk of living in poverty, low educational attainment, poor housing and health, and have lower rates of economic activity in later life. 1 in 5 girls aged 16-18 not in education, employment or training (NEET) are teenage mothers and are 22% more likely to be living in poverty at age 30. (Source: Teenage Mothers and Young Fathers Support Framework, (2016))

Young parents have significantly poorer health and educational outcomes than their peers and their own children are likely to have worse outcomes than their peers. This creates a generational cycle of poor outcomes for this group of children and young people, particularly as young women are ten times more likely to become a teenage parent if they are the daughter of a teenage parent.

Current Activity & Services

 

Integrated Sexual and Reproductive (SRH) services are a mandatory responsibility of the Local Authorities under the Health and Social Care Act 2012, bringing together Contraception and Genito-Urinary Medicine (GUM) from 1 April 2016.

Lincolnshire County Council has commissioned a range of services to meet local needs as identified in the Sexual Health Needs Assessment (SHNA) 2014. These are managed within a pooled budget and funded by the Public Health Grant.

Table 1: Main Sexual Health Service Providers in Lincolnshire

Service Provider Services
Lincolnshire Integrated Sexual Health Service – LISH (provider is Lincolnshire Community Health Services) Integrated, specialist sexual and reproductive health service for 13 years and over
Mobile clinics
Flyby clinics
'Vulnerable and hard to reach' outreach services
Chlamydia screening and treatment (NCSP)
HIV testing and treatment
Local SRH training
Primary Care Under the GMS contract, GP practices provide general prevention advice, contraception including Emergency Hormonal Contraception (EHC), pregnancy testing, testing and treatment for STIs and gynaecological conditions, fertility advice and referral for termination of pregnancy to ULHT,
In addition, many are commissioned by Lincolnshire County Council (LCC) for LARC and by LCC for chlamydia screening.
Pharmacies are commissioned by LCC to provide Emergency Hormonal Contraception (EHC) and by LISH to provide chlamydia testing and treatment. They currently also provide pregnancy testing for under 20 year olds, however this is ending March 2019 as it is no longer being utilised by the target group.
The C-Card Condom Scheme is a voluntary offer provided by many GP Practices and Pharmacies, managed by LISH. A reduced number of community organisations also deliver the C-Card scheme with more sites being recruited and trained.
Relate Psychosexual counselling (LISH sub contract)
Positive Health Direct provision of RSE to schools, further education settings, community groups and health & social care staff
Wellbeing and social support to people with HIV
HIV prevention and equality campaigning
Outreach services

All SRH services in Lincolnshire are free, accessible, non- judgemental, non-discriminatory and demonstrate respect and inclusion of people with protected characteristics, including the Lesbian, Gay, Bisexual, Transgender (LGBT+) community.

Services such as sterilisation, termination of pregnancy and complex gynaecological services are provided by United Lincolnshire Hospitals Trust (ULHT).

Sexual Assault Referral Centres (SARC), HIV treatment and Human Papilloma Virus (HPV) Immunisation are provided by NHSE.

Lincolnshire Integrated Sexual Health Service (LISH)
The service commenced on 1st April 2016 and combines sexual health and contraception services in a flexible delivery pattern. All LISH clinical staff are dual trained which provides a 'one stop shop' experience for clients, reducing the need for more visits and ensuring a holistic approach to prevention and promotion.

The Level 3 specialist clinics are located in Lincoln, Grantham, Boston, Spalding, Sleaford, Skegness, Louth and Gainsborough. New clinics have started in Market Deeping, Stamford, North Hykeham, Monks Road Lincoln, and at two Maternity Hubs.

Pop Up Clinics are demand led and temporary, but experience indicates that they need to run more consistently with increased marketing to become established, success is influenced by finding the right location.

A Mobile Community Clinic follows regular weekly routes to include rural areas and target areas of higher incidence of under 18 pregnancies and STIs. LISH provide specialist sexual health support to Positive Health clients, Addaction clients and work closely with the school age immunisation team and looked after children.

