Sexual health in lockdown: experiences from 56 Dean Street

Guest blog by Dr Diarmuid Nugent, Consultant Physician, 56 Dean Street

It has been over six weeks since the UK went into lockdown to tackle the COVID-19 pandemic and the fabric of our everyday life changed beyond recognition almost overnight.

Like many other sectors, we in sexual health have had to adapt rapidly to the ‘new normal’. From the outset of the pandemic there has been no question that provision of sexual health and HIV services is vital and must continue, both for the health and well-being of those who need them, and to avoid undue pressure on other medical services like A&E and GP surgeries. Our challenge at 56 Dean Street has been to do all we can to maintain the excellent standards in the care that we provide while keeping our patients safe and, where possible, at home.

A new way of working

For our sexual health services, we asked our patients to phone ahead first before attending in person. We find that a remote consultation with an experienced sexual health clinician means that many concerns can be managed with advice, support, sending out medication or prescriptions by post where needed and referring for self-testing for STIs.

We’re lucky in that there is already established service for home STI testing in London, managed by Sexual Health London (SHL). Typically this has been for people with no symptoms, but with the right support some individuals with low-risk symptoms can be directed to home testing alongside the expert advice and treatment they receive from us.

Those with urgent symptoms who need to be assessed or to receive treatment in person still come in but with fewer patients needing to attend, we have the space to maintain effective social distancing measures.

Patients living with HIV

For our patients living with HIV, many have understandably been really anxious about what the COVID pandemic means for them. The advice from the British HIV Association (BHIVA) has been very clear and reassuring that there is no evidence that those living with well controlled HIV are at any greater risk of either getting COVID-19 or becoming unwell if they do become infected.

That said, those with a low CD4 count, who are not on treatment or have recently had an infection associated with HIV will be at greater risk of infections in general and so may be at increased risk. We’re providing extra support to these people; however this is a small proportion of our patients and a minority of people living with HIV in the UK.

For the majority, the priority has been to maintain an uninterrupted supply of antiretroviral medication. To do that we reached out to all our patients who were due to come in, and then set up a telephone service where patients can contact us when approaching their last month of medication. If the most recent blood tests were stable and there are no urgent health concerns we prescribe and supply six months of antiretroviral medication without the need for additional blood tests or a face-to-face review. But for the few that do need to see us, the fact that most patients have been reviewed virtually means we have the capacity to see those who do need to come in quickly and safely.

PrEP and lockdown

At Dean Street we estimate that we support over 10,000 PrEP users either through the IMPACT study, purchased directly through our PrEPshop and self-sourced on-line. For many people on PrEP, lockdown means they are not sexually active and therefore not at risk of HIV.

Through our social media channels we promoted video advice about how PrEP can be started and stopped safely but we have continued to provide PrEP to those who remain at risk with telephone support, home HIV testing and posting out medication when it’s still needed.

Trends in STI transmission and behaviour

As a busy clinical service we tend to see trends in STI transmission and behavior quite quickly here at Dean Street. What was clear in the first week or two of lockdown was that our rates of STI diagnoses had dropped dramatically – we went from 350 cases of gonorrhoea each week to around 50.

When it’s in the penis, gonorrhoea has a short time lag before symptoms show so most cases urethral gonorrhoea will have been picked up quite recently. So when gonorrhoea cases fall, that may indicate that people have been having less sex recently. Of course, it may also be that people are testing less during lockdown, in particular as gonorrhoea in the throat and rectum often shows no symptoms, so it might be that it’s there but we are just not finding it.

However our presentations for PEP, emergency medication after a potential exposure to HIV after condomless sex, have also dropped dramatically, from around 50 cases per week to less than 10. We think PEP is a clear indicator of sexual behavior, and as most of our PEP and gonorrhoea presentations are in gay and bi men, we think this means that gay and bi men are having much less sex during lockdown.

It might seem like a simple observation, but we felt it presented us with a fantastic opportunity. When people have acquired HIV very recently, within the last four weeks, it may be too early to show up on even the best tests and so if someone with recent HIV tests negative they can continue to pass on the infection unknowingly. Also, those who have acquired HIV recently will often be highly infectious to their sexual partners, again without realising.

Under normal circumstances, this kind of HIV transmission is very difficult to eliminate. But our lockdown data suggests that the number of people with recent HIV is greatly reduced at the moment, so there’s much less chance of missing an infection on the tests and fewer people who are highly infectious.

