When we get ill: sexual health

Page last updated: 2019 - due to be refreshed in 2021.

 

1 Five key points    

  1. The general picture of sexual health in Suffolk is positive, with low prevalence of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) and lower rates of teenage pregnancy compared to other parts of England. (3.1 Overview
     
  2. However, pockets of need exist within the local population. The burden of STIs is higher amongst people aged under 25, black ethnic groups and residents of Ipswich. (3.1 Overview
     
  3. The consequences of poor sexual health are not limited to infection, they also include an increased risk of unwanted pregnancies. In Suffolk, the under 18 conception rate has consistently been significantly lower than the England rate since 1998. (3.6 Teenage pregnancy
     
  4. Considering all STIs together, diagnoses have decreased over the last 5 years. However, diagnoses of syphilis and gonorrhoea have increased over this period both locally and nationally. (3.2 Sexually transmitted infections
     
  5. The rate of abortion gives an indication of lack of access to good quality contraception services and advice, as well as problems with individual use of contraceptive method. In 2017, the Suffolk rate of abortions was significantly lower than the England average. (3.5.2 Abortion)

2 Why is sexual health important in Suffolk?        

The World Health Organisation defines sexual health as a state of physical, emotional, mental and social wellbeing in relation to sexuality. 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 violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.[1]

Most adults are sexually active and good sexual health matters to individuals and communities. Sexual health needs vary according to factors such as age, gender, sexuality and ethnicity. However, there are certain core needs common to everyone such as high quality information and education to enable people to make informed responsible decisions, and access to high quality services, treatment and interventions. Ensuring that people have the support and resources to maintain good sexual health is vital for promoting good health across the population.[2]

Nationally, there were around 420,000 diagnoses of sexually transmitted infections (STIs) in 2017, with reported cases of syphilis and gonorrhoea increasing by 20% since 2016.[3] The impact of STIs remains greatest in young heterosexuals aged 15 to 24 years, black ethnic minorities and men who have sex with men (MSM).

The consequences of poor sexual health are not limited to infection, they also include an increased risk of unwanted pregnancies. Available evidence shows that unplanned pregnancies can have a negative effect on women and children’s lives and result in poorer outcomes than those that are planned.[4] Teenage pregnancy is associated with poor educational, social and economic opportunities for parents and their children.[4]

3 What is the local picture?       

3.1 Overview

The general picture of sexual health in Suffolk is positive, with low prevalence of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) and lower rates of teenage pregnancy compared to other parts of England. However, some populations in Suffolk have higher needs.

There is a correlation between deprivation and higher rates of teenage pregnancy, with higher rates in Ipswich than across England as a whole. The burden of STIs is higher amongst people aged under 25, black ethnic groups and residents of Ipswich. Although absolute numbers are relatively low, rates of gonorrhoea and syphilis (both historically rare STIs) are on the rise. The diagnosed prevalence of HIV is low in Suffolk compared to England but late diagnosis of HIV is higher than England in Forest Heath, Ipswich and St Edmundsbury. 

3.2 Sexually transmitted infections

Sexually transmitted infections (STIs) represent an important public health problem both locally and nationally. In 2017, there were 3,344 new diagnoses of STIs in Suffolk. This represents a rate of 445 diagnoses per 100,000 population, which is one of the lowest rates in the country, significantly below both the East of England (585.9 per 100,000 population) and England average (793.8 per 100,000 population).[5] The rate of STI diagnoses has decreased over the last 5 years, falling from 570 to 445 diagnoses per 100,000 population between 2012 and 2017.[6]

However, this positive picture hides some key areas of need. Ipswich has significantly higher rates of STI diagnosis (708 diagnoses per 100,000 population) than all other Suffolk districts, although still significantly lower than the England average[6]. Considering all STIs together, diagnoses have decreased over the last 5 years. However, diagnoses of syphilis and gonorrhoea in Suffolk have increased over this period to 35 and 188 cases in 2017, respectively[6]. Despite the numbers being relatively small, this rise represents a key challenge in light of the rise in antibiotic resistant strains of gonorrhoea now found in the UK.[7]–[9] This is a trend reflected across the UK and action is being taken nationally to address these rises.