Strategic Development - Effective contract management is being enhanced with a Strategic Contract Management Meeting (CMM) for LISH and a Lincolnshire SRH Peer Review to encourage engagement of strategic stakeholders and effect change in their organisations; to support and embed SRH into different services

C-Card service
A variety of sites are available in Lincolnshire to provide registration for the C-Card for young people aged 13-19, to obtain education about sexual and reproductive health and free condom supplies. Regular training is provided to practitioners who are encouraged to discusses chlamydia screening, safe condom use and raise awareness of all types of STIs with young people and signpost to online testing and sources of information.

With diminished teenage pregnancy services and reduction of youth services generally, there are fewer local registration sites available and a review has being carried out to identify gaps and attract new sites.

Chlamydia Pathway (PHE)
The LISH service has increased outreach and targeted work and is currently reporting a 9% positivity rate against a Public Health Outcomes Framework (PHOF) target of 8%. A new pathway is being introduced which focuses on achieving higher detection rates by greater follow up after 6 weeks of initial diagnosis for retesting (which can achieve a 14% positivity rate) and partner notification (which can achieve a 60% positivity rate).

On-line Chlamydia and Gonorrhoea Testing is available through LISH which provides an online self-testing kit for personal use at home for under-25 year olds.

HIV Support
A Section 75 agreement is in place between LCC and NHS England (NHSE) to ensure the provision of HIV testing and Anti Retro-Viral Therapy (ART).

Currently LISH provide support and treatment for 300 HIV positive patients, working closely with Positive Health. LISH Genitourinary Medicine (GUM) Consultants have joined the NHSE PrEP-Pre-exposure prophylaxis pilot trial and had 60 places available - which are currently filled.

Promotion and Prevention work
LISH has a SHAPP (Sexual Health Advice, Prevention and Promotion) Team that focuses on the NCSP, using the Chlamydia Screening Pathway and providing advice and support and triage. A dedicated Communications Officer supports client engagement and marketing for LISH.

Social media is used to successfully advertise services and promote a healthy and safe sex life. Local campaign work through the Sexual Health Alliance Lincolnshire (SHAL) partnership is planned to promote safer sex, personal responsibility and greater access to condom supplies supporting national events such as Sexual Health Awareness Week, National HIV Awareness Week, HIV Testing Week and the annual Pride event.

Training
An accredited FSRH Trainer supports the planning and delivery of LISH training including dual competency training for LISH staff to provide a one stop shop service for patients
Royal Society for Public Health (RSPH) course in Understanding Sexual Health
LARC competency CPD
Basic and Advanced Contraception
A bi-annual Sexually Transmitted Infection Foundation course (STIF)
A bi-annual Sexual Health Conference
C-Card and chlamydia training, on a monthly basis, widely available to all stakeholders

Positive Health
Positive Health is commissioned directly by LCC, to increase awareness of HIV, provide social care support to clients and their families where there is an HIV positive diagnosis, provide PHSE education sessions in schools and colleges working closely with the Stay Safe Partnership and using this platform to promote their training portfolio, reaching around 15,000 young people a year. They also provide HIV awareness in care homes, hospital wards, higher and secondary education settings.

They provide outreach work to hard to reach groups: Lesbian, Gay, Bisexual and Trans-sexual (LGBT+) communities and MSM. They reached 600 people in 2017-18 and several are starting to attend the Point of Care HIV Testing (POCT) clinic at Positive Health.

Positive Health provides free condoms to clients and provides weekly (POCT) sessions at two locations with referral to LISH services for treatment. They provide support groups and host a 24 hour helpline.

Positive Health focuses on raising awareness of HIV which includes support of national campaigns such as National HIV Testing Week, World Aids Day and PRIDE events.

Long Acting Reversible Contraception (LARC)
GP practices are commissioned to provide LARC implants and IUDs and new contract management arrangements alongside local training are being developed to ensure competency is maintained. Audits indicate a need to develop a sustainable approach to continue to offer women this service at a choice of locations.

