Innovation and progress under threat

The UK began offering free, confidential advice and treatment for Sexually Transmitted Infections (STIs) in 1916, when the Local Government Board issued the Public Health (Venereal Diseases) Regulations.

Since then, responsibility for commissioning those services, which also now include contraception, has changed hands a number of times, with it most recently passing to Local Authorities (LAs) in England in 2013.

The English HIV and Sexual Health Commissioners’ Group (EHSHCG) provides a forum for commissioners to meet, network and work together to improve the delivery of services so that both population and patient level outcomes in sexual health can be improved.

Yesterday, EHSHCG held its first ever online conference, bringing together over 200 attendees including HIV and sexual and reproductive health (SRH) commissioners, civil servants, and people from the voluntary and community sector. The event looked at the progress made over the last decade, and explored what the future might bring.

Although there have been significant strides forward in terms of public knowledge and understanding of STIs and contraception, as well as advances in diagnosis and treatment of STIs, rates are increasing with record numbers of gonorrhoea, and increases in new HIV diagnosis. There has also been a rise in the number of unplanned pregnancies, with nearly a quarter of a million abortions being carried out in 2021.

Of course, part of the reason for the increase in diagnosis is an increase in testing. That consultations have increased by 36%, and screening has increased by 29%, since 2013 is a testament to the hard work of those people working on the ground who provide a safe, non-judgemental environment where people feel comfortable seeking advice and treatment. That is no easy task given the stigma around STIs and it is hugely important that the rise in cases is not viewed in any way as the fault of service providers – it is in fact the very opposite.

However, service providers are only able to provide services if they are adequately resourced and funded and, over the last decade, the public health grant, which provides funding for SRHS, has been repeatedly cut forcing the sector to find new, innovative ways to meet demand.

Commissioners have worked incredibly hard in partnership with the NHS and the Voluntary and Community Sector to do just that, and we now provide a range of remote services in addition to those in-clinic. For example, in Brighton and Hove, an app has been developed that allows people to manage their PrEP digitally, reducing the number of face-to-face appointments they need. Meanwhile, in Liverpool, a network of hubs has been set up so that women are never more than a 15-minute walk away from a hub that offers a range of services from contraception to cervical screening and menopause advice.

However, our capacity to further innovate is reaching an end. After all, it is not just a question of meeting current demand. Instead, we face increasing demand that reflects life in a society where many more people of all ages have multiple sexual partners and where opportunities to have sex are quite literally at people’s fingertips thanks to a myriad of ‘hook-up’ apps.

Therefore, as well as supporting people now, we must put more resources into prevention, raising awareness, not just in high-risk groups, but in the whole population.  If we don’t, we may well see a permanent increase in STI rates, undoing years of hard work.

Of particular concern is the national HIV Action Plan target of achieving no new HIV transmissions by 2030. Through close partnership at both a local and national level with a range of organisations including BASHH, BHIVA, NAT and THT, we have made huge progress but without sustained financial commitment, and improved access to PrEP, testing and treatment, we are in serious danger of not meeting the target.

In England, because public health teams are based in LAs, we are already working with colleagues in departments whose work has an impact on wider and social determinants of health – like housing and education. This makes us ideally placed to reach the right people at the right time to implement a range of effective prevention measures. We can work with schools to give children and young people the correct tools and knowledge at the right age to make informed decisions about sex, and we can work with adult social care services to make sure that vulnerable young adults are given information at the right time, in the most appropriate formats.

For example, the sexual health team in Southend City Council have worked with a wide range of partners, including health visitors, children’s services, the access and inclusion team, health improvement practitioners, the NHS, and private providers to revise its approach to teenage pregnancy in looked after children and young people. As a result, training is now offered to foster carers, as well as staff working with children and young people to learn how to have conversations around sexual health and wellbeing. In addition, children with a personal education plan are now being asked about the relationship and sex education (RSE) they receive to ensure equity of access, and a coordinated support group for young parents has been established.

Through working with colleagues across departments, we have a tremendous amount of knowledge and understanding about our local communities and how to effectively co-produce messages that work, and empower them. This understanding wouldn’t be complete without collaborating with local community groups who are pivotal to supporting our work to connect with people who have traditionally found it harder to access our services.

In Birmingham for example, SRHS work with Birmingham LGBT, the city’s leading charity for lesbian, gay, bisexual and trans people to run a supported self-testing drop-in service and a weekly clinic for the LGBT community, and are developing a trans specific clinical service based on service users feedback and local need.

We know though that more work is needed to reach certain groups. For example, the numbers of heterosexual women coming forward for testing are far lower than other groups. We also know that stigma around STIs is still a big driver of people not coming forward for treatment.

As well as working at a local level to tackle these issues, ADPH and EHSHCG work at a national level with organisations including the Local Government Association, Faculty of Sexual and Reproductive Healthcare, and Brook to advocate for improved funding and resources to ensure that information and treatment are available and given in a non-judgemental way. Crucially, in order to tackle the current, unsustainable situation, this must be done in a way that empowers the whole population to look after their own sexual health and wellbeing.

Ultimately, we need to do more work, not less, but without better funding, it is hard to see how we can achieve that. Apportioning more of the Public Health Grant to SRHS would mean taking away from other, equally vital services, and so it is incumbent on the next Government to address this shortfall and make a commitment with a properly funded long-term strategy to continue the work that was started back in 1916 to promote good sexual health and wellbeing for all.