Sexually transmitted infections disproportionally affect particular sub-groups of the population. Nationally, STI rates are higher among certain groups such as young people, black ethnic populations and men who have sex with men (MSM).[5] These findings are also true in Suffolk. In 2017, approximately 4 in 10 (40%) STI diagnoses in Suffolk were among individuals aged under 25, with STI diagnosis rates several times higher among these groups compared to older residents (Figure 1). It is probable that higher rates amongst younger people are partly increased by opportunistic screening of young adults, where sexually active individuals without symptoms are tested for STIs such as chlamydia. Men who have sex with men (MSM) are a particularly high risk group for STIs in Suffolk, accounting for 3 in 4 (74.3%) cases of syphilis and nearly 1 in 3 (31.4%) gonorrhoea diagnoses.[10], [11] For this reason, targeted work is required among these groups alongside the delivery of universal sexual health services to ensure that those with the greatest need are enabled to maintain good sexual health.

Figure 1: Rate of STI diagnoses per 100,000 population by age group, Suffolk, 2017[10], [11]

 

Figure 1: Rate of STI diagnoses per 100,000 population by age group, Suffolk, 2017

Sources: Public Health England. GUMCAD STI Surveillance System; Public Health England. GUMCAD data extract. (2018).

3.3 Chlamydia screening

Chlamydia is the most common bacterial STI, with sexually active young people at highest risk. As chlamydia often has no symptoms and can have serious health consequences (such as pelvic inflammatory disease, ectopic pregnancy and infertility) opportunistic screening remains an essential element of good quality sexual health services for young adults. To address the fact that STIs disproportionately affect young people, population screening programmes such as the National Chlamydia Screening Programme (NCSP) have been put in place to control the spread of infection among 15-24-year olds.[12]

In 2017, the proportion of 15-24-year olds screened for chlamydia in Suffolk was 17.4%, which is below the average England coverage of 19.3% but above the regional average of 16.8%.[6] Despite fluctuations in screening coverage over recent years, the detection of chlamydia has remained stable. Possible explanations for this could be that screening has become progressively more targeted to those most at risk of infection, or that overall rates of chlamydia in the populations are rising.

3.4 HIV

In 2017, there were an estimated 420 people living in Suffolk with a diagnosed HIV infection. Suffolk has a lower diagnosed prevalence rate of HIV (1.03 diagnoses per 1,000 population aged 15-59) compared to England (2.32/1,000) and the East of England (1.55/1,000).[6] Nationally, an area is considered to have high prevalence if the rate is above 2.0 diagnoses per 1,000 population aged 15-59. Although all districts and boroughs had a significantly lower diagnosed prevalence rate of HIV than England, the prevalence in Ipswich (1.66/1,000), Waveney (1.22/1,000) and Forest Heath (1.09/1,000) were all higher than the Suffolk average.[6]

In 2017, around 29 new cases of HIV were diagnosed in Suffolk, which equates to a new HIV diagnosis rate of 4.6 diagnoses per 100,000 population aged 15+. This is significantly lower than the England (8.7/100,000) and East of England (6.7/100,000) rates.

People who are diagnosed promptly with HIV and can start taking medication early can expect to live to a near normal life expectancy. Conversely, for those who are diagnosed later, when the immune system has been severely damaged by HIV, the outlook is less positive. Late diagnosis is the most important single predictor of morbidity and mortality among those with HIV infection, with those diagnosed late having a ten-fold risk of death compared to those diagnosed promptly.[6] The proportion of people experiencing late diagnosis of HIV is worse in Forest Heath, Ipswich and St Edmundsbury compared to England. 

3.5 Reproductive health

3.5.1 Long acting reversible contraception (LARC)

The National Institute for Health and Clinical Excellence (NICE) advise that long acting reversible contraception (LARC) methods, such as contraceptive injections, implants and coils are highly effective as they do not rely on daily compliance and are more cost effective than condoms and the pill.[13] Implants and coils can remain in place for up to 10 years depending on the type of product.

A national strategic priority is to ensure access to the full range of contraception for all. Therefore, an increase in the provision of LARC is a proxy measure for wider access to the range of contraceptive methods. In Suffolk in 2017, 49.3 per 1,000 females aged 15-44 were prescribed LARC excluding injections, which is around 1 in 20 individuals.[6] This was slightly higher than the England rate of 47.4 per 1,000 females aged 15-44.

Within the districts/boroughs of Suffolk, the rate of prescribed LARC was highest in Waveney (58.3 per 1,000) and Ipswich (56.7 per 1,000).[6] This is likely to be influenced by the relatively younger female population found in Ipswich and Lowestoft compared to other areas of Suffolk.

