Sexual health

Introduction

Sex is part of life.

Sexual health is just one part of the bigger health picture. Regrettably, sexual health can be surrounded by stigma, prejudice and discrimination.  This is a barrier to accessing information and openly discussing issues which affect both individuals and communities.

Local data does not indicate a clear direction upwards or downwards in the diagnoses of gonorrhoea, herpes, syphilis and genital warts. However, diagnosis rates indicate a continuing burden of sexually transmitted infections (STIs) in Bracknell Forest.  Whilst preventable, the symptoms of many STIs go unrecognised by individuals affected by them, and misdiagnosed.  As well as poor longer-term health outcomes, late diagnosis also increases the risk of onward transmission.

Anyone who has concerns about their sexual health or thinks they may be at risk of  sexually transmitted infection needs to visit their GP or sexual health clinic for testing.  Early testing, diagnosis and treatment is essential to protect individual health and reduce the likelihood of transmission to others.

Key inequalities and risk factors

All sexually active men and women can reduce their risk of acquiring a sexually transmitted infection by reducing their numbers of partners and always using condoms correctly and consistently.

Factors that have a strong influence on our health (and sexual health) include education, housing, employment, living and working conditions and standard of living. In addition, cultural norms, health beliefs and mental wellbeing impact on our sexual behaviour. These can be difficult to challenge at an individual, community and societal level.

The inequalities section of NICE guidance on STIs and under 18 conceptions (2007) sets out some groups that are at higher risk to poor sexual health outcomes than others (not ranked):

• people with poor mental health
• offenders
• sex industry workers
• clients of sex industry workers
• young people who are looked after
• adolescents
• people with learning disabilities
• people who misuse drugs or alcohol
• victims of domestic violence
• victims of sexual assault
• lesbian, gay, bisexual and transgender people
• people at risk of sexual exploitation

Results cited from the National Survey of Sexual Attitudes and Lifestyles (Natsal-3) show that 4% of men aged 16–44 years reported paying for sex in the 5 years prior to interview in 2010–2012, and that prevalence is similar to a decade ago. Men who pay for sex (MPS) are considered to be a ‘bridging population’ for STI, as their paid partners are often individuals at high STI risk, whose risk is conferred to the unpaid partners of MPS, with whom condom use is less likely.

Some people are at greater risk of developing specific STIs:

• HIV disproportionately affects black Africans and men who have sex with men.  HIV is also linked to deprivation and living with HIV can lead to further disadvantage such as the impact upon a person’s ability to work, resulting in financial and social difficulties, often made worse by the impact of stigma associated with the infection.
• Syphilis is relatively rare in comparison to other STIs but highest rates are in men who have sex with other men (accounting for 73% of infectious syphilis cases), the over 25s and certain urban areas (London, Brighton, Manchester).  Many people may be HIV+ as well (and may not even know it) and there is an increasing number of cases in women, especially those from abroad.
• Genital warts is the most common viral STI in the UK, with the highest rates of new cases being found in 20 – 24 year old men and 16 – 19 year old women.
• Gonorrhoea is more likely to be found in young adults / urban areas / men who have sex with men (MSM) / black ethnic minority populations. Young people are most commonly infected, with current rates highest in males aged 20-24 years and females aged 16-19 years.  An infected person may have no symptoms, but still transmit the infection without knowing.  A pregnant woman can pass infection onto her newborn baby during delivery.

Facts, figures and trends

Chlamydia

Young people are amongst the most sexually active age groups and are at highest risk of chlamydia, particularly young women. More detail can be found in the children and young people’s sexual and reproductive health chapters.

Gonorrhoea

Gonorrhoea is the second most common bacterial STI in the UK after chlamydia.  If left untreated, gonorrhoea can occasionally cause serious complications, such as pelvic inflammatory disease. Gonorrhoea also facilitates the transmission of HIV.  Between 2014 and 2015, there were large increases in diagnoses of gonorrhoea (11%) and syphilis (20%), continuing the rising trends in these infections of the past 5 years. These rises have occurred mostly in gay, bisexual or other men who have sex with men.

Treatment is usually with antibiotics, often given as a single dose.  However, many strains of gonorrhoea are now resistant to commonly used antibiotics which means it is essential that anyone with suspected gonorrhoea must have the infection properly investigated.

Gonorrhoea diagnosis rates in Bracknell Forest have shown an improvement over time with an all-time high in 2014 at 25.7 per 100,000 population:

Historically, annual diagnosis rates in Bracknell Forest have been consistently significantly better than the England averages since 2009.

