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Version 11 10 August 2015 Edinburgh Shadow Health and Social Care Partnership Joint Strategic Needs Assessment Topic Paper 7.8 SEXUAL HEALTH AND BLOOD BORNE VIRUSES 1. OVERVIEW OF CURRENT AND FORECASTED NEEDS We have made good progress against the five outcomes which are integral to the Lothian Sexual Health and HIV Strategy 2011-2016. Evidence has informed our clinical priorities and activities over the last year, with a focus on reducing and responding to teenage pregnancy; reducing unintended pregnancies for those over 20 years of age; increasing uptake of Long Acting Reproductive Contraception in all settings; increasing access to early abortion services; reducing infection and transmission of Sexually Transmitted Infections and Blood Borne Viruses (primarily HIV and Hepatitis B and C); improving gender reassignment services; improving sexual health and relationship education in schools and community settings and improving our understanding of the health needs of men who have sex with men amongst primary care and other staff groups. Work has also progressed to increase access to integrated services in both a central location (Chalmers) and in areas of high deprivation. To meet the above objectives partners work with children and young people; men who have sex with men; women and men involved in the sex industry; people who use drugs; people with a diagnosis of HIV and Hepatitis C and men and women who do/could benefit from other sexual health services. Significant progress has been made in monitoring and evaluation through investment in resources to support the National Sexual Health System (NaSH), providing invaluable data to inform future priorities. The Sexual Health Data Chapter 2014 is updated each year. This is used along with the Annual Report of the Sexual and Reproductive Health Service and published evidence to inform our priorities for action in Lothian. We have prioritised work and services in areas of high deprivation and with groups who are most disadvantaged. This includes the development of Sexual and Reproductive Health Services/Chalmers locality clinics, young people drop-ins and work with primary care. The integration of health and social care provides us with an opportunity to ensure that local services are relevant and coordinated. Sexual health data summary: Under sixteens pregnancy rate in Lothian showed a 22% reduction in 2011 and a further small decrease in 2012. Gonorrhoea: in 2012 Lothian males had the second highest rate of infection in Scotland, mostly among Men who have Sex with Men (MSM). Syphilis: there is again a slight rise in cases in 2011 and 2012, with 205 cases in Lothian - the majority of cases are in Men who have Sex with Men. The needs of men who have sex with men are being addressed through the implementation of the findings from the Men who have Sex with Men Needs Assessment. Version 11 10 August 2015 Chlamydia: In Lothian, chlamydia testing rates remain high. Prevalence is highest in the under twenties and under twenty-five year old age groups. Work continues with primary care and specialist services to ensure that chlamydia testing is provided to those who need it and that unnecessary testing is stopped. HIV Testing: testing activity in Lothian in 2013 totalled 35,768 tests, an increase of 14% since 2008. Testing activity is monitored each quarter by source. A proposal to undertake an anonymous study on 70,000 blood samples to ascertain actual prevalence in the 16-79 population has been agreed. This will inform Lothian's future actions to extend and increase HIV testing. The total number of people living with HIV in Lothian is 1,479 (March 2014) and the diagnosed prevalence is 1.7/1000 for the whole population, and 2.6/1000 among 15-59 year olds. A transition clinic for young people with HIV has been set up at Regional Infectious Diseases Unit (RIDU) with staff from Sick Kids, Chalmers and RIDU. Milestone House re-opened in February 2014 and has had 120 referrals since then (65 HIV, 46 HCV, 9 co-infected). There are a variety of Blood Borne Viruses (BBV) of which Hepatitis C and HIV have the most serious long term implications. There is no vaccine for either illness. There is no cure for HIV. For Hepatitis C there is a treatment which leads to sustained viral clearance in the majority of patients. Health Protection Scotland publish BBV data by Health Board but not by Local Authority. During calendar year 2013, 235 cases were newly identified as hepatitis C antibody positive in Lothian. The majority of these are likely to have been infected some years ago. This compares with an average of 203 in the years 2002-2009. Since testing became available in the late 1980s there have been 4876 persons reported as hepatitis C antibody positive in Lothian (to 31st Dec 2013) of whom 3960 are still alive. The number of new cases of HIV infection in Lothian has been falling since 2005 and in 2013 totalled 88. However, the prevalence of people with HIV is increasing due to decreased deaths, due to antiretroviral therapies and due to new cases being diagnosed. At 31 March 2014 there were an estimated 1,479 people living with HIV in Lothian, up from just over 1,000 in January 2010. There are around 5,500 people living in Lothian with HIV or Hepatitis C infection. Further planning work is required to estimate the numbers now and in the next five to ten years living in Edinburgh who are likely to require Health and Social Care services. 