Emergency Oral Contraception and Pregnancy Testing
Community pharmacies are commissioned to provide these services for young women and new contract management arrangements are being developed. A new approach is being planned to use the Healthy Living Pharmacies.

Young people can access pregnancy testing from RSH clinics and GP surgeries across the county. This free service is currently offered via Lincolnshire pharmacies, however the service is underutilised and not acceptable to young people, therefore will be decommissioned from April 2019.

Support for Teenage Parents
Children’s Services support for teenage parents is delivered mainly through 48 Children’s Centres in Lincolnshire along with one to one work carried out by Early Help Support Workers, usually in the home. Teenage parents can access a range of provision at Children’s Centres which provides an opportunity for peer support.

0-19 Children’s Health Service
LCC directly provides the 0-19 Children’s Health Service, with an integrated approach to public health to ensure patient safety; strengthening the focus on health promotion and the National Healthy Child Programme. LISH is working in partnership as part of an enhanced service for young people aged 13 plus.

The Young People Sexual Health Service Enhancement specification has been added by contract variation to the LISH contract which aims to embed clinical support for young people into universal LISH provision; support all staff to develop relationship building skills with young people based on attitudes and values; and improve engagement and marketing.

The 0-19 Children’s Health Service offers universal and universal plus health visiting and nurses for school aged children. Health visiting provides universal care to children and their families from the antenatal period until the child reaches the end of reception class (0-6 years). Children and young people’s specialist nurses offer health support to school aged children (6-19 or up to 25 years for those classed as having SEND) and their families in managing health issues and long term conditions.

A new emotional wellbeing service has been commissioned to give greater access to support through on line counselling. Healthy Minds Lincolnshire, delivered by Lincolnshire Partnership NHS Foundation Trust, provides emotional wellbeing support to children and young people up to 19 years old (or up to age 25 for those with special educational needs/disability or who are leaving care).

Emotional wellbeing is about being happy, confident and having good relationships and Healthy Minds Lincolnshire can help with a range of emotional wellbeing concerns that affect this, such as exam stress, worries, low mood, poor body image, self-harm, relationship difficulties and low self-confidence.

An NHS wellbeing website has been developed to support young people, parents/carers and professionals in the first instance to view self-help information and to identify and access relevant national and local emotional wellbeing, behaviour and mental health support services, ensuring access to the right service at the right time, using:

  • Cognitive behavioural therapy (CBT) techniques, which are designed to help young people think about things differently and learn to cope in a more positive way.
  • Support and advice to parents and carers.
  • Bespoke training to education and children’s services professionals designed to build confidence in dealing with emotional wellbeing issues and providing a toolkit to support children and young people’s needs.

A free, confidential, safe and anonymous way for young people to ask for help is provided by the Kooth on line counselling service.

Relationships and Sex Education (RSE)
The Children and Social Work Act 2017 introduced new legislation on Relationships and Sex Education in schools. Chapter 4 section 34 introduces statutory ‘Relationships and Sex Education’ across all secondary schools, including academies and independent schools; and statutory ‘Relationships Education’ across all primary schools. A team has been recruited in Public Health who engage with schools to ensure readiness for RSE becoming statutory in September 2020.

Appropriate RSE delivered within an integrated spiral curriculum has been shown to have a significant positive effect on pupil health and wellbeing, improving educational attainment and attendance. All children and young people, of all ages and protected characteristics, will have the benefits of a tailored curriculum that is age appropriate and will empower them with knowledge and information.

All schools and staff will be further equipped to have a robust framework for RSE to meet the requirements of OFSTED. Staff will feel more confident and have the knowledge base to be able to support and inform children and young people of all ages, and all protected characteristics about the key RSE messages. Relationships and Sex Education (RSE)

Unmet Needs & Gaps

 

Support to young people around teenage pregnancy has reduced in Lincolnshire over recent years and new methods are needed to improve young people’s access to reproductive and sexual health services. The existing free condom scheme (C Card) is being redeveloped and extended to new sites such as maternity hubs and made available through new partnerships such as YMCA and Early Help Workers, alongside improved data capture to better inform ongoing service development.

