Sexual Health Week 2020

Get your RSE in gear, Sexual Health Week 2020

The theme of this year’s Sexual Health Week is ‘Get your RSE in gear’, focusing on the introduction by the Department of Education of compulsory Relationships Education for primary pupils and Relationships and Sex Education (RSE) for secondary pupils this month in England.

Despite the impact the school curriculum has faced since March 2020 due to COVID-19, schools are being encouraged to begin teaching RSE. The subject is now compulsory, with schools who are facing challenging circumstances being advised to begin lessons by at least the start of the summer term 2021.

The implementation of compulsory RSE provides an opportunity to provide young people with the tools and skills they need to have good sexual health, and enable them to make informed decisions which impact their wellbeing. It will also provide young people with the education they need to learn about HIV and sexually transmitted infections (STIs).

What support do teachers need?

– Dave Grimmett, Head of PHSEE, Highgate Wood School

‘RSE is an important part of every student’s education which should not be underestimated. RSE empowers students to make informed life choices in situations which may affect their mental or physical health, RSE also holds the power to reduce the negative consequences of these decisions in the future.

‘RSE is often thought of as being focussed on romantic and/or sexual relationships. However, it also empowers students to become better citizens by encouraging them to value or at least appreciate the differences of others’ states of being, experiences, choices and beliefs. Whether this relates to gender, sexuality, culture or religious custom it inspires students to reflect on their own actions and how this may positively or negatively impact on someone else. In other words we are teaching students to be kind in their adult relationships, a trait which we try to instil at a young age in friendships but don’t always discuss as they become older.

‘My school highly welcomed RSE becoming compulsory as it has provided us with a greater understanding of what education young people need rather than what areas we think we should cover. It was validating as I felt our school had already delivered key areas of RSE, but it was obvious there were subjects we still needed to tackle.

‘As we create and update our curriculum, it is the perfect time to be innovative in what is taught and the way it is taught. This can be daunting for schools and colleagues who are new to teaching the content or have limited experience of teaching RSE. It may also be difficult for some schools to know how to adapt to the change, and to create enough time and space for RSE to be taught effectively, although this is important.’

Teachers can be supported with practical information from experienced health professionals and Voluntary, Community and Social Enterprise (VCSE) partners including:

The shared experiences of how to approach sensitive issues in group settings.
Examples of group activities that deliver health promotion work effectively that teachers could adapt to deliver RSE.
Resources such as videos or stories that communicate with young people clearly and could be used as a platform for further discussion and learning.
Key contacts in your organisations who can liaise with RSE leads in local schools and pass on relevant information and messages across local authorities.
Willing colleagues visiting schools or engaging via video conferencing to speak with RSE teachers and other key groups such as students school councils to answer questions they may have or to provide advice.
As the experts in sexual health, provide particular messages or local campaigns you want teachers to share with young people in your area.

While teachers and educational professionals are updating their curriculums and ensuring the professional development of RSE leads and their peers includes training on RSE, now is the best time to embed good practice and creatively share ideas and experiences.

Sexual health and HIV prevention ambitions

The Government has made clear commitments to establishing a national sexual health strategy to tackle increasing rates of STIs, and to reducing new HIV transmissions to zero by 2030.

The introduction of compulsory RSE adds vital support to these initiatives achieving their targets. Not only does RSE educate current and future generations of young people, but it also increases the volume of professionals working within the systems that can nurture good sexual health.

Health professionals working in sexual health and HIV, including those from VCSE organisations, commissioners and public health experts, clinicians and researchers, must support teachers as they navigate the new curriculum.

Educational professionals can provide vital expertise and pathways to reaching young people, who are some of the most disproportionately affected populations by high rates of STIs.

‘Get your RSE in gear’ is a perfect call to action to encourage experts in sexual health and HIV to think about how they evaluate the support they provide to educational professionals, and to motivate teachers to deliver good quality and engaging RSE in their classrooms.

Sexually transmitted infections in 2019

Public Health England (PHE) has released the latest sexually transmitted infection (STI) surveillance data for 2019. Following the upward trend since 2015, STIs diagnoses have risen again and 468,342 diagnoses were made in England in 2019, a 5% increase from 2018.

