Despite years of public health campaigns and better education in schools, the rate of sexually transmitted infections (STIs) in the UK continues to rise.
Latest figures from Public Health England (PHE) show there were 447,694 STI diagnoses in 2018, up by 5 per cent on the previous year. A real concern is the rapid increase in cases of gonorrhoea and syphilis. There were 56,259 diagnoses of gonorrhoea, a jump of 25 per cent on the previous year, and the largest annual number since 1978. Rates of gonorrhoea have increased 249 per cent since 2009. Syphilis rates are up by 5 per cent and are now at levels not seen since the 1940s. Chlamydia cases were up by 6 per cent and genital herpes by 3 per cent.
A November 2019 survey by the Royal College of Obstetricians and Gynaecologists found that 37 per cent of 3,000 women were unable to access contraceptive services and 60 per cent couldn’t access unplanned pregnancy services. Abortions are at an all time high, up 4 per cent in the past year. Some 34 per cent of women did not attend their last smear test and only 50 per cent were able to access STI services.
PHE’s new Infectious Diseases Strategy 2020-2025 focuses on prevention and early detection of STIs and HIV and on eliminating hepatitis B and C. To enable this, PHE plans to continue to raise awareness of the importance of using condoms, encourage regular STI screening and provide partners with data to help stop transmission of STIs.
Last year, PHE published The Pharmacy Offer For Sexual Health, Reproductive Health And HIV, with the goal of raising the profile of community pharmacy among commissioners and other health professionals.
37 per cent of women were unable to access contraceptive services and 60 per cent couldn’t access unplanned pregnancy services
“Community pharmacies are a health, social and community asset,” says PHE. “They see people in every state of health and are well placed to play an important role in supporting people with their sexual health (SH), reproductive health (RH) and HIV. They are accessible to all, especially deprived communities who may not access other conventional NHS services, helping to reduce health inequalities and the burden on existing providers.”
PHE acknowledges that many pharmacies already provide these services, but it says they are not consistently provided nationwide. “It is critical that there is a more consistent approach, integrated with other service providers,” it says.
The Pharmacy Offer aims to help commissioners and providers improve delivery of sexual health (SH), reproductive health (RH) and HIV services through pharmacy, and increase public access. As well as providing more services through pharmacies, PHE wants to encourage pharmacy teams to make every contact count.
“Pharmacy teams regularly have contact with women asking for emergency contraception and pregnancy testing services, women who are sexually active but not using a barrier contraceptive, men and women in the target age range (16 to 24) and drug users,” it says. “These encounters offer opportunities to provide an integrated package of SH and RH services that goes beyond a single treatment approach.”
With appropriate training, PHE would like to see pharmacy teams deliver sexual and reproductive health advice, supply ongoing and emergency contraception, offer pregnancy testing, annual STI screening and partner notification, and encourage referral of positive test results to GPs and clinics. “This will increase capacity within other service providers, allowing them to attend to more complex cases,” says PHE. “Furthermore, a feedback loop could be established, whereby the service provider refers the person back to the pharmacy for repeat testing, treatment and ongoing support.”
Will the recommendations make a difference? “PHE raising awareness is valuable and may lead to some local authorities either rethinking their existing strategy or thinking how this will influence that strategy to enhance the services provided,” says Heidi Wright, policy and practice lead for England at the RPS. “The guidance has highlighted the role community pharmacy can play nationally, but we are not sure it has made a significant difference on the ground. We believe there is still large variability in the services commissioned via community pharmacies. Were provision of EHC to become a nationally commissioned service, as it is in Wales, this would ensure standardisation across the country.” Ms Wright believes that while the new guidance highlights the role community pharmacy can play, it is unlikely to result in increased commissioning of services due to limited funds.