Local campaign work is needed to better inform young people and address the wider cultural issues which prevent children and young peoples’ access to information and advice about healthy relationships and positive sexual health from their parents and carers.

Relationships and sex education (RSE) provision is recognised by the National Children's Commissioner to be inadequate in the UK and legislation is planned to make RSE and Health Education compulsory in all schools by 2020. To support this new programme Lincolnshire Public Health has a team of RSE Advisors who are embedding the resources required and support educational settings to develop their policies and curriculum.

Access to terminations has become increasingly difficult for Lincolnshire women with reduced capacity in ULHT and LISH staff report they experience problems in referring women in a timely manner. At present women who are below 12 weeks of pregnancy can be referred to United Lincolnshire Hospitals Trust (ULHT). Women over 12 weeks of pregnancy have to attend Scunthorpe General Hospital. The number of terminations has reduced overall, however LISH refer 30-40 patients per month and patients will also be referred through GPs. A local review is needed to evaluate current provision and look at new methodology for hormonal terminations.

There appear to be gaps in provision of STI screening as the rate in Lincolnshire is below regional and national levels. This could be due to the nature of being a University City with a high number of students and the access issues faced by young people living in rural areas, with poor access to transport. The highest rates of new STI's are in the younger population of under 25 year olds and there has also been a reduction in attendance at SRH clinics nationally. Young people need rapid access to quality information, advice and treatment therefore communication needs to be improved using digital technology and self- help options, alongside targeted provision by LISH, such as Pop Up Clinics using the mobile clinic.

Rising numbers of over 25s are contracting chlamydia and there are limited screening services for this age group. There is an increased demand and need for more preventive services and testing for mature age groups; however the under-25 age group remain at higher risk. Further work is needed to identify the needs of older females in particular and plan strategically to meet their needs.

The total numbers of people in Lincolnshire living with HIV is not accurately known, partly due to the desire of patients to maintain anonymity. LISH reports approximately 300 clients with a positive diagnosis. Patients often travel to out of area clinics to preserve their anonymity so obtaining accurate data capture is challenging.

Lincolnshire residents have the choice to use out of area, non- contracted services, at the point of need, which causes significant cost pressures for LCC. Out of area SRH service costs are monitored and challenged with considerable success in reduction. More work is required to investigate the reasons for using alternative clinics, which may include using more anonymous services, fitting in appointments around work and accessing evening and weekend clinics. Increased capacity in LISH has been created at weekends and evenings with more locations of clinics on the county borders, to reduce out of area appointments.

Gaps in sexual health provision includes people in LGBT+ communities, couples who change sexual partners frequently as part of the ‘swingers community' and men having sex with men (MSM). This last group do not usually see their behaviour as risky and do not identify themselves as either homosexual or bi-sexual. A higher profile is required for health protection for these groups and innovative methodology is needed to improve reach and service provision.

Local Views & Insights

 

The Sexual Health Alliance is a new partnership group encompassing a Youth Forum where joint event planning takes place, alongside sharing knowledge of services, best practice and developments. This group are already forming strong relationships and delivering SRH Wellbeing in cost effective ways.

Positive Health has excellent engagement with hard to reach groups particularly with those practising unsafe sex in the LGBT+ and MSM communities and patients who are HIV positive. Due to their outreach work they are able to provide a better understanding of current trends and activity within these groups which can help tailor the services to meet needs in an appropriate and non-judgemental way. Staff act as strong advocates for their client groups and rapidly identify changes in sexual behaviour patterns. Client perspectives are gathered through regular evaluation, quarterly case studies and engagement opportunities at the annual quality review.

LISH publishes patient comments and has engaged the Young Inspectors team in mystery shopping, review of promotional resources and they also provide a young person's perspective on sexual health provision. The main identified need is to provide digital platforms and be more direct in communications about how to seek advice and support.