Key findings

Diagnoses

468,342 diagnoses of STIs in England in 2019.
- 249,690 recorded gender ‘male’.
- 216,058 recorded gender ‘female’.
26% increase in gonorrhoea since 2018, the highest since records began in 1918.
10% increase in syphilis since 2018. In women the increase is 36%, but 81% of infections were recorded in men who have sex with men (MSM), of which almost a third (31%) were MSM living with diagnosed HIV.
7% increase in number of consultations at sexual health services.
- This is largely driven by a 84% increase in consultations reported by internet services (from 260,708 to 480,112).
11% decrease in genital warts.

Testing and screening

The National Chlamydia Screening Programme (NCSP) conducted 2% more tests in 2019 compared to 2018; however, there has been a 13% decline since 2015 (from 1,546,180 in 2015 to 1,339,913 in 2019).
181 sexual health services reported testing for Mycoplasma genitalium (M.Gen) in 2019, compared to 107 in 2018.
- This increase in testing capabilities has largely influenced the 196% increase in M.Gen diagnoses in 2019, up to 5,311.

Disproportionately impacted populations

Young heterosexuals 15 to 24 years; black ethnic minorities; and gay, bisexual and other MSM continue to report the highest rates of STIs in England.

Young heterosexuals

The majority of chlamydia diagnoses (62%) and gonorrhoea diagnoses (54%) in sexual health services were made in young heterosexuals. This group was also attributed to 41% of genital herpes diagnoses and 40% of genital warts.

MSM

Bacterial STIs are more likely to be diagnosed in MSM than other men. 81% of syphilis diagnoses were in MSM as well as 66% of gonorrhoea. The most common STIs have seen substantial increases in this population, with gonorrhoea diagnoses increasing by 26% and chlamydia diagnoses by 21%.

Of all MSM diagnosed with an STI in sexual health services in 2019, 18% were living with diagnosed HIV. A breakdown of STIs diagnosed in MSM by HIV status is provided in the graph below.

STI diagnoses among MSM by HIV status, 2010-2019

Black minority ethnic and other impacted populations

Black minority ethnic (BME) populations continue to be disproportionately impacted by STIs. In particular, the rate of gonorrhoea in BME people is 3.5x that of the general population and the rate of trichomoniasis is 9x that of the general population.
The largest proportional increase in all new STI diagnoses was in people of Asian ethnicity (16%; from 15,168 to 17,522), this was largely due to large increases in new gonorrhoea (36%) and chlamydia (27%) diagnoses.
The disparities between different ethnic groups are best seen in these images below, looking at rates of STIs for both men and women.

Rates of STI diagnoses by ethnic group among males, England 2019

Rates of STI diagnoses by ethnic group among females, England 2019

PHE has provided data based on World regions of birth, these have shown high overall increases of STI diagnoses in England with:

9% of people born in the EU,
11% of people born in North America,
12% of people born in South Asia,
16% of people born in South America,
21% of people born in Central America.

Impact of COVID-19

The latest data release does not cover the period since the COVID-19 pandemic began. However, PHE has advised that they are already analysing the surveillance data and how the impact of the COVID-19 response in England has affected HIV and STI service provision and epidemiology. Provisional findings are due in the coming months.

The latest report outlines how the national programme with PHE, Terrence Higgins Trust and 56 Dean Street delivered 10,000 free self-sampling HIV (and opt-in syphilis test) kits as part of the summer ‘Break the chain’ campaign.

PHE has also published a new national framework for e-sexual and reproductive healthcare. This provides information on how e-sexual and reproductive services can complement specialist, clinic-based facilities in local areas, providing other methods of accessing healthcare.

Resources from PHE

Sexually transmitted infections and chlamydia screening in England: 2019 [PDF].

Latest STI data tables, infographics and supplemental information.

National framework for e-sexual and reproductive healthcare: User guide [PDF]

Community HIV testing and COVID-19

HIV Prevention England and NAT (National AIDS Trust) invite you to join us for this online event exploring how to deliver safe and effective community HIV testing in the current context of COVID-19, and launching NAT’s two new toolkits, created to support the effective design and evaluation of community HIV testing.

Community-based HIV testing is a valuable contributor to the effort to end HIV transmissions in England. By drawing on the best practice of current community testing providers, these toolkits explore the key questions to consider when designing and delivering community testing interventions in England. They also support stronger evaluation of interventions to ensure that lessons are learned and national understanding of community testing is improved.

This event is intended for:

Providers and commissioners of community testing.
Community organisations interested in setting up testing interventions.
Wider colleagues in sexual and public health.

