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The latest data released by Public Health England (PHE) in early June highlights the ongoing burden of sexually transmitted infections (STIs), with new diagnoses of both gonorrhoea and syphilis now standing at their highest levels for decades.1 Although the total number of STI diagnoses in England remained relatively flat in 2017 at just over 420,000, there was a 20 per cent increase in the number of syphilis cases relative to the prior year and a 22 per cent rise in gonorrhoea diagnoses.1
Overall, 7,137 people were diagnosed with syphilis in 2017 and 44,676 with gonorrhoea.1 This represents a 148 per cent increase in syphilis rates since 2008, with levels now standing at those not seen since World War 2.1 The rise in gonorrhoea rates is particularly concerning given the recent emergence of an extensively drug resistant stain of Neisseria gonorrhoea, which is untreatable with all standard antibiotic therapies.1 High-level azithromycin resistant gonorrhoea is also continuing to circulate.1
Coupled with rising rates of STIs there is also worrying evidence that testing and screening for key infections is tapering off. PHE reported an 8 per cent drop in the number of tests for chlamydia carried out between 2016 and 2017 – continuing the trend of the previous year.
The rise in STIs comes as sexual health services in England continue to face ongoing financial pressures. In the five years since public health services were moved into the local authority domain, sexual health has undergone significant changes in the commissioning and provision of services, as well as reductions in funding budgets and recruitment freezes. According to the British Association for Sexual Health and HIV (BASHH), the local authority public health budget, from which sexual health services now draw funding, has been cut multiple times by the Government in recent years.2 Overall, public health funding will have been slashed by £531 million between 2015/16 and 2019/20.2
The financial pressure on local authorities is especially stark as, unlike the NHS, they are not permitted to accumulate debt – and the delivery of sexual health services is an expensive undertaking. In the 2017-18 period, the cost of providing sexual health services, ranging from contraceptives to STI testing and treatment, added up to £600 million (20 per cent of local authorities’ £3.4 billion public health spend).3
As the British Medical Journal (BMJ) has recently reported: “A succession of cuts in funding from central government has squeezed budgets, forcing councils to work smarter to avoid reducing services.”3 In a continuation to the steady raft of cutbacks to the public health grant since 2015, annual budgets are set to be slashed by 9.6 per cent overall by 2020-21.3
Even PHE acknowledges that services cuts are having a direct impact on the nation’s sexual health, noting in its report that: “Most of this decrease in [chlamydia] testing took place in sexual and reproductive health (SRH) services, where chlamydia testing has fallen by 61 per cent since 2015, likely reflecting a reduction in service provision.”1
Yet these services also see the highest rates of positive chlamydia test results, suggesting they provide screening for the populations at greatest risk. Given the drop in testing and high level of positive results seen within SRH services, PHE concedes it is “likely” some infected women are going undiagnosed.1
“These dramatic increases in syphilis and gonorrhoea are a huge concern and must provide a wake-up call to the Government about the importance of ensuring that high-quality, easilyaccessible sexual health services are available for all those who need them,” says BASHH president, Dr Olwen Williams.
“Worryingly, however, we are seeing an increase in the number of clinics that are being closed and patients are finding it increasingly difficult to access care. With the recent emergence of multi-drug resistant sexual infection, cuts in funding are coming at the worst possible time and are leaving services across the country at tipping point.”
The stark impact of funding cuts on sexual health services has been further highlighted in a new report by the Royal College of Nursing (RCN).4,5 The report, which focuses on the results of a survey of over 600 nurses working in sexual and reproductive health, claims that the public is being left unprotected as a result of staffing shortages at sexual health clinics.4,5
In addition to the reduction in healthcare professionals (blamed on recruitment freezes), key areas of concern pinpointed in the RCN report were a lack of clinics, an inadequate mix of skills and little access to training.4,5 Nurses working in sexual health also described low morale and a ‘tick box’ culture.
Commenting on the findings, Helen Donovan, professional lead for public health at the RCN, noted: “This is a worrying picture of understaffed services going to extreme lengths to try to cope, even turning people away – the last thing a health professional ever wants to do. If people are not able to access services, serious STIs could go undiagnosed and untreated – a major risk to public health.”4,5
The RCN report also includes evidence from other stakeholders that further highlights the recent upsurge in infection rates. Figures from the frontline of sexual health indicate a higher level of positive diagnoses for chlamydia – now 128,000 cases per year – coupled with a 12 per cent increase in syphilis diagnoses.4,5 The RCN also reports a fall of almost half a million in the number of 18-24 year-olds being tested for chlamydia.4,5
Other data gathered through freedom of information (FoI) requests by the BMJ and the BBC confirms the scope and severity of the problems faced by sexual health services in England.3,6 The BMJ enquired about sexual health service provision and spending over the previous three years in all 152 commissioning local authorities and received responses from 147.3
Of the local authorities who replied, over three quarters admitted spending on sexual health services had been reduced in any given year and nearly one in five had cut spending every year since they took control of budgets.3 The bulk of the yearly cuts were between 5-10 per cent, but some were as high as 23 per cent.3
Similar findings were recently reported by the BBC, which found that 72 of the 151 councils questioned planned to curtail sexual health funding for 2018-19 compared to the previous year.6 Avenues being explored by local authorities to make savings in sexual health spending and increase service efficiencies include closing clinics or reducing their opening hours, as well as restricting free access to emergency hormonal contraception (EHC) in some pharmacies to women under the age of 25.6 Councils in other areas are also taking steps to increase the availability of home self-test kits that can be ordered online.6
Looking to the future, this picture seems unlikely to improve as councils exhaust available options to constrain costs and demand for services continues to soar. Such is the level of concern that BASHH has launched a public petition in conjunction with 25 leading patient, professional and third sector bodies, calling on the Government to reverse cuts to public health budgets and ensure sufficient funding for high-quality sexual health services in England is maintained.7
The impact of the shrinking public health purse on pharmacy sexual health services is currently difficult to estimate but Hala Jawad, a former community pharmacist and GP practice pharmacist mentor for the Royal Pharmaceutical Society (RPS), notes that any pharmacy cuts “will have an impact on sexual health as it is a very important area, especially considering community pharmacy is the first place that patients approach before visiting their GP”.
We provide chlamydia testing and treatment, emergency hormonal contraception for under-25s (above that age they buy it themselves) and take part in the C-card system, whereby pharmacies give free condoms to young people.
It is good for patients to be able to access these services in pharmacies. We are open six days a week – unlike some GUM clinics and GP surgeries – with no appointment necessary. With the chlamydia service, they pick up a test pack, do the test at home and then send the sample off in the post, getting their results by text after a couple of days. If there is a positive result, we bring the patient back in, fill in a form and make a free supply of an antibiotic.
With these services we make sure people don’t feel stigmatised or judged in any way. People should feel comfortable walking in, particularly if they’re a teenager, as it can be very frightening asking for the morning-after pill. You need to make sure nobody else hears, which is why we take them into the consultation room.
You could give out chlamydia test kits willy-nilly or to somebody who is getting EHC, but deep down you know they’re just going to throw the test away. It counts as a supply made and pushes the numbers up, but it really doesn’t mean anything quality wise. On the other hand, if you sit them down, have a chat about the symptoms of chlamydia and then tell them how easy and confidential the service is, they are more likely to go ahead with it.
It is the conversion rate that is important. If you give out 100 kits and 75 per cent are used, that is a very good conversion. It is a quality mark, basically, and we come out very high in that. If you are going to do it, then do it properly.
We usually come out top regarding performance and were awarded a Certificate of Achievement in 2017 for our delivery of integrated sexual health services in Bromley
I offer sexual health services both privately and on the NHS. The NHS services include emergency contraception, chlamydia testing and treatment, and the C-card condom scheme. In Greenwich we have to pass an accreditation called ‘You’re Welcome’ for health services aimed at young people. The audit of Greenwich sexual health services is via mystery shoppers and they evaluate the handling of a query via the information given to the young client and the confidentiality of the encounter. We have successfully passed the audit many times since the scheme has been running in Greenwich.
We offer a full testing service privately, from HIV to syphilis and HPV. This is offered under the CityDoc umbrella, but on my own premises. Someone who wants a test can book online through CityDoc or they can just come into my pharmacy off the street. The CityDoc sexual health service is offered at the pharmacy via a blood test or by a swab or urine test. The service user goes through an assessment and we decide together what tests they want. Samples are collected and sent off to a laboratory, with the results taking between 24-72 hours. If there is a positive result I refer them on, usually to a NHS GUM clinic.
I did phlebotomy training for taking bloods, and also have to pass tests annually and keep up with my CPD.
The advantage of a private sexual health service is that some people prioritise speed – both in terms of fast results and not needing to make an appointment. There are others who are able to wait or who present too early for tests to be accurate. To these, I suggest they wait for the NHS service because the costs are substantial – you’re talking £250-£300 for a comprehensive test when someone decides to go privately.