Time to Test

We created our #TimeToTest campaign based on the above trends. If as many gay and bi men can test as possible now, before the end of lockdown, we have a real chance to break the chain of new HIV infections that result from undiagnosed or recent infections. We could also make a similar impact on other STIs like gonorrhoea and syphilis.

Our Test Now Stop HIV site aims to encourage people to take a test and to access home testing kits. As local authorities across the UK differ in how they offer HIV and STI testing for their residents, we have also tried to bring this information into one place to make it easier for people to find out how they can access HIV testing not matter where they live.

While the COVID-19 pandemic has been devastating for so many, we feel that a drop in new HIV infections could be one unexpected silver lining on a very dark cloud. We may not get a similar opportunity again which is why we’re encouraging everyone to take a test.

State of the Nation

Guest blog by Amber Newbigging-Lister, Policy and Campaigns Officer, Terrence Higgins Trust.

STIs are soaring, sexual health services are overstretched and public health funding continues to be cut in England. Sexual health inequalities, hindered access, changing behaviours and STI stigma, all contribute to further challenges in the sector.

Terrence Higgins Trust and British Association for Sexual Health and HIV (BASHH) have launched their new report ‘Sexually transmitted infections in England: The State of the Nation’. With a stocktake of current evidence, the report has attempted to answer the what and why questions of STIs facing us today.

Findings

New STI diagnoses rose by 5% in 2018 from 2017, with new diagnoses of gonorrhoea and syphilis increasing by 249% and 165% respectively over the past decade. STIs disproportionately impact certain groups: men who have sex men make up 75% of all new syphilis diagnoses; 20% of new diagnoses are in people from specific ethnic minority communities; and young people account for nearly half of all new diagnoses.

A host of potential challenges perpetuate the trends seen in STIs, exacerbated by the lack of national vision around STIs and the impact of funding cuts. Both impact on access in the face of rising demand for sexual health services. The report highlights a need for more up-to-date research and data across STI trends, inequalities, behaviours, access, and stigma. Without this data, we struggle to identify clearly why we are seeing these trends.

There are some successes. The HPV vaccine has seen major decreases in genital warts among women, and with the expansion of this programme to boys and men who have sex with men, the success is likely to continue. This success can point to what’s missing in other areas of STI prevention.

The report makes several recommendations, including the timely delivery of a cross-system and fully funded national sexual health strategy. While the government has committed to this, the question remains on what the process and timeline for the strategy will be.

But what can those working in the health and, in particular, the sexual health sector do?

To address inequalities in sexual health, the sector needs to ensure the co-production of future research and policies, and look at the broader context in which STIs occur. Recognising the social determinants of health, we need to question why people from marginalised groups experience worse burdens of STIs, and what we can do about it.

By empowering the voices of sexual health community champions, we can tackle STI stigma and encourage a change in knowledge, perceptions and actions, as well as the visibility of STIs. As a sector, we can help encourage conversations, positive messaging and stigma busting that can positively impact STI outcomes and engage people in services.

The support of strategy and funding is essential. The government needs to recognise and reinforce the important role of sexual health charities, health professionals, and community organisations. It is through such collaboration that we can improve the picture of STIs for the nation.

Rolling into a dream visit to a sexual health clinic

Guest blog by Lorraine Stanley, Managing Director, Sex With A Difference CIC.

My carers arrived on time this morning. I’m feeling fresh as a daisy and ready for close encounters of the genital kind. Childcare for my two children is in place. I’ve carved out a couple of hours free from my mum, who is also my carer. She is fantastic support, but like any able-bodied person, I don’t fancy discussing my intimate sex life in front of my mother! My electric wheelchair is charged up, and I have psyched myself up for having my nether regions explored by a complete stranger.

It’s a lovely sunny day for a roll across the park, and the access ramp to the GUM clinic is a good one, with a buzzer entry phone system and a door release button. This is really important to me as my arm strength isn’t good, and I don’t have anyone with me to help with heavy doors.

Like most people with access needs, I checked the clinic’s website for accessibility information like ramps before I made the appointment. On one occasion, the intercom and doorbell were both broken when I arrived at my local GUM clinic. After resorting to banging on the door, a member of the public in the waiting room heard me and opened the door. For anyone already anxious about attending a clinic, and not wanting to draw attention to themselves, this might’ve proved to be the beginning and end of their appointment.