NAT’s community testing project was funded through the Public Health England Innovation Fund and some of the content of the toolkits is specific to England. However, the toolkits and discussion will still be likely to have relevance in other parts of the UK.

HIV Prevention England and a wider Advisory Group have supported NAT throughout the project.

When: 3.30-5pm, Wednesday 26 August 2020

PrEP knowledge, attitudes and usage among Black African communities in England

There is overwhelming evidence of the effectiveness of PrEP at preventing HIV transmission. Public Health England has credited PrEP as a key factor for the dramatic drop in new HIV diagnoses in the UK, particularly among gay, bisexual and other men who have sex with men (GBM) (PHE, 2019). Recently, it was announced by the UK government that PrEP would become routinely available across England by autumn 2020.

Despite making up less than 1.8% of the British population (ONS, 2020), Black Africans (BA) are over-represented in the rates of new HIV diagnoses every year. The latest figures showed that they constituted 44% of all new heterosexual HIV cases (PHE, 2019). This population stands to benefit from PrEP, however, there is very limited evidence answering the following questions:

Whether Black African communities in the UK are aware of PrEP.
Whether Black African communities in the UK are willing to use PrEP.
Whether Black African communities are currently using PrEP.
Whether the current and forthcoming access options are acceptable for Black African communities.

To determine the knowledge of and attitudes towards PrEP in BA communities in England ahead of the rollout of routine commissioning of PrEP, HIV Prevention England (HPE) is currently reviewing available research and health promotion programme data, including HPE community and evaluation survey results and PHE innovation fund reports.

Key findings

PrEP Knowledge

Initial data suggests that knowledge of PrEP is very low among BA men and women particularly compared to GBM counterparts. HPE ran a small face-to-face community survey in 2019 for BA men and women where only 22% (15/68) people were aware of PrEP. An online survey that was run as part of the It Starts With Me (ISWM) 2019 campaign evaluation found also that just 53% (124/234) of BA had heard about PrEP before, compared to 84% (465/554) of GBM.

In some cases where BA have reported hearing of PrEP, individuals may conflate it with PEP (post-exposure prophylaxis) or believe it to be for GBM only. For example, 21% of people who said they knew what PrEP was in HPE’s face-to-face community survey had these misunderstandings (4/19).

PrEP attitudes

Once BA people know what it is and how it works, many say that they would be willing to take PrEP under certain circumstances. In the HPE community survey, when asked if they would be willing to take PrEP in a scenario where condoms were unavailable, 63% (43/68) said that they would in the following situations:

Where personal risk perception is high. For example, if sexual risk-taking behaviour increased or if other methods, such as condoms, were not available or individuals did not want to use them.
For protection (‘to be safe’) as a general precaution towards others’ unknown status.
Due to belief in the science, that it is effective at prevention.

At the same time, a number of BA people were hesitant to take PrEP for some of the following reasons:

Needing more information on PrEP.
Scepticism and worries regarding the evidence/science: whether they could trust messages regarding side effects and interactions, PrEP effectiveness.
A dislike of taking ‘Western’ medication unless absolutely necessary.
Finding it not personally relevant (‘I don’t do those things anymore’ or ‘I prefer condoms’).

PrEP Use

In the ISWM evaluation findings, BA men and women consistently report low condom use: only 18% used condoms ‘all the time’ or ‘often’; 77% ‘never’ or ‘sometimes’ only. Despite this, none reported using PrEP. This contrasts with GBM, where 38% of low condom use individuals reported using PrEP.

When considering data from the rest of the UK, from July 2017-June 2019, there were only 14 individuals with African ethnicity taking PrEP in Scotland (0.4% of all PrEP users) (HPS, 2019). In Wales, from July 2017-March 2019, <10 individuals taking PrEP were of Black ethnicity (<1% of all PrEP users) (PHW, 2019).

Summary

In these examples there is a low level of knowledge among Black Africans about PrEP, which is markedly different from GBM cohorts. In addition to this, people who have heard of PrEP may have misconceptions about what it means, who it is for and how to access it.

A significant proportion of BA individuals are open to taking PrEP in situations where they have the correct information about it and can recognise that they may benefit from taking it.

According to available data, extremely few Black Africans are currently using PrEP in the UK.

