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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.
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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%
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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.
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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
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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.
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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
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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.
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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