Since June 2011, there has been dual testing for gonorrhoea and Chlamydia in the east of Berkshire which may explain the increase in the rate of diagnosis of gonorrhoea in Bracknell Forest.

Syphilis

Syphilis is a bacterial infection spread almost exclusively by sexual contact. It is a relatively rare infection, compared to other STIs such as chlamydia, warts and herpes. Nationally, rates have increased since the late 1990s with annual diagnoses of infectious syphilis increasing twelvefold (from 301 to 3,789 between 1997 and 2007).  The increased number of syphilis cases in women of reproductive age has resulted in an increase in cases of infection passing from mothers to their developing baby through the placenta.

Syphilis was known as the ‘Great Imitator’ because the symptoms and signs are complicated and varied and can be easily misdiagnosed as a variety of other clinical conditions. There are three developmental stages:

• the initial stage is the appearance of an ulcer, which is painless and can go unnoticed, especially if it cannot be seen easily (anal area, vagina, cervix, tonsils) and clears up spontaneously
• secondary syphilis shows up as a rash which can sometimes affect palms and soles which resolve spontaneously. This is the period at which most treatment occurs. If untreated, organisms remain in the body sometime without symptoms although they can recur episodically for up to 2 years
• tertiary syphilis is the most serious and affects the cardiovascular and nervous systems and causes ulceration of the skin and damage to bone tissue

In Bracknell Forest, syphilis diagnosis rates have remained relatively low since 2009 despite a spike in 2012.  The national trend is upward, however, the rate in Bracknell Forest is relatively stable and below the average for the area of 1.42 per 100,000 people (when the 2012 outlier figure is removed).  Since 2013, rates in Bracknell Forest are significantly lower than the England averages.

Genital Warts (Human Papillomavirus or HPV)

There are over 100 different types of HPV, around 40 of which are sexually acquired.  HPV can exist as a latent infection, with no visible signs or symptoms and therefore individuals are unaware that they have been infected and can pass it on easily. Recurrent infections are common with patients returning for treatment.

Nearly all cases of cervical cancer have been linked to particular sexually transmitted HPV infection and cervical cancer can take many years to fully develop so monitoring.

Historically, between 2009 and 2014, the highest diagnosis rate of genital herpes in Bracknell Forest was in 2012 (133 per 100,000 population) when it was the second highest rate in Berkshire.  Despite this exception, the rate has been consistent around the Bracknell Forest average of 123.5 per 100,000 for all years (2009-2014) and statistically similar to the south east and England averages.  For this measure, a low rate is considered good and the lowest diagnosis rate was in 2014, which is significantly lower than the England average and the lowest in Berkshire.

HPV vaccination programme

As HPV is a significant public health risk, it is subject to a vaccine programme against two high-risk HPV types – 16 and 18 – that cause over 70% of cervical cancers.  Details of vaccine coverage are highlighted in the immunisation and vaccination chapter.

Genital Herpes

Genital herpes is a viral infection. It is most common ulcerative sexually transmitted disease in the UK. Recurrent infections are common with patients returning for treatment.

Genital herpes is problematic because approximately 50% of those infected will display no symptoms early on.  The virus can lead to severe systemic disease in newborn babies and in those whose immune system is compromised.

When they start, affected individuals will present with mild soreness and groups of small painful blisters appearing on the genitals and surrounding areas.  Further episodes of these symptoms can occur from time to time as recurrent episodes.

Historically, the genital herpes diagnosis rate in Bracknell Forest between 2009 and 2014 was highest in 2010 (54 per 100,000 population).  The average of all years since 2009 is 43 per 100,000 and the rate for 2014 falls just below this figure.  In all periods, the rate has been lower than the south east and all England average, significantly so in 2012 and 2014.

Human Immunodeficiency Virus (HIV)

HIV damages a person’s body by destroying specific blood cells (CD4+ T cells) which are crucial to helping the body fight infection. HIV remains a serious communicable disease for which there is no cure or vaccine.  It affects both men and women, although specific groups are at higher risk than others.

HIV is associated with serious morbidity, significant mortality and high number of potential years of life lost. However, anti-retroviral therapy makes HIV practically undetectable and means most people living with HIV can now expect a near-normal life expectancy if diagnosed early and the condition is well managed.  Stigma and discrimination still exist with regard to HIV and people with HIV which limit access to HIV testing, treatment and other HIV services. Late diagnosis or poor management of the condition can lead to poor health outcomes and AIDS (Acquired Immune Deficiency Syndrome) as well as increase the risk of onward transmission.

In the UK, HIV is most commonly transmitted sexually but can also be transmitted through blood (i.e. via sharing needles or via a contaminated blood transfusion) or breast milk. HIV can also be transmitted from a mother to a child during pregnancy or child birth.