“All the areas highlighted by PHE can be significantly impacted by community pharmacy,” she says. “We know from research that, generally, sexual health service users find pharmacies convenient and non-judgemental and would therefore use pharmacies more if more services were available. Unfortunately, as long as we have commissioning functions and resources divided in a way where there is no consequence for local authorities for not commissioning services, this variation and lack of joined up services will continue. Ideally, nationally commissioned services are the only absolute way of ensuring a consistent service and maybe that should be a further extension of the CPCS service.”
Screening ensures low-risk, uncomplicated cases are dealt with appropriately, freeing up capacity for more complex and high-risk patients
Pharmacies could also be better used to promote sexual health campaigns to raise awareness, address risky behaviour and offer signposting. “Pharmacists and their teams are exceptionally well placed to be the champions of better sexual health for all our communities,” says Dr John McSorley, president of the British Association for Sexual Health and HIV (BASHH). “The difficulty is that community pharmacies don’t have, or are not seen to have, the same confidential environment that a sexual health clinic offers. Many people may not think of a community pharmacy as somewhere that offers SH services. To improve awareness, leaflets could be made available in pharmacies. Community pharmacists are a vital resource in the promotion of good sexual health. Their skills need to be recognised and mobilised to help the UK meet our common goals of better sexual health for all.”
The National Chlamydia Screening Programme recommends that at least 70 per cent of screening takes place in core services, including community pharmacies. However, only a third of pharmacies nationwide are commissioned to provide a screening service. “Commissioning chlamydia screening ensures that low-risk, uncomplicated cases are dealt with appropriately, freeing up capacity for health professionals to manage more complex and high-risk patients,” it says. It would like to see commissioners consider chlamydia screening and treatment from pharmacies offered as part of a package of sexual healthcare, alongside the C-Card scheme and EHC.
“The guidelines for chlamydia testing are under review, but it will remain the case that detection rates need to increase in order to ensure more people are treated and infection rates are driven down,” says Dr McSorley. “Making testing for chlamydia accessible in non-clinical settings such as pharmacies would provide a vital tool for reaching more people within the community.”
PHE would also like to extend the role of pharmacies to supply the oral contraceptive and establish links to LARCs to reduce the burden on GPs.
Only 50 per cent of pharmacies are commissioned to provide a free EHC service and PHE would like to see this increase. It would also like pharmacy to be considered for HIV testing services, especially in high prevalence areas.
PHE concludes that there are great opportunities to further utilise pharmacies in provision of these services. “A more consistent and integrated approach, working alongside commissioners and other professionals, is needed to ensure consistent quality standards and seamless delivery of a comprehensive SH, RH and HIV service within pharmacies across the country,” it says. “Commissioners need to recognise the value of pharmacy teams as a key asset, especially given their convenient position and value within the community.”
In response to the alarming rise in syphilis cases, PHE has produced an action plan, which pharmacists should be aware of. Diagnosis was up by 5.5 per cent in the past year. Between 2008 and 2018, diagnosed cases were up by 162 per cent. Most cases (75 per cent) are among men who have sex with men, but cases among heterosexuals have also risen.
Knowledge of syphilis and how to prevent it needs to be improved. Left untreated, it can result in cardiovascular, ocular and neurological complications. Infectious syphilis is also associated with an increased risk of HIV transmission. Syphilis is divided into primary, secondary and tertiary stages and is most infectious in the first two stages. It usually presents as a painless ulcer on genital sites. If not treated, 25 per cent of patients develop secondary syphilis, which is seen as a rash on the palms of the hands and soles of the feet.
The four main aims of the action plan are:
The Umbrella service working group for community pharmacy is multi-disciplinary and comprises clinicians (consultants in HIV and sexual health, pharmacists and nurses), a business manager, senior managers in health promotion, finance and education, and Birmingham LPC representation.
In 2015, Birmingham City Council and Solihull Metropolitan Borough commissioned Umbrella to provide an integrated and outcomes-based sexual health service in the area. Since its launch, Umbrella has transformed sexual health services for residents by improving accessibility and health promotion, and by forging close links with community partners, including pharmacy.
Umbrella collaborated with Birmingham and Solihull LPC to design and deliver sexual health services in community pharmacies across Birmingham and this continues to grow. Community pharmacies have now become a significant partner in the Umbrella integrated sexual health service in Birmingham. It has been well received by clients and provides a walk-in service that is confidential and free. There are now 176 pharmacies involved in the service and there were 55,216 pharmacy contacts in 2018-19. Provision now stands at 4,000 to 5,000 Umbrella activities delivered by pharmacies every month.
When the service was set up, pharmacies were selected on a ward basis, with the number of required pharmacies identified using demographic and infection-risk indicators. Pharmacies could bid to provide Tier 1 (EHC, chlamydia screening, STI kit service and condoms) or Tier 2 (as Tier 1, plus oral contraception – combined pill and progesterone-only pill – start-up and continuation, injectable contraception, STI kit initiation, chlamydia treatment and hepatitis B vaccination second and third dose). Emergency contraception and condoms are the most popular services. The Umbrella service plans to upgrade all Umbrella pharmacies to Tier 2 status in the future.
One area where pharmacies are making a real difference is in the provision of chlamydia treatment. From April 2018 to 2019, they provided 1,593 chlamydia screening kits – up 64 per cent on the previous year. Provision of emergency hormonal contraception increased by 87 per cent, condom provision by 82 per cent and STI kits (initiated) by 251 per cent.
Pharmacies are driving the message of chlamydia testing to their local populations through the use of the home test kits for STIs. One of the national public health outcomes is to increase the number of chlamydia diagnoses in 15 to 24-year-olds. The introduction of pharmacy services has been associated with more chlamydia being diagnosed and treated in Birmingham.
Last year, 229 community pharmacists received training and 84 counter staff received training in communications skills with young people, confidentiality, condom provision and signposting. EHC is linked with the chlamydia screening programme, so every woman who asks for ECH is offered a chlamydia screen.
The Umbrella service has been promoted through Adshels, digital screens, social media, bus panels and radio. All pharmacies are provided with promotional resources. Throughout the year, there are eight health promotion campaigns that focus on Umbrella’s services.
Umbrella service pharmacies have proved popular with the public, especially young people, who like the anonymity and convenience of attending a pharmacy rather than a clinic. The service has also formed a strong and collaborative relationship between University hospitals Birmingham health trust, the LPC and the pharmacies involved. The services provided by community pharmacists will continue to expand and there is potential for the delivery of HIV pre-exposure prophylaxis (PrEP) and long-lasting Depo contraception injections.
“It is important that team members realise the role they have to play in raising awareness of sexual health to customers through their conversations when they receive enquiries about products, and through offering sexual health awareness campaigns for a less direct approach,” says Numark pharmacy services manager Lucy Morris. “To encourage conversation, make every contact count. For example, if a customer is asking for EHC, consider opportunities for safe sex advice, contraceptive choice consultation, chlamydia screening or treatment, and know where to signpost.”
Self-test STI kits are a good opportunity for pharmacy. “As appointments become more difficult to make, self-test kits offer an alternative route, allowing customers to have ease and accessibility to review their own health,” says Ms Morris. “Patients must have clear guidance on how to use kits effectively to ensure accuracy and understand how to interpret results. With increased availability of private PGDs and more independent prescribers, the availability of appropriate treatment for some STIs is becoming more readily available in the community and public confidence is growing.”
It’s important that pharmacy staff are non-judgemental, open and honest. “Always approach sensitively,” says Vinay Patel, services and contract manager at Alphega Pharmacy UK. “Generally, customers feel more comfortable discussing these issues in an environment where they can’t be overheard. Remove as many barriers to service uptake as possible. It’s important your team are aware of service provision as those working at the counter are most likely to encounter requests. Using EHC notification slips to flag EHC requests to the pharmacist is a sensitive way to approach this.”
Dr McSorley says: “Making our community spaces permissive to discussing sexual health matters, having the conversations, knowing who and where to signpost to is an enormously impactful role. It is important for specialist services to reach out and work with all community partners to make access as seamless as possible. Pharmacy services are often the embodiment of ‘making every contact count’ approaches to health interactions.”
Offering sexual health services to customers can have positive effects on other areas of health too. “A recent survey by Viagra Connect showed that 72 per cent of men over 40 who had sought advice for erectile problems admitted to paying more attention to their health and were taking active steps to improve it,” says Pfizer medical affairs advisor Justin Nnawuchi. “And 51 per cent of 40-plus men who have sought advice for erectile dysfunction are more likely to visit a pharmacist or GP about other health issues. This provides a real opportunity for pharmacists to build relationships with a whole raft of new customers.”
“We break the category down into two sections: sexual health and protection, and pregnancy care and ovulation,” says Cathy Crossthwaite, marketing co-ordinator at Numark. “Try to create a clear distinction between the two. The order I would suggest is sexual protection, health, EHC, pregnancy care and ovulation. Positioning of leading brands together and to the left of the fixture helps customers navigate the category. For example, Durex would be used as a beacon for the category, as would Clearblue. It can be embarrassing for customers, so include POS materials to signpost customers to speak with a member of staff for guidance or promote a service the pharmacy runs.”
“A major barrier to sales of sexual health products can be the need for the customer to have to ask you where these products are sited,” says Alphega’s Vinay Patel. “There is often also a concern about theft in community pharmacy as these are pricey products and are sometimes relocated from the fixture to reduce this risk. Appropriate signage and the correct category adjacencies can remove this hurdle. Ensuring you have the correct products is key. Alphega provides a suite of planograms for its members. These planograms provide a core range by category and ensure key products are placed in the optimum location.”
“Making sure customers know they can have a private conversation with a pharmacist by displaying a sign to the consultation room is an easy way to help them overcome any hesitation,” says Pfizer’s Justin Nnawuchi. “During the consultation, customers may well disclose personal information. Keep facial expressions neutral and be mindful of the language you use.”
“Create a positive environment towards sexual health,” say Richie and Jane Bowles, founders of Skins Condoms. “Don’t just put the sexual wellness brand in a corner. Champion sexual health and the importance of condoms. Empower your staff to sell condoms with confidence by training them on the products so they are comfortable talking about sex and can offer informed advice. Display condoms in strategically placed, up-selling spots.”
Lila Thakerar, Shaftesbury Pharmacy, Harrow
“This is a popular category – especially EHC and thrush treatment. More women are coming to the pharmacy to discuss sexual health problems. They often pay for their prescriptions anyway, so it makes sense to buy treatments OTC and avoid waiting to see the doctor. With the morning-after pill, they can get it from us quickly without waiting for a GP appointment, and this is vital when it comes to effective treatment. With thrush, women ask if oral treatment or pessaries are best. Canesten is a good seller. Put products that must be kept behind the counter at eye level.”
Lindsey Fairbrother, Goodlife Pharmacy, Hatton, Derbyshire
“This is an important category because it’s a public health service. We run the C-Card scheme here and it’s good for getting youngsters talking about their sexual health. We supply a lot of EHC. Thrush treatment is popular here too, again because it’s so convenient to purchase OTC. We rarely get asked about chlamydia testing, which is a shame, because that’s an area where pharmacy could play a wider role. We’ve won the battle with EHC and customers now know that they come to pharmacy first for this. We do far fewer pregnancy tests than we used to.”
Gareth Evans, Wansford Pharmacy, Peterborough
“We receive lots of prescriptions for erectile dysfunction products. As we are closely linked with the GP surgery next door and we have pharmacist prescribers, lots of patients come to us for sexual and reproductive health issues. Common topics include EHC, infections and sexual dysfunction. We can refer patients on if necessary. It’s not all about sales, but about providing an important service. We do well with pregnancy tests (Early Bird and Clearblue) and vitamin and generic folic acid supplements. It’s important to make the category as visible as possible. It’s still a sensitive subject for many.”