Guest blog

This European Testing Week, National AIDS Trust reflects on the vital role of community-led testing in helping us to end HIV transmission.

In August, National AIDS Trust launched two new resources to support community HIV testing in England:

• Community HIV testing: Intervention design toolkit
• Community HIV testing: Evaluation toolkit.

Community HIV testing is vital to the effort to end HIV transmissions in England. Led by community organisations and delivered outside of traditional healthcare settings that may not be accessed by all, community testing can reach a different audience to clinical services [PDF].

Its success in doing so has led it to be recommended in both national [PDF] and international HIV testing guidelines.

As with all HIV testing, community testing aims to reduce the number of people with undiagnosed and late diagnosed HIV. But it also has a much wider set of functions. By being community-led, it helps to break down barriers to talking about HIV, thus normalising HIV testing, reducing stigma, and empowering people to manage their own sexual health.

Community testing provides a gateway to accessing prevention, treatment and care, as well as other services relevant to people’s needs, and can play an important role in linking people into the wider health system.

Impact of COVID-19

Now may seem an odd time to be talking about HIV and community-based testing. COVID-19 has limited the ability of face-to-face services to be delivered, and many community organisations have had to shut their doors and move online. Summer saw some resumption of services, but the current lockdown and ever-changing restrictions have limited capacity and hindered long-term planning. Clinical sexual health services are also operating at a reduced capacity.

Yet we know people didn’t stop having sex with the arrival of COVID-19 and that sexual activity increased with the easing of lockdown [PDF]. Back in June we wrote that the need for judgement-free safe, discreet and accessible services is as high as ever. This will only become truer again as restrictions lift.

Ensuring that varied options for safe and effective HIV testing remain accessible is therefore vital to prevent COVID-19 from undermining progress in ending HIV transmissions. The end of COVID-19 may seem in sight, but we cannot become complacent.

The role of community testing during the pandemic

As COVID-19 transformed the ways healthcare can be delivered, services adapted at speed. Sexual health clinics now conduct much more of their engagement virtually, and there has been an increase in the use of postal testing.

Some community organisations are assisting their clients to conduct these tests remotely. HIV Prevention England (HPE) has produced an excellent Framework for delivering Community-Based HIV and Sexual Health Services during COVID-19 [PDF], which includes guidance on providing services in this way.

While the shift to virtual sexual health services has been necessary, and for many people effective, it’s important to acknowledge the limitations. Not everyone has access to virtual services, and some who do may feel uncomfortable if they lack privacy at home. Fears of judgement or recrimination for breaking COVID-19 restrictions can also deter people from getting tested.

There aren’t easy solutions to these barriers, and the safety of staff and clients is paramount. However, it’s safe to say community testing providers, already working in communities and experienced in involving those not accessing testing elsewhere, have a role to play and are well placed to manage risks carefully.

This was evident at the community testing event we delivered with HPE back in August. There we heard about some of the important outreach and testing that community organisations such as Yorkshire MESMAC had recommenced, with risk management and infection control processes in place to ensure safety.

For a recording of this event, please contact [email protected].

Adapting services to COVID-19 and beyond

National AIDS Trust’s toolkits support the design and evaluation of community testing interventions based on knowing what you are trying to achieve – i.e. your objectives – and who it’s for. The basic principles and stages set out in the toolkits still apply during the pandemic, but providers may have to take additional consideration when making some decisions based on context.

Even with vaccines for COVID-19 on the horizon, there remains a great deal of uncertainty and we still expect to be grappling with varied and changing restrictions across the country in the immediate future.

There are ways to adapt. Through the summer, some organisations made the decision to move client recruitment online (including developing online booking systems which have potential beyond COVID-19). Others reconsidered the locations used for testing and recruitment, with ability to social distance a key factor. Spaces which run the risk of getting crowded or that have poor ventilation should be avoided, and organisations should consider how the closure of venues might impact on where they can operate.

Appropriate personal protective equipment (PPE) and training on management of infection risk must also be in place to protect staff and volunteers. HPE’s framework is an invaluable resource to use alongside the toolkits to advise on the specific safety measures related to COVID-19.

Community HIV testing is about ensuring everyone who needs an HIV test can get one. It is the most marginalised who find it the hardest to access scaled-back services during COVID-19, and we must make sure that no one’s left behind. Agile community-led testing is critical if we are to do so.

National AIDS Trust’s Community HIV testing toolkits were supported by funding from Public Health England’s HIV Prevention Innovation Fund.

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.

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.