3.5.2 Abortion

The rate of abortion in a population gives an indication of lack of access to good quality contraception services and advice, as well as problems with individual use of contraceptive method. In 2017, the Suffolk rate of abortions per 1,000 females aged 15-44 years (12.9 per 1,000) was significantly lower than both England (17.2 per 1,000) and the East of England (15.6 per 1,000).[6] In Suffolk, 1,592 abortions took place in 2017.[6]

Nationally, over a quarter (26.7%) of abortions among women aged under 25 years are repeat abortions. This is another indicator of lack of access to good quality contraception services and advice. In 2017, Suffolk had the lowest proportion of repeat abortions among under 25s in the East of England (20.1%), which equates to 130 repeat abortions occurring among under 25s.[6]

3.6 Teenage pregnancy

Nationally, conception rates for women aged under 18 years hit a record low in 2016, declining by 10% since 2015 and 60% since 1998.[14] This could be associated with improved access to contraception, a shift in aspirations for young women towards education, stigma associated with being a teenage mother and programmes invested in by successive governments. In Suffolk, the under 18 conception rate has consistently been significantly lower than the England rate since 1998. In 2016, the Suffolk rate was 16.0 per 1,000 females aged 15-17 compared to the England rate (18.8/1,000).[6]

At a district/borough level, the under 18 conception rate has decreased in all areas over the last five years. However, the rate in Ipswich has remained significantly higher than the Suffolk rate since 1998. Since 2015, decreases in the national rate mean the Ipswich rate (31.2 per 1,000 females aged 15-17) is now significantly higher than the England rate.[6]

4 What policies affect sexual health?       

National policy plays a key role in shaping the delivery of sexual health services at a local level. ‘A Framework for Sexual Health Improvement for England’ is a key policy framework which supports the commissioning of sexual health services in Suffolk.[2] The framework identifies 8 key objectives which contribute to the overall goal of improving sexual health across the population (Figure 2). In addition to this framework, a number of more specific policy documents on areas such as chlamydia screening, HIV treatment and care and the delivery of specialist sexual health services are used to inform local commissioning of specialist services and interventions.[12], [15], [16]

Figure 2: Key objectives for improving the sexual health of the whole population[2]

Figure 2: Key objectives for improving the sexual health of the whole population

Source: Department of Health. A Framework for Sexual Health Improvement in England

The 2015 Sexual Health Needs Assessment was conducted to better understand the sexual health needs of the population of Suffolk.[17] This provided some key recommendations and areas for action around improving access to services, increasing knowledge and awareness across the population and reducing stigma and inequalities associated with sexual health. Together, national policy and local data and intelligence are used to inform the ongoing development of services.

The delivery of sexual health services is complex. Local authorities are responsible for commissioning free, open access sexual health services for everyone present in their area. This includes STI screening and treatment, notification of sexual partners of infected persons, free contraception and reasonable access to all methods of contraception. However, some specialist services are directly commissioned by local NHS Clinical Commissioning Groups (CCGs), and at the national level by NHS England.[18] The responsibilities of each commissioning organisation are set out below (Table 1). Sexual and reproductive health services are therefore provided in a range of settings including community based sexual health clinics, general practice, pharmacies, acute hospitals and via wider services such as voluntary and community sector organisations.

Table 1: Sexual health commissioning responsibilities[18]

Local authorities:

  • Comprehensive sexual health services including most contraceptive services and all prescribing costs (but excluding contraception provided additionally by GPs)
  • Sexually transmitted infections (STI) testing and treatment, chlamydia screening and HIV testing
  • Any specialist services, including young people’s sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, services in schools, colleges and pharmacies

Clinical Commissioning Groups:

  • Most abortion services
  • Sterilisation
  • Vasectomy
  • Non-sexual health elements of psychosexual services
  • Gynaecology including use of contraception for non-contraceptive reasons

NHS England Commissioners:

  • Contraception provided as an additional service under the GP contract
  • HIV treatment and care
  • Promotion of opportunistic testing and treatment for STIs and patient-requested testing by GPs
  • Sexual health elements of prison health services
  • Sexual assault referral centres
  • Cervical screening
  • Specialist foetal medicine services

Most GPs in Suffolk provide contraceptive services including the contraceptive Pill, Long Acting Reversible Contraception (LARC) such as the coil or implants. GPs can also provide Emergency Hormone Contraception (EHC) for episodes of unprotected sexual activity. GPs also screen for chlamydia, a common sexually transmitted disease, for those aged under 25.Source: Public Health England. Commissioning local HIV sexual and reproductive health services - GOV.UK. (2013).

Further information about Sexual health services in Suffolk can be found on the Healthy Suffolk website: https://www.healthysuffolk.org.uk/advice-services/adults/sexual-health-suffolk.