Views and insights are gathered through a range of engagement activities such as Family & Friends Tests, back to floor walks, feedback and evaluations. At contract management meetings, services provide anonymised case studies which 'tell the story' of how clients have used the services. Quality is reviewed at annual CMMs with site visits and arrangements made to meet service users and gather their opinions.

LISH have a dedicated engagement and marketing officer and all promotional resources are being refreshed and a new website is in development. LISH held a three month engagement exercise with young people to gather views on how young people would be best served and their preferred routes and communication styles. The outcomes are now being implemented.

Risks of not doing anything

Programme reduction may result in:

  • Increased morbidity and mortality
  • Increased transmission of STIs causing avoidable ill health and serious disease
  • Increased burden on health systems and a reversal of economic and social gains
  • Less choice around contraception and consequent rise in unwanted pregnancy
  • Increased numbers of women seeking termination of pregnancy
  • Disruption of family life, mental health and personal relationships

Chlamydia infection causes sexual and reproductive ill health, including complications such as pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility, conjunctivitis, and epididymitis in men, all of which impact physical and mental health and increase NHS costs. Chlamydia often has no presenting symptoms: about 70% of infected females and 50% of males will not have any obvious signs or symptoms or they may be so mild they are not noticed. Therefore opportunistic screening is essential for reducing prevalence of this avoidable infection.

Reduced public awareness may continue the trend for people to make risky health choices and for stigma around HIV to increase.

Reduced training could result in sexual health practitioners losing competency and reduce the current high quality clinical services.

Failing to increase service capacity on county borders would likely increase out of area costs significantly, which is borne by the LCC Public Health Grant at present.

Key early intervention with those most vulnerable may reduce which may result in poorer SRH outcomes for the most vulnerable families.

There is a strong economic argument for investment in services, as RSH consequences that are not addressed causes a significant burden on public services. Examples include undetected HIV. The cost of treatment per annum when HIV is diagnosed early is around £14,000 per case compared to £28,000 for late diagnosis and each case of HIV infection is estimated to represent between £280,000 and £360,000 in lifetime costs. (Source: NICE)

There were approximately 5,200 new HIV diagnoses in England in 2014. (Source: Resource impact report: HIV testing. December 2016). If 1% of these (52 cases) had been prevented, between £15 and £19 million lifetime treatment and clinical care costs would have been saved (Source: Health Protection Agency - Evidence and resources to commission expanded HIV testing in priority medical services in high prevalence areas:)

As regards teenage pregnancy, over 20% of under-18 conceptions occur in the most deprived communities, thus the negative consequences are disproportionally concentrated among those who are already disadvantaged. (Source NICE) The cost of teenage pregnancy to the NHS alone is estimated to be £63million a year.

Alongside the physical and psychological impact on women who find themselves in this situation, there is also the significant financial impact of unplanned pregnancy on the NHS. From data submitted by Bayer Healthcare, it has been estimated that the annual cost to the NHS in England of unintended pregnancy stands at £817 million. Consequently, taking steps to reduce the number of unintended pregnancies could deliver significant cost savings to the NHS. Bayer proposes that every £1 invested in contraception saves the NHS £12.50.

One fifth of births amongst under-18s are repeat pregnancies, when for every £1 invested in contraception saves the NHS £11 in costs for abortion services, ante-natal and maternity care. Estimates also suggest that every £1 spent delivering teenage pregnancy objectives saves approximately £4 to the public purse. (Source: The Morning After: A Cross Party Inquiry into Unplanned Pregnancy February 2013)

What is coming on the horizon?

The Department of Health and Social Care (DHSC) issued a new Sexual Health Service Specification in August 2018 which includes cross charging guidance. The SRH services in Lincolnshire will be reviewed against the new guidance.

The DHSC Termination Specification is due for publication which will require local decision makers to review current pathways and provision as there is a move towards a small number of Centres of Excellence. Access is already difficult for women in Lincolnshire and may worsen, especially for young people and vulnerable women, who may be in financial difficulties or who want to protect their confidentiality.