As England prepares for the routine commissioning of PrEP in the autumn, it is important that the issues outlined in this article are considered further and appropriate steps taken to ensure that everyone who may stand to benefit, including Black African communities, are aware of and can access PrEP appropriately.

Hepatitis C: testing in sexual health services and HIV co-infection

In May, Public Health England (PHE) published their Hepatitis C in England 2020 [PDF] report. In order to improve national surveillance of the cascade of care for the first time, PHE included data on people attending sexual health services and people who are homeless.

Of the estimated 89,000 people in England who are chronically infected with hepatitis C (HCV), many are from marginalised and underserved groups in society. It is hoped the new and updated data will help to identify where improvements can be introduced to stop people falling through the net.

Co-infection in people living with HIV can be common in certain population groups. The liver has an essential role in processing medicines used to treat HIV and other conditions. Viral infections that affect the liver, such as hepatitis A, hepatitis B and hepatitis C, can make the liver less able to process medicines properly. This is one of the reasons the British HIV Association (BHIVA) have introduced targets for the micro-elimination of HCV in people with HIV.

Testing in sexual health services (SHS)

The number of individuals tested for HCV in sexual health services shows an increase of 37.4% between 2014 and 2018.
The proportion of individuals testing anti-HCV positive (reactive or positive antibody test means you have been infected with the hepatitis C virus at some point in time) shows little change over the same time period, remaining at around 1.3% (1.2 to 1.4%).

GUMCAD data (from 2014 to 2018)

Decrease in rates of HCV diagnoses in all individuals attending specialist SHSs in England.
Among attendees of negative or unknown HIV status, rates decreased from 48 per 100,000 attendees to 21 per 100,000 attendees (fall of 56.3%).
Among HIV-positive attendees, the decrease was greater from 14 to 3 per 100,000 over the same period (fall of 78.6%)/
- The lower rates are attributed to people living with HIV (PLWH) being diagnosed with HCV in their HIV care rather than in SHS.
Compared to the overall rate in all attendees, men who have sex with men (MSM) showed elevated rates of HCV diagnoses regardless of HIV status: likely due to high-risk behaviours including higher number of condomless anal sex partners, and injecting recreational drug use.

HIV HCV PHE 2020 rates

HIV/HCV co-infection

BHIVA has targets for the micro-elimination of HCV in people with HIV: curing HCV in 80% of those co-infected by April 2019, 90% by April 2020, and 100% by April 2021.

HARS data suggests that of people with HIV accessing care in England:

0.69% (598/86,997) tested positive for either an acute or chronic HCV infection in 2017
1.47% (1,298/88,002) in 2018

In 2018 HCV prevalence highest in:

People living with HIV who inject drugs (27%)
MSM living with HIV who inject drugs (6.5%)

Lowest in:

Heterosexual men living with HIV (0.8%)
Women (0.5%)

HIV HCV PHE 2020

Impact and opportunities of COVID-19

While the COVID-19 pandemic poses a threat to HCV elimination targets, it has also presented opportunities to test and link individuals from some underserved groups into care.

Many local authorities and charities worked together during lockdown to support homeless people and rough sleepers by moving them off the streets into individual hotel rooms. This provided a unique, short-lived opportunity to reach out to this group to address some health needs while their accommodation was more secure.

In June The Martin Fisher Foundation and EmERGE M-Health Ltd launched a new partnership to provide Hepatitis and HIV testing in Brighton and Hove for approximately 200 temporarily housed rough sleepers in the city.

Working with outreach workers from Brighton & Sussex University Hospitals NHS Trust and the Terrence Higgins Trust, aided by St Mungo’s support workers, colleagues visited hotels to offer screening using a simple finger-prick test. All face-to-face interactions involved the use of personal protective equipment (PPE). The project incentivised people to test by offering them £5 food vouchers for their engagement.

107 people had been tested through the programme by 20 July 2020. Processing lab results takes some time but from the cohort of the first 25 individuals tested, five HCV infections had been identified, which is broadly in line with the anticipated HCV prevalence. There were no HIV diagnoses within the first 25 tests returned.

Normalising testing and enabling early access to treatment, which reduces onwards transmission risk of both viruses, has the potential to significantly reduce the public health impact of HIV and HCV during the next decade.

A combined method of upscaling integrated testing and exploring innovative ways to reach people most likely to be affected by HIV/HCV co-infection (as we have seen during the COVID-19 epidemic) would help to achieve this.