According to PHE data, pharmacies carried out 13,030 chlamydia tests in 2017, representing just 1 per cent of the total number of tests that year (over 1.3 million).1 This is an almost 10 per cent reduction on the 14,335 tests performed in pharmacies in 2016, indicating that the ripples of funding restrictions may already be extending to the community pharmacy sexual health setting.1
Despite the obvious challenges, the need – and opportunity – for greater pharmacy involvement in sexual health remains clear. Pharmacy combines convenience and location with the benefits of a more informal and less medicalised setting for discussing sensitive issues such as sexual health. There is also increasing awareness of pharmacy teams as trained professionals, well equipped to provide accurate, informed counselling and treatment.
Opportunities for greater pharmacy involvement in the nation’s sexual health are manifold and include general advice on safe sex practices, contraception (including EHC supply) and signposting to additional sources of support or other services. The pharmacy role has also been successfully expanded to include testing and treatment of STIs as part of locally commissioned services (see the case studies panel).
In light of ongoing funding pressure, Hala Jawad advises that pharmacists wishing to become more involved in providing these types of services contact their local commissioners to see what services are paid for, and to speak to local surgeries to see if there are any specific areas that they could assist with.
“A good place to start would be the PHE sexual and reproductive health profile web pages,” she suggests. “These pages were set up by PHE to allow interested parties to monitor the sexual and reproductive health of the population. Through the data available on this database, you are able to see where your locality stands with regard to various sexual health issues and act accordingly. For example, you may see that the chlamydia detection rates are below average in your area and so could target any campaign specifically at this to improve that figure.”
Vaginal dryness, also known as vulvo-vaginal atrophy or atrophic vaginitis, is estimated to affect around 60 per cent of menopausal women.
“Vaginal dryness is one of the most common genitourinary symptoms of the menopause but is under-treated because many women don’t want to talk about it, so don’t seek help from a health professional,” says Heather Currie, a gynaecologist and founder of Menopause Matters.
“Yet vaginal dryness is the easiest of all symptoms to treat and is incredibly common, but can have the greatest impact and severity. Pharmacy staff can play a key role in improving awareness and helping women to get the right treatment.”
Angela Gregory, lead for psychosexual therapy at Nottingham University Hospitals Trust, agrees. “After 17 years as a NHS sex therapist, I’m passionate about early treatment for vaginal dryness and discomfort during sex. It prevents more complex problems developing – and it can be easily treated with a vaginal moisturiser.
“Painful sex caused by vaginal atrophy can lead to a loss of sexual interest, problems getting aroused and pelvic floor muscle dysfunction to the extent that women are so tense that penetration is anything from painful to impossible.
“Urinary symptoms can lead to social isolation and vulval soreness can impact on how long a woman can stay seated, so long car or plane journeys, for example, become a distant memory.”
Vaginal moisturisers such as Hyalofemme provide moisture that lasts for several days and restore the ability to have spontaneous sex for many women.
An estimated 4.3 million men in the UK experience erectile problems, which can have a negative impact on both a man and his partner. Research shows:
Pfizer’s ‘Sex lives after 40’ study of 2,000 men and women aged 40 and over also found that men who had sought treatment for the symptoms of erectile dysfunction felt happier (35 per cent), more confident (28 per cent) and more in control of their lives (23 per cent).
Addressing erectile problems with a loved one can be difficult for some men. The study for Pfizer found that a fifth of men affected (21 per cent) have not discussed the condition with anyone. Viagra Connect, which is now available as a P medicine following its high profile switch earlier this year, is indicated in adult men with erectile dysfunction (ED), which is defined as the inability to achieve or maintain a penile erection sufficient for satisfactory sexual intercourse.
Pharmacy teams can use the impetus created by local and national awareness initiatives and campaigns to increase their activity and encourage dialogue with at-risk individuals. It is important to be particularly aware of, and alert to, the needs of those groups of customers in whom the impact of STIs remains greatest. According to latest PHE data, this group includes young heterosexuals aged 15-24 years old, black ethnic minorities, and gay, bisexual and other men who have sex with men (MSM).1
Materials related to campaigns can often be downloaded online and used to augment in-store displays or generate additional useful in-pharmacy resources for customers.
The Royal Pharmaceutical Society also provides a specialist toolkit to support the integration of pharmacy into care pathways for sexual and reproductive health. This highlights many of the current and new pharmacy services across the UK, the regulatory and professional background to these, the drivers for change and potential routes by which services could be delivered. Pharmacists should also remember to ensure their training is up to date as service commissioners may demand a Declaration of Competence for pharmacies intending to provide treatment services such as chlamydia testing or EHC supply under the NHS.