2. PROFILE OF ACTIVITY Sexual health service usage: the service at the Chalmers Centre (including its peripheral clinics in other parts of Lothian) has seen levels of service provision continue to increase in the past year. New registrations have increased by 8.7% to a total of 17466 and an increase in patient contacts overall of 2.9%. The service has seen an increase in activity such as a 33% increase in contraceptive implants and a 16% Version 11 10 August 2015 increase in IUD/IUSs. There has been a 7.5% increase in attendances for HIV care and a 9.3% increase in MSM using the service. Overall attendance at the service was 44,843 in 2013/2014. A Healthy Respect plus service for young people five days per week at Chalmers was established in 2014. Healthy Respect is the brand we use for young people’s services in Lothian; we have twenty-five local drop-in services and will link these into the more specialist service at Chalmers for those that need more specialist service. Planning is underway to extend the young people’s specialist service in areas of highest deprivation in order to meet the levels of need in these areas. City of Edinburgh Substance Misuse and BBV Social Work Team: during September 2014 four existing substance misuse and BBV teams at City of Edinburgh Council were combined. The new team covers assessment, care management and recovery. This change supports the move to greater integration and locality working. People living with BBV require a range of information, advice, counselling and support services depending on the level of chronic physical and or mental illness associated with long-term Hepatitis C and HIV infection. Table 1: Numbers of People -BBV services provided or Service Type 2011/12 2012/13 2013/14 Financial support/ assistance 78 47 97 Housing Support (specialist) 73 69 77 Care at home, home care, care and support 12 16 18 Reablement 5 8 7 Equipment 19 26 13 Waverley Care (Milestone House) 0 30 26 Care Home 11 2 20 Residential Respite 9 4 3 Day centre or activities 9 8 9 Direct Payment 1 3 3 Other Services 0 1 3 Total 217 214 276 This table excludes services arranged for people with HIV or Hepatitis C by Sector Practice Teams or Hospital Social Work Teams, however these teams usually refer people whose needs are related to BBV to the BBV care management team and so the numbers missing are expected to be low. This table indicates that financial support and specialist housing support were the most commonly provided services to people with BBV. People with HIV are less likely to be in paid employment than the general population and one in three people diagnosed with HIV in the UK have experienced severe economic hardship. Housing support includes support relating to treatment and medication, access to recovery services, developing life or social skills or end of life care. Version 11 10 August 2015 Waverley Care was reprovisioned in 2013 to meet the changing needs of people with BBV. NHS Lothian and City of Edinburgh Council fund short stay residential provision for people with complex health needs and community support. There are ten beds which provide: Respite for people with BBV and complex health needs. Step down support from hospital to home and to avoid hospital admission where support at home is not an option. Step up service for people, including those with Hepatitis C, who need support to establish treatment. The community support service provides short term care management (e.g. following hospital discharge). It addresses isolation, physical and mental ill-health, limiting coping skills, poor family relationships, employment issues, welfare rights and access to housing, substance misuse and other services. The new service is intended to reduce hospital bed days used by people living with BBV infection, increase respite care for people with complex needs, increase the number of people supported to remain in the community and increase the number of people with Hepatitis C who start and maintain drug treatment regimes. Hepatitis B and C service activity – multi-agency In 2013/14 services (health, council, voluntary sector) reported the following activity: 25 outlets in Lothian provided clean injecting equipment for people injecting drugs A total of 18,808 hepatitis C antibody tests were performed 589 BBV dry blood spot tests were performed 235 new hepatitis C diagnoses were reported in calendar year 2013 145 people started treatment for hepatitis C, including 34 prisoners 66 people started treatment for hepatitis C on the protease inhibitor medications (introduced April 2012) 10 patients started treatment for hepatitis C with new medications under trial At March 2014, 25 individuals were on the waiting list for hepatitis C treatment and ready to start 24 babies born to mothers who had hepatitis B started their course of hepatitis B immunisations (100%) during 2013 97 babies born to parents with problem drug use started their course of hepatitis B immunisations during 2013 Key successes: Following extensive consultation, the Reducing and Responding to Teenage Pregnancy paper was finalised. The implementation has now been agreed in all Children's Partnerships/Getting It Right For Every Child Boards and will form part of Integrated Children's Services Plans. Jointly with NHS Greater Glasgow and Clyde, we undertook an extensive needs assessment into HIV prevention among Men who have Sex with Men. This has provided evidence to refine our approach to addressing the inequalities and complex sexual health and HIV needs that have remained persistent among Men who have Sex with Men in Lothian and Glasgow. We have worked with our third sector partners to Version 11 10 August 2015 review what is currently provided and agreed to stop some things and re-prioritise others. Our goal is to meet the recommendations through service redesign with the NHS and third sector. We have delivered a pilot project to move the abortion service from the Royal Infirmary Edinburgh to the Chalmers Centre resulting in the service being provided at Chalmers, Royal Infirmary Edinburgh and St John’s Hospital. One of the reasons for moving the service is that we have reduced our use of surgical terminations over the past ten years and now mostly provide medical abortion. A significant amount of work has taken place to get women into the service prior to nine weeks and the majority of these women opt for early medical discharge (they can leave upon receiving their treatment). This reduces the need for women to go to a hospital setting. Furthermore, the uptake of post abortion contraception has increased in the Chalmers Centre (39% at Royal Infirmary Edinburgh and 49% at Chalmers Centre), which will hopefully lead to a reduction in the number of repeat abortions over the next few years. It is our goal to make the provision of abortion services at the Chalmers centre a permanent feature and to move more of the service there away from the Royal Infirmary Edinburgh which will be used for surgical cases and women with high levels of medical or social need who do not fit the criteria for