The government announced in July 2018 that adolescent boys aged 12- 13 will be offered the human papilloma virus (HPV) vaccine to protect them from cancer.

NHS England will fund a major extension to the national HIV prevention programme led by PHE with the aim of supporting those most at risk and reducing the incidence of HIV infection. They will commission ten new specialised treatments as part of the annual prioritisation process for specialised treatments.

The Pre Exposure Prophylaxis (PrEP) trial with PHE is ongoing for the next two years after which this type of treatment will be assessed. Decisions will need to be taken about the provision of PrEP treatment in the future and how it will be funded. Following judicial reviews and appeals, NHSE has been advised they have the ability but not the obligation to commission PrEP.

HIV Prevention England has been contracted on behalf of Public Health England, to produce, a range of activities/resources that aim to reduce HIV incidence in MSM and other most at-risk populations. The FPA have been commissioned to provide 'Sexwise' a new information portal with downloadable resources.

The reconfiguration of local services, as part of the Sustainable Transformation/ Lincolnshire Health and Care Plan, are due to be announced in 2019.

LISH had a variation of contract in 2017 to include elements of sexual health provision to young people. The service is registering for the "You're Welcome" Standard with upskilling of every member of staff to interact with young people sensitively and appropriately.

A three month participation and engagement exercise with young people has been extended to include rural areas and a report is in production to inform service development. It was clear that LISH needs to develop digital services to support young people to take the first step in using local RSH services.

Lincolnshire County Council's Young Inspectors are market testing pharmacy provision of EHC and chlamydia screening and treatment annually, following their exercise in 2017, when they advised much more work was required to provide an accessible consistent and youth friendly service. Their input helps to clearly identify what young people need and where they would like to access services.

Chemsex activity is starting to be observed in Lincolnshire and the local Addaction service is working in partnership with LISH to provide greater levels of detection and testing/treatment support, including psychological and emotional support.

Child Sexual Exploitation and abuse is an issue of growing concern and PHE are looking at Co-commissioning support for younger children (under 13) in Lincolnshire who need long term counselling and follow up testing and treatment, after referral to Paediatric SARC in Nottingham for the initial assessment, support and treatment during the forensic window.

What should we be doing next?

Access to good quality sexual and reproductive care reduces the risk of adverse outcomes which impact upon life chances. Therefore the priorities are:

  • Empower young people to make confident and informed sexual and relationship choices, to reduce the transmission of STIs and maintain low rates of teenage pregnancy. Help parents and carers to confidently engage in conversations about sexual health throughout their child's development and growth.
  • Improve digital and self-serve options to increase STI testing rate and accessibility, adopting the UNAIDS 90:90:90 ambition that sets out a global target for 90% of people living with HIV to have their status known, 90% of those diagnosed to receive treatment and 90% of those treated to be virally suppressed.
  • Increase the capacity and accessibility of LISH clinics and reduce out of area costs.
  • Improve wider working initiatives through the Sexual Health Alliance to facilitate RSH at the right time in the right place.
  • Adopt the U=U message (BHIVA) that ‘Undetectable Equals Untransmittable’ to bring hope and reduce the stigma of HIV.
  • Work closely with Maternity Transformation Services to bring SRH closer to where women live and develop early post-natal access to LARC.
  • Target RSH to vulnerable groups, such as young people with special educational needs or disability, Eastern Europeans, travellers, MSM, homeless people and improve the RSH offer for more mature women.
  • Monitor outbreaks of syphilis and engage in targeted prevention work.
  • Work with the integrated children's commissioning team and PHE to map sexual health services for under-13s in Lincolnshire and identify gaps to inform new commissioning directions.
  • Influence local decision making as regards access to termination services and consider Skype or telephone support for hormonal methods of contraception.
  • Produce a county-wide Sexual Health Strategy in 2019 following a mid-term Review of current services and utilise return on investment and social impact tools.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk