New data for 2015 shows that London faces some of the most significant levels of sexual ill-health and wider sexual and reproductive issues in the country. While STI rates are falling in the rest of England, in London they have risen by 2 per cent in a year.
The situation in the capital
- STIs have increased by 2 per cent year-on-year in London from 116,692 in 2014 to 118,774 in 2015. That means that one in every four STIs diagnosed in England is in London
- Nearly half of all people living with HIV live in London. Fifty-seven per cent of new HIV diagnoses are in London and the trend is rising. One in 12 men who have sex with men (MSM) in London have HIV, with one in five undiagnosed
- Chlamydia is the most common STI in London, with 47,291 cases in London diagnosed in 2015, meaning it represents 40 per cent of all new STIs
- Gonorrhoea cases rose by 15 per cent in 2015 in London, with 18,945 cases diagnosed. London makes up nearly half of all gonorrhoea case in England
- Syphilis cases in London have increased 22 per cent since 2014, with 2,811 cases in 2015 compared to 2,306 cases in 2014. London cases represent 56 per cent of all cases in England.
Evidence suggests that certain groups of people in London are more at risk than others of contracting STIs. Young people aged under 25 and men who have sex with men (MSM) are particularly at risk, implying that new approaches are needed to reach these groups and get the safe sex message across. In particular it is worth noting that:
- 36 per cent of new STI diagnoses were in Londoners aged between 15 and 24
- Despite the fact that they represent only 2 per cent of the adult London population (3.8 per cent of the male population), more than two thirds of all gonorrhoea cases in London - 72 per cent - were in MSM last year.
- Diagnosed cases increased from 2014 at the rate of 22 per cent in this group from 10,866 cases in 2014 to 13,229 in 2015
- MSM accounted for the majority of syphilis cases in London, making up 2,406 cases diagnosed out of the total of 2,811 (85.6 per cent of London cases).
The figures show that London’s 2 per cent increase in STI rates bucked the national trend for a fall in infections. However, public health experts say that the 3 per cent nationwide reduction in STIs cases was potentially due to cuts in the numbers of tests being done rather than any drop in infection rates. While continuing to conduct more tests may reveal more incidence, if not enough testing is done, infections go undetected with the associated continued spread of infection.
Is there any good news? Cases of genital warts have decreased in women, and consequently heterosexual men, since the implementation of the HPV vaccine programme to 12 and 13 year-old girls in schools in 2008. Maps, charts and tables showing snapshots and trends by local authority can be found in Public Health England’s sexual and reproductive health profiles
There are a number of explanations for why STI rates are increasing so rapidly in London including:
- The incidence of STIs and HIV is growing partly due to the rise of new forms of risky behaviour, including some evidence of an increase in recreational drug use (often referred to as “chemsex”) and the growth in accessibility to smartphone dating apps. These apps, such as Tinder and Grindr, allow for the opportunity to change partners quickly and frequently, with the result that people with untreated STIs can rapidly pass them on to many others if condoms are not used every time.
- Chemsex is the increasing use of drugs with sex. The drugs may be illegal or legal highs, some of which are available on the internet, often very cheaply. People using such drugs may become very disinhibited, leading to engagement in sexual risks they wouldn’t usually take when sober, with a concomitant impact on exposure to transmission of HIV and STIs.
- Better testing is also reflecting a more accurate measurement of STI and HIV rates, showing an overall rise. This includes improved availability of community-based chlamydia screening and the increasing use of more sensitive diagnostic tests.
- In 2011 it was estimated that one in five Londoners with HIV did not know they were HIV positive. Although progress has been made to increase testing, 41 per cent of diagnoses in London are still late (meaning a person has tested positive for HIV after the virus has already begun to damage their immune system), which affects the health of the individual and increases the danger of onward transmission.
- London has a significantly higher population of key risk groups for STIs and HIV than the rest of the country, including MSM; black Africans; black Caribbeans and young people. In addition, London’s population is at 8.6 million and is growing by 8,000 people per month. The rate of population churn in London, where churn in some boroughs is as much as a third in any one year, means that public health interventions need to be repeated continuously to ensure that new populations are reached.
Commissioning sexual health services in London
From April 2013, local authorities have had responsibility for commissioning the provision of certain sexual health services, including:
- Commissioning HIV prevention and sexual health promotion.
- Open access genitourinary medicine (GUM) services including STI testing and treatment.
- Contraception services for all age groups
Local authority sexual health services are commissioned and delivered through a range of providers and places, including by GPs, acute hospitals (GUM clinics), community services, pharmacies and the voluntary sector, so the commissioning and delivery of sexual health services is complex. The NHS remains responsible for other sexual health services including:
- HIV treatment and care
- Health services for prisoners
- Sexual assault referral centres
- Cervical screening
- Community gynaecology, vasectomy and sterilisation and abortion services.
Public health funding cuts and how London boroughs are dealing with them All local authorities are commissioning sexual health services with ever-decreasing resources. Public health budgets in England suffered a £200 million in-year cut in 2015/16, meaning a cut of £40 million to London local authorities. The Spending Review in 2015 announced further cuts to public health budgets from 2016/17 onwards and we estimate that London public health budgets will be cut annually by around £70 million by 2020/21.
Spending on sexual health services in London makes up about one third of the public health grant for London boroughs, it is therefore impossible to fully protect such services from cuts. This takes place in the context of the rising demand for sexual health and other public health services. Balancing this rising demand for services against a decreasing budget requires new approaches to providing sexual health services, including using economies of scale, looking at opportunities for more effective ways to reach the most at-risk groups, the greater negotiating power of commissioning as groups of boroughs, and increasing the use of online and self-help services.
What London boroughs are doing to improve the sexual health of Londoners
There are a number of initiatives which London local authorities are taking to improve the sexual health of their residents. Some are local to individual boroughs, others cover a number of boroughs, and there is the London HIV Prevention Programme which covers the whole of London.
The London HIV Prevention Programme (LHPP)
The London HIV Prevention Programme (LHPP) includes the large, public Do it London campaign. This programme is delivered across the capital on behalf of all the 32 London boroughs and the City of London. It receives funding from each borough based on the level of HIV prevalence in that borough, with a total annual budget of £1.13 million. It has three key elements, identified to take account of the unique HIV needs of London. Its key messages are for Londoners to get tested and to practice safe sex. It does this through:
- Media and communications on HIV prevention for all Londoners, with specific campaigns targeted at key at-risk groups of MSM and black African communities, including via social media. Since launching in May 2015, it has delivered four unique campaigns for the city – focusing on HIV testing, safer sex and condom use – with advertising across the London transport network, roadside billboards and telephone kiosks, social media (Facebook, Twitter and Instagram) as well as a large digital media campaign, with over 25 million display ads on sites such as Evening Standard, Time Out, Nigerian Watch, The Voice, Gaydio and Grindr. All this is targeted at Londoners’ smartphones, tablets and computers via in-app and online advertising for key demographics. The www.doitlondon.org website now has almost 100,000 visitors.
- Condom procurement and distribution for MSM: since April 2014, the programme has delivered over 2.5 million condoms to gay and bisexual men across London. These are branded “Do It London” condom packs and can be picked up from almost 80 venues in London. Cheap (and subsidised) condoms are also available through the Do it London website
- Targeted digital and risk-focused physical outreach for MSM at gay venues and on gay dating apps.
The Do it London campaign has been highly successful – evaluation six months into the campaign was carried out by independent market researchers of its target audiences. This found that awareness and recognition of the campaign is very positive amongst MSM and black African communities in particular. The research showed that 67per cent of respondents who had seen the campaign felt it had influenced their behaviour towards HIV testing and that a quarter (25per cent) claimed it made them take an HIV test.
The research also showed a clear higher recognition amongst sexually active audiences (4+ sexual partners in last six months) which indicates that Do It London’s approach is having a noticeable impact on awareness for those engaging in the highest risk behaviours. Almost a third (32 per cent) claimed it prompted them to talk about safer sex with their partners.
Do it London has evolved as behaviours and attitudes have changed, to ensure it reaches its most at- risk audiences. So it has moved some resources from outreach sessions in gay bars and clubs to additional digital adverts on social media and multichannel public, print and digital channels, which have been found to be more effective at having the greatest influence on the most at-risk people. The campaign also uses ongoing market research and “consumer” panels to ensure that each phase reflects changing sexual health need and the feedback of target audiences. The current summer 2016 HIV testing campaign (“You can do it too”) was strongly informed by feedback from black African females on how better to appeal to them through imagery and media placement.
The London Sexual Health Transformation Project
The London Sexual Health Transformation Programme (LSHTP) covers 32 London boroughs with the aim of drawing together a new collaborative commissioning model for sexual health Genitourinary Medicine (GUM) services, to deliver cost-effective and improved public health outcomes. One of the elements of the programme is the introduction of access to self-sampling kits that can be ordered online. This will be introduced from April 2017. The service will link to GUM clinics, which will be open longer hours and will be properly linked with a network of integrated local one-stop shops. They will also work closely with primary care. 22 London boroughs are currently involved in a procurement exercise to identify a provider for the e-services and others may join in the future.
The Programme will encourage Londoners to use online and self-help services more, rather than just face-to-face services in GUM clinics, in an effort to reach more people and get them to the most appropriate services more quickly, so they only have to visit a clinic if they need to. The new online service will allow patients to access information, get initial triage that directs them to the best service for their needs and order self-sampling services for HIV and STIs online.
The service will send testing kits to patients when they request one if it is clinically appropriate to do so and they meet the required criteria. Kits can also be collected from sexual health clinics if patients prefer. Results are analysed and sent to patients within 72 hours, with advice given if further treatment is needed. The on-line service will also tell patients which clinics they can attend if they need to, or advise them to contact their GP or other health professional if that is the best course of action for them. By enabling more people to get services online and on their smartphones, time will be freed-up to allow more face-to-face consultations in clinics for those with more urgent needs or serious conditions.
In a survey of 2,200 potential users, over half said that they would be happy to use an online service to order sexual health kits to take a sample at home which is sent off to a lab for analysis (self-sampling). This makes testing easier and more accessible, and therefore more likely to happen. Those tested will get follow-up with any necessary treatment.
Over half of respondents said that the reason they attended a sexual health clinic was for a check-up, rather than because they had specific symptoms, so if that group can use home sampling to ensure they are free of infection, it is hoped that will result in more testing being done. The anticipated increase in the rate of testing will pick up more people who are infected but do not have symptoms yet, helping prevent the spread of infection.
Given the scale of STIs and HIV in London and the continuing rising number of infections, it is key that boroughs improve public health through increased levels of testing and improving outcomes. Borough commissioners continue to work hard to modernise and improve how London approaches the prevention of STIs and HIV, and we need to ensure we are making the most effective changes in the best way.
However, there is a resurgence in London of unsafe sex. People practicing condomless sex with new or casual partners need to be tested on a regular basis. The way to halt the rise of HIV and STIs is to make sexual encounters safe, such as promotion of safer sex messages and providing easy access to condoms and lubricant, and importantly through more education for all groups. In particular, a focus is needed on engaging with and influencing at-risk groups, including through schools to reach young people, and through social media and other channels to reach young people, MSM and black African men and women. In addition, we need to build on the messaging of Do It London campaigns to ensure that those at risk of passing on infections are tested as soon as possible, to help prevent the spread of infection.
Sexual health commissioning in London will need to carry on advocating the message that testing is easy by making it as accessible and trouble-free as possible. On behalf of all boroughs, the London HIV Prevention Programme is taking innovative steps do achieve this through prevention and testing promotion such as ‘You can do it at home stressing how easy and quick it is to get tested – and that it does not necessitate attending a clinic (with the associated cost to boroughs of clinic attendance). Encouraging more online and home testing is vital so that potential at-risk groups have options in addition to conventional clinic-based testing. These sorts of approaches create a more flexible and engaging approach, and vitally work to catch those people who are at risk but would not otherwise get tested.
London boroughs will have further opportunities from 2017 to take on new and transformative approaches to sexual health through the London Sexual Health Transformation Project by improving prevention, testing and detection. The changes the Programme introduces build on commissioners’ knowledge and on other programmes influential in changing behaviours. Other issues, such as PrEP (Pre-exposure Prophylaxis), if commissioned, will bring down the incidence of HIV infection in London, but will not change rates of STI infections. It is not yet known whether PrEP will be commissioned or when. If NHSE decides to commission it, PrEP would be given through GUM clinics to those most at risk of contracting HIV. The use of PrEP, as with many preventative treatments, would result in a saving to the NHS in terms of treatment costs, but any savings will not be felt by local authorities to make up for any extra costs for them in delivery.
As spend on sexual health takes up an ever greater proportion of boroughs’ public health budget, managing this in a climate of increasing public health budget cuts is a difficult balance to strike. It requires new approaches to providing sexual health services, using economies of scale and the greater negotiating power of a larger commissioning footprint, developing self-help options, increasing use of on-line services and increased prioritisation of prevention.