5 Further information

The Department of Health document, ‘A Framework for Sexual Health Improvement for England[2] is a key policy framework which supports the commissioning of sexual health services in Suffolk. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf 

The British Association for Sexual Health and HIV (BASHH) are a specialist association for professionals working in the field of STIs and HIV. They provide information on the subject in addition to writing guidelines on STI screening and treatment. www.bashh.org

NHS Digital publish data about activity taking place at dedicated Sexual and Reproductive Health services in England. digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2017-18

The PHE Fingertips Sexual and Reproductive Health Profiles[6] have been developed to monitor the sexual and reproductive health of local populations and the contribution of local public health related systems. Topics such as teenage pregnancy, abortions, contraception, HIV, sexually transmitted infections and sexual offences are included. Wider influences on sexual health such as alcohol use, and other topics particularly relating to teenage conceptions such as education and deprivation level, are also included. fingertips.phe.org.uk/profile/sexualhealth

The British National Surveys of Sexual Attitudes and Lifestyles (Natsal) are among the largest and most detailed scientific studies of sexual behaviour in the world. Three Natsal surveys have taken place, with the first two providing major sources of data which informed sexual and reproductive health policy in Britain. 

The Terrence Higgins Trust (THT) are the largest voluntary sector provider of HIV and sexual health services in the UK, running services out of local centres across Great Britain. THT support people living with HIV, provide testing services for HIV and other sexually transmitted infections, and help people to achieve good sexual health. As well as provide services, THT also campaign on issues from relationships and sex education in schools to the funding of HIV services. www.tht.org.uk

6 References

[1]         World Health Organisation, “Defining sexual health.” [Online]. Available: https://www.who.int/health-topics/sexual-health#tab=tab_2

[2]         Department of Health, “A Framework for Sexual Health Improvement in: Best Practice Guidance,” 2013. [Online]. Available: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf

[3]         Public Health England, “New data reveals 420,000 cases of STIs diagnosed in 2017.” [Online]. Available: https://www.gov.uk/government/news/new-data-reveals-420000-cases-of-stis-diagnosed-in-2017

[4]         Public Health England, “Sexual and reproductive health and HIV: applying All Our Health,” 2018. [Online]. Available: https://www.gov.uk/government/publications/sexual-and-reproductive-health-and-hiv-applying-all-our-health/sexual-and-reproductive-health-and-hiv-applying-all-our-health

[5]         Public Health England, “Spotlight on sexually transmitted infections in the East of England - 2017 data,” 2017. Available: https://www.gov.uk/government/publications/sexually-transmitted-infections-east-of-england-data

[6]         Public Health England, “Sexual and Reproductive Health Profiles,” PHE fingertips tool, 2017. Available: https://fingertips.phe.org.uk/profile/sexualhealth

[7]         World Health Organization, “Antibiotic-resistant gonorrhoea on the rise, new drugs needed” 2017. [Online]. Available: https://www.who.int/news/item/07-07-2017-antibiotic-resistant-gonorrhoea-on-the-rise-new-drugs-needed

[8]         Public Health England, “Two cases of resistant gonorrhoea diagnosed in the UK,” 2019. [Online]. Available: https://www.gov.uk/government/news/two-cases-of-resistant-gonorrhoea-diagnosed-in-the-uk

[9]         Public Health England, “Multi-drug resistant gonorrhoea in England: 2018,” 2018. Available: https://www.gov.uk/government/publications/multi-drug-resistant-gonorrhoea-in-england-2018

[10]      Public Health England, “GUMCAD STI Surveillance System.” [Online]. Available: https://www.gov.uk/guidance/gumcad-sti-surveillance-system

[11]      Public Health England, “GUMCAD data extract,” 2018.

[12]      Public Health England, “National Chlamydia Screening Programme (NCSP),” 2017. [Online]. Available: https://www.gov.uk/government/collections/national-chlamydia-screening-programme-ncsp

[13]      National Institute for Health and Care Excellence, “Long-acting reversible contraception: clinical guideline,” 2014. Available: https://www.nice.org.uk/guidance/cg30

[14]      Office for National Statistics, “Conceptions in England and Wales: 2016,” 2018. Available: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/bulletins/conceptionstatistics/2016

[15]      Department of Health & Social Care, “Integrated Sexual Health Services: A suggested national service specification,” 2018. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/731140/integrated-sexual-health-services-specification.pdf

[16]      British HIV Association, “British HIV Association Standards of care for people living with HIV 2018,” 2018. Available: https://www.bhiva.org/standards-of-care-2018

[17]      Suffolk County Council, “Sexual Health Needs Assessment,” 2015. 

[18]      Public Health England, “Commissioning local HIV sexual and reproductive health services,” 2013. [Online]. Available: https://www.gov.uk/guidance/commissioning-regional-and-local-sexual-health-services