early medical discharge. Different approaches have been employed to increase uptake of Long Acting Reversible Contraception (LARC). During 2014-15 the limit on the number of LARC insertions that GPs receive payment for lifted and it is anticipated that the number of procedures will have increased. Figures are awaited. The process for those attending Chalmers was also improved. Previously, all women attending for an IUD/IUS had to attend the service for an assessment appointment and then return for a fitting appointment. We now have a DVD on the sexual health Lothian website that women can watch in advance; they then complete a short form and can come to the service and have the method inserted that day either by appointment or through the walk in clinic. This has led to 73 out of 100 women not needing an assessment appointment, saving time of the service and the women. The DVD can be found here: http://www.lothiansexualhealth.scot.nhs.uk/Contraception/Coil/Pages/default.aspx Late Diagnoses of HIV (Health Improvement Scotland standards 6 & 7): 87 cases were newly reported in Lothian in 2013, 53 of which were new diagnoses for the individuals. 23 cases were late diagnoses. Following a pilot in 2012, it is now policy in Lothian to review all of our HIV late diagnosis cases to identify all healthcare presentations in primary and secondary care of each individual within the 24 months leading up to their diagnoses. This is used to provide learning opportunities in instances where cases have been missed. Version 11 10 August 2015 3. EXISTING PLANNING GROUPS The Sexual Health and HIV Strategy Board is responsible for the strategic direction of sexual health and BBV services. It involves representatives from health, local authority and the voluntary sector. There are sub-groups working on specific areas of work. There is also the Hepatitis C MCN (Managed Care Network) that continues to lead the programme of activity designed to reduce the prevalence of Hepatitis C in Lothian. 4. EXISTING STRATEGIC PLANS National: Sexual Health and Blood Borne Virus Framework (2011-2015) On 25 August 2011, the Scottish Government brought together sexual health, HIV, hepatitis C and hepatitis B policy into this Framework. It articulates a joined-up approach to improving sexual health and tackling blood borne viruses (BBVs) in Scotland. The Framework built on the success of the Hepatitis C Action Plan (Phase II) and Respect and Responsibility as well as further developing the HIV Action Plan in Scotland. Lothian: Lothian Sexual Health and HIV Strategy 2011-2016 5. CURRENT PRIORITIES reducing and responding to teenage pregnancy; reducing unintended pregnancies for those over 20 years of age; increasing uptake of Long Acting Reproductive Contraception in all settings; increasing access to early abortion services; reducing infection and transmission of Sexually Transmitted Infections and Blood Borne Viruses (primarily HIV and Hepatitis B and C) (This involves implementing Hep C treatment procedure); improving gender reassignment services; improving sexual health and relationship education in schools and community settings; improving our understanding of health needs of men who have sex with men amongst primary care and other staff groups; increase access to integrated services in both a central location (Chalmers) and in areas of high deprivation focusing on addressing health inequalities; improve efficiencies (eg use of generic drugs) develop a clearer pathway into Hepatitis C treatment. Funded social work post provides practical and emotional assistance to enhance service users’ ability to engage with treatment. develop a post treatment recovery plan. Work with the Third Sector to develop a pathway of ongoing support, including community and residential step up/ step down supports. Version 11 10 August 2015 6. FUTURE USE OF RESOURCES We will be working to progress the challenges listed above (section 5) and to continue to support the delivery of universal and specialist services within NHS Lothian, CEC and with partners that positively impact on sexual health and wellbeing. Moving to locality working The integration of health and social care and the emphasis on locality working is in line with the strategic direction of the Sexual Health and HIV Strategy Board. Work will continue to have sexual health services delivered in primary care where appropriate; specialist sexual health services will be delivered in localities, particularly in areas of deprivation, in locality based clinics; specialist services for gay and bisexual men will be expanded into locality based clinics; clinical sexual health services for young people, Healthy Respect Plus will be established in additional areas of deprivation over the next two years; Healthy Respect will continue to review and increase drop-in provision across the city, along with partner agencies, and will adjust and expand where applicable and feasible; the network and education services delivered by Healthy Respect will be planned and delivered according to local area priorities; the strategic direction of the Board will be influenced by local area evidence and reporting and the work of voluntary sector partners and others will be commissioned according to available evidence, including evidence regarding particular communities. Locality working should also maximise the opportunities to integrate services across disciplines and health areas. Healthy Respect has already implemented this by taking a holistic approach to health and wellbeing at drop-ins. There are opportunities to improve the local integration of services to improve person centred support, such as better integration of sexual health, substance misuse, gender based violence, mental health, housing, welfare and other service areas. Work has progressed on this but significantly more effort is required. In order for the above to be effective we must continue to listen to people who use our services as well as those who don’t. This requires investment. Chapter Authors Colin Beck, Senior Manager Mental Health, Criminal Justice & Substance Misuse Mairi Simpson, Strategic Programme Manager - Drugs, Alcohol, Sexual Health & BBV References Title: HIV Prevention Needs Assessment of Men Who Have Sex with Men, Scottish Government 2014