HIV is also associated with high costs of treatment and care so key public health priorities are to (i) reduce the proportion of late HIV diagnoses and, (ii) increase the proportion of HIV infections diagnosed. Late diagnosis is the most important predictor of morbidity and mortality among those with HIV infection.

Prevalence

Knowledge of HIV status increases survival rates, improves quality of life and reduces the risk of HIV transmission.  HIV testing is therefore integral to the treatment and management of HIV.

According to the HIV in the UK – Incidence, prevalence and prevention Situation Report 2015, in 2014, an estimated 103,700 people were living with HIV (PLWH) in the UK of which 69,200 were men.

The overall HIV prevalence in the UK in 2014 was 1.9 per 1,000 people aged 15 and over. Among heterosexuals aged 15-44 in the UK, prevalence is higher among black African heterosexual men (one in 56) and women (one in 22). The report estimates that in 2014, 18,100 (17%) of people PLWH were unaware of their infection.  The estimated number and proportion of people living with undiagnosed HIV have declined since 2010 (from 22,800 and 25% respectively), with the majority of this decline happening before 2012.

New diagnosis

HIV testing continues to increase throughout most of England with high coverage and take up particularly among men who have sex with men (MSM), the highest risk group.

In Bracknell Forest, although the figures are still significantly below national averages, the proportion of tests taken up when offered in 2014 shows improvement on previous years:

The rate of new HIV diagnosis between 2012-2014 shows that nationally and regionally there is little annual variation compared to the Bracknell Forest figure which fluctuates year by year.  This is because the actual numbers are small but show large variance when converted:

 

In 2014, of all people diagnosed, 114 residents accessed HIV related care.

Late diagnosis

A late diagnosis of HIV is defined as the person having a CD4 count below 350 cells/mm3.  People with a late diagnosis of HIV have a tenfold increased risk of dying within one year.

The 2013 Framework for Sexual Health Improvement in England reported a number of factors attributable to late diagnosis with rates lower in gay and bisexual men compared with heterosexual men and women but older adults (aged 50 and over) were significantly more likely to be diagnosed late compared with younger adults.  Late stage diagnosis was also a issue for people of black African origin.

Nationally, rates of late diagnosis have decreased over the last ten years, but still nearly half (45%) of all diagnoses were considered to be late in 2011-13. (Public Health England, 2014).  The high rate of late diagnosis is also reflected in Bracknell Forest which is significantly worse than the England average.  The actual numbers are small but the differences are large when expressed as a proportion.

Hospital admissions for STIs and HIV

Main diagnosis hospital admissions for English hospitals show:

• Infection with predominantly sexual mode of transmission – 2,313 in 2014-15 compared to 2,333 in 2013-2014, almost equally spread 50/50 across both genders
• HIV – 3,545 in 2014-15 compared to 3,598 in 2013-2014 mostly affecting men at just over 70% in each period

Drug use in a sexual context – “Chemsex”

Chemsex describes drug use in a sexual context.  It increases the risk of transmission of HIV, hepatitis B and C and other sexually transmitted infections (STIs) increases. It is important to note that whilst drug and alcohol misuse is higher in lesbian, gay, bisexual and transgender (LGBT) communities, drug use in a sexual context is not exclusive to this community, most MSM do not use drugs, not all MSM who use drugs use them in a sexual setting, and not all MSM who use drugs in a sexual setting do so in a problematic way.  Individuals are more likely to engage with sexual health services rather than drug or alcohol services which is important when commissioning safer sex services and identifying individuals that may benefit from STI testing.

Mortality

In 2014, there were 159 registered deaths attributable to HIV in England and Wales.

In 2013, one in four adults living with diagnosed HIV were aged 50 years and over. One year mortality is particularly marked for people aged 50 years and over at diagnosis, where more than 7 in 100 diagnosed at a late stage died within a year (Public Health England, 2014).

Contraception

The mandatory contraception services for which local authorities are responsible in Berkshire are: school / college based outreach services and contraceptive and sexual health clinics (CASH services).  Bracknell Forest also commissions specialist GPs and outreach nurses who can prescribe and fit long acting reversible contraception (LARC) such as implants, coils, and injections.  In total, 28 services are commissioned across Berkshire as described in the sexual health needs assessment.

The A Framework for Sexual Health Improvement in England highlights evidence that that ‘provision of contraception, particularly LARC methods, supplied or fitted by the abortion provider can reduce repeat abortions’ and notes the implications for training of staff in maternity services. However, the report cautions that ‘LARC methods are not acceptable or suitable for all women, and it is important that women are allowed to make informed choices.’