The waiting area is really welcoming, much more like a regular doctors or dentists waiting area – very different to the feel of a sexual health clinic 20 years ago, where you’d feel ‘dirty’ just by being there.

The receptionists are smiley and professional, and the forms simple enough to complete. The receptionist offers help in filling in the form if I need it. On a ‘brain fog/butterfingers’ type of day, I would take them up on this. Thankfully it’s a low-fog day, and I am able to hold the pen myself.

Everything is calm and relaxed as I wait. I’m a bit early, having allowed extra time for hazards, obstacles, and lifts that might not be working. After a short wait, I am shown into a good-sized examination room, with plenty of turning space for my wheelchair. Staff offer help, but don’t force me to accept it by taking over, or try to move my wheelchair without asking.

We manage to have a chuckle over some of my sexual activities – it turns out most people don’t use the term “recreational sex” in their appointment. I’m a swinger, as and when my health allows, so the conversation about how many times you’ve had sex in the last few months and whether it was with a man or woman, makes things a bit interesting (I happen to be bisexual too).

My life partner Mike (also a swinger) enters into the equation as well, and I explain that I use sexual activity and orgasms as a form of pain relief as much as I can – it reduces my reliance on prescription painkillers and their side-effects (also saving some money for the NHS!).

How samples are taken has changed over the years. I am able to swab myself with some physical support from the nurse. Throat swabs are taken, and blood tests for regular screening such as HIV. As a firm supporter of safer sex, I see this as being the responsible adult actions of a sexually active person.

We also talk about contraception, any follow-up tests that might be needed, and whether I prefer contact by email etc. It’s just the right amount of banter and laughter during the consultation, and I roll out of the appointment feeling very satisfied that all necessary topics were covered, and armed with several leaflets for further reading.

On this occasion, I didn’t have to use stirrups, or get on the examination couch, but it was brilliant to see that the clinic room had a full hoist set up, so if I had needed to transfer out of my wheelchair, it would have been possible.

With a cheery goodbye and a wave to the reception staff, I press the open door button and off home I roll…

Some points to ponder if you provide a sexual health service in your community

  • On your website, do you provide access information regarding ramps; door access buttons/intercoms; induction loops; and how to request a sign language interpreter? Have you considered the needs of people with visual impairments?
  • Not all disabilities or conditions are visible. Clients on the autistic spectrum, and clients with learning disabilities or anxiety related conditions would really appreciate some photos of the entrance set-up of your clinic/ the reception area/ the treatment room (including the wheelchair friendly room).
  • Do you have a hoist with sling available for clients that may need to transfer out of a wheelchair onto an examination couch? If you do, have you made it clear on your website that they are in place? Have you provided the necessary staff training?
  • If you have stirrups available, could you highlight this on your disability access page? Any client living with conditions affecting their muscle strength and control would welcome the option of using stirrups.
  • Does your clinic have at least one treatment room that has plenty of wheelchair manoeuvring space? If you have, have you made it clear on your website? Bear in mind that some clients (myself included) use a large electric power chair, which needs more space than the standard self-propelled wheelchair. Providing room dimensions and the option to reserve this room would be even more welcome.
  • Do you provide ‘extra-time appointments’ on request by disabled clients? The physicality of hoisting/ transferring to and from a wheelchair, or indeed, extra-processing time for people with communication processing conditions (hidden disabilities) can eat up appointment time. If you do, have you made it clear on your website?
  • Your staff is your greatest asset when it comes to being disability-friendly. People that provide great service to clients in general are often disability-friendly by default. That great website that I keep mentioning? Highlight on it how welcoming and non-judgemental your staff are.
  • Do you provide an outreach service? Some people with disabilities are house-bound. Do you have an option for providing sexual health services to them?
  • As part of your leaflet displays, do you have any in easy-read format? People with learning disabilities find these simpler, picture-based leaflets more accessible.
  • Find a way to self-check for unconscious bias within your team – yes, disabled people are just as likely as an able-bodied person to have sex/ have children/ be LGBTQI+. If there is a need for additional training, provide it.
  • Do you have an independent living centre and/ or condition specific centres (like MS Society, Parkinson’s, etc) near you? Have a chat with them about displaying your leaflets in their venue, or even offering an information sharing session to them as part of a bigger event.

Find our further information on sex and disability at Sex With A Difference or by emailing [email protected]