Long Acting Reversible Contraception (LARC)

LARC methods, such as contraceptive injections, implants, the intra-uterine system (IUS) or the intrauterine device (IUD), are highly effective as they do not rely on daily compliance and are more cost effective than condoms and the pill.

• The intrauterine contraceptive device (IUCD) is an effective method of contraception which is also known as ‘the coil’. It sits inside the womb (uterus). Once fitted, it can stay in the womb for up to ten years. Once an IUCD is inserted women no longer need to use other contraception. So, unlike users of the contraceptive pill, women don’t need to think about contraception every day and negate the risk of forgotten contraception.
• Nexplanon is an effective method of contraception which is also known as ‘the implant’. It sits under the skin in the arm. Once fitted, it can stay in the arm for up to three years. Once Nexplanon is inserted women no longer need to use other contraception. So, unlike users of the contraceptive pill, women don’t need to think about contraception every day and negate the risk of forgotten contraception.

In Bracknell Forest and Ascot CCG, the 2014 rate of prescribed long acting reversible contraception (LARC) by GP and Sexual and Reproductive Health Services (SRH) is 62.2 per 1,000 population.  The percentage of women aged under 25 choosing long acting reversible contraceptives (LARC) as their main method of contraception at Sexual and Reproductive Health Services in 2014 was 23% which is comparable with the England figure of 20.1%.

Emergency Hormonal Contraception (EHC)

In 2012/13, there were 2,926 prescriptions for emergency hormonal contraception issued by general practices across Berkshire. This equates to a rate of 15 prescriptions per 1000 registered women aged 15-44 years although there were wide variations in GP prescription of EHC across the county.

Bracknell Forest Council Youth Service provides 9 young people’s drop-in sessions per week these deliver mainly condoms, sex education, oral contraception with some EHC and pregnancy testing subject to the availability of GP or nursing staff.

The estimated prevalence of LARC and EHC issued by general practice per 1000 registered 15-44 year old females in Berkshire shows:

• during 2012/13 general practice in Bracknell Forest had the highest rate of EHC prescribing in Berkshire at approximately 18 per 1000 registered 15-44 year old females
• the rate of contraceptive implant fitting in Bracknell Forest was second highest in Berkshire at just under 50 per 1000 females
• contraceptive injections were issued to around 25 per 1000 registered 15-44 year old females in Bracknell Forest whilst Intrauterine Contraceptives (IUCDs and IUS) were issued to around 46 per 1000

Conceptions and abortions

Clinical commissioning groups (CCGs) are responsible for commissioning most abortion services, local authorities are responsible for commissioning comprehensive sexual health services including contraception services and advice, and sexual health specialist services such as young people’s sexual health and teenage pregnancy services, outreach, sexual health promotion and services in schools, colleges and pharmacies. Local authorities need information on abortions to inform the provision of these services.

For data relating to girls aged under 16 please see the children and young people’s sexual and reproductive health chapters.

Conceptions (women aged 15-44)

According to Office for National Statistics data, in 2014 there were an estimated 871,038 conceptions nationally to women of all ages, compared with 872,849 in 2013, a slight decrease of 0.2%.  Conception rates in 2014 increased for women aged 25 years and over, and decreased for women aged under 25 years.  The under 18 conception rate for 2014 is the lowest since 1969 at 22.9 conceptions per thousand women aged 15 to 17.

The rate of conceptions per 1000 women aged 15-44 in Bracknell Forest has remained stable between 2009 and 2014 and lower than the England average.  The local, regional and national figures follows the same general pattern.

Abortions (women aged 15-44)

The percentage of conceptions leading to abortion in Bracknell Forest increased between 2009 and 2014 (16.1% in 2009 to 19% in 2012 with a peak of 20.5% in 2013). This is, however, similar to both the south east average and the England average:

Repeat abortions

The percentage of repeat abortions in women aged under 25 years is a measure of women who had an abortion and who had previously had an abortion at any time. Reported in the Public Health England Sexual and Reproductive Health Profiles, it is used as an indicator to assess access to good quality contraception services and advice as well as problems with individual use of contraceptive method because over a quarter of England abortions in this age group are repeat abortions.

The percentage of women who had an abortion and who had previously had an abortion at any time has fallen from 35% in 2012 to 26.2% in 2014. This improvement means the rate is statistically similar to the south east and England figures.

Prevention, care and support

The Garden Clinic is a fully integrated sexual health service hub (combining CASH and GUM) running at Skimped Hill, Bracknell. GUM provision available in the south of the borough is available from Frimley Park Hospital and residents in the north can access the Florey Clinic at the Royal Berkshire Hospital in Reading. A person may visit a GUM clinic anywhere but the local authority in which the person is resident will be invoiced for these additional non-directly contracted services.  The 2013 Berkshire Sexual Health Needs Assessment states that Bracknell Forest had the greatest proportion (19%) of residents using clinics outside Berkshire, with clinics in Surrey being the most commonly used non-Berkshire clinics.  This may be connected to outflows of residents for employment in those areas.

Currently, a full picture of attendances and activity at the Genito-Urinary Medicine (GUM) clinic at Skimped Hill in Bracknell is not available.  Further work is required to disaggregate available data for Bracknell Forest on the basis of key demographics.

Safe Sex Berkshire is the locally commissioned sexual health, information and advice service for Berkshire residents and professionals.  The site can provide information on local services and groups, contraception, pregnancy, STI testing, sex and relationships, keeping safe and emergency help and support for victims of sexual violence.

Want to know more?

A Framework for Sexual Health Improvement in England (Department of Health, 2013) – information, evidence and support tools to enable those involved in sexual health improvement to work together effectively to deliver accessible, high quality services and support.

Commissioning sexual health, reproductive health and HIV services (Public Health England, 2014) – guide is for commissioners of sexual health, reproductive health and HIV services in local government, clinical commissioning groups (CCGs) and NHS England to achieve an integrated approach at individual, population and service delivery levels.

Commissioning regional and local HIV sexual and reproductive health services (Public Health England, 2014) – guidance on commissioning sexual and reproductive health services in a wider context, including relationships, sexuality and sexual rights and beyond preventing disease or infection.

Contraceptive services for under 25s (NICE, 2014) – guidance commissioners, managers and practitioners who have a direct or indirect role in, and responsibility for, contraceptive services.  A useful resource for  people working in local authorities, education and the wider public, private, voluntary and community sectors. It may also be of interest to young people, their parents and carers and other members of the public.

Guidance for long acting reversible contraception (NICE, 2005 updated 2014) – best-practice advice for all women of reproductive age on LARC methods, covering method use by particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years.

HIV testing: increasing uptake in men who have sex with men (NICE, 2011) – recommendations on strategic planning and implementation of services, promoting HIV testing in primary care, secondary care and specialist sexual health services including outreach schemes and rapid point-of-care tests, referrals pathways and repeat testing.

Making it work: Part 3: Annexes (Public health England, 2014) – a full list of policy, guidance and advice documents, including commissioning guidelines and service specifications, health outcomes, national guidance and clinical guidance.

Sexual health, reproductive health and HIV in England: A guide to local and national data (Public Health England, 2015) – a comprehensive summary of the data collected in relation to STI related measures, including links to strategies, policies and guidance.

Safer Sex (British Association for Sexual Health and HIV, 2012) – a guide to safer sex to improve sexual health and reduce spread of HIV.

Substance misuse services for men who have sex with men involved in chemsex (Public Health England, 2015) – data and evidence of the relationship between substance misuse and STI specifically in men who have sex with men. Also suggests wider approaches to preventative interventions across LGBT communities and sub-cultures.

UK national guidelines for HIV testing 2008 (British Association for Sexual Health and HIV, 2008) – guidelines to facilitate an increase in HIV testing in healthcare settings to reduce the proportion of individuals with undiagnosed HIV infection.

UK national guidelines on safer sex advice (British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA), 2012) – evidence based guidance on the content of safer sex advice and the format and delivery of brief behaviour change interventions deliverable in healthcare and other settings. Includes advice on condom use and effectiveness, oral sex and other sexual practices and advice specific to the transmission of HIV infection.

UK national Guidelines on the management of anogenital Warts (British Association for Sexual Health and HIV,  2015) – recommendations on the diagnosis and treatment of benign ano-genital lesions caused by human papillomavirus (HPV) infection in men and women over 16 years of age. It does not deal with screening or treatment of pre-malignant or malignant ano-genital disease.

UK national guidelines for the management of gonorrhoea in adults (British Association for Sexual Health and HIV, 2011) – advice on diagnosis, treatment and health promotion for anogenital and pharyngeal gonorrhoea.

This page was created on 12 June 2014 and updated on 22 June 2016.  Next review date February 2017.

Cite this page:

Bracknell Forest Council. (2016). JSNA – Adult sexual and reproductive health. Available at: jsna.bracknell-forest.gov.uk/living-working-well/health-protection/sexual-health (Accessed: dd Mmmm yyyy)

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