Written evidence from The British Association for Sexual Health and HIV [WRH0021]

Executive Summary

• Currently, the commissioning of reproductive and sexual health services is fragmented and complex, making it harder for patients to navigate their needs.

• There is a need for greater integration between different elements of reproductive and sexual health services, to join up care and ensure women have access to the right care at the right time.

• In particular, greater prioritisation should be given to HIV care for women, both in terms of prevention and treatment, as women currently experience inequalities in HIV care.

• Models for supporting women’s health should support access to high quality reproductive health care, including routine contraception, whilst also enabling access to high quality genitourinary medicine (GUM) specialisms wherever it is required.

• High quality care for women’s sexual health and reproductive health go hand in hand, there can be no high quality sexual and reproductive healthcare without high quality STI and HIV care offered in sexual health services.

Introduction

This submission is made on behalf of the British Association for Sexual Health and HIV (BASHH).

BASHH is the lead professional representative body for specialist physicians in GUM managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.

Commissioning of sexual and reproductive health services

• The current landscape for SRH services is complex and fragmented, with different aspects of reproductive and sexual health care commissioned and delivered by different bodies. This can make it difficult for people to access care effectively and in a joined-up, holistic way.

• It is important that women are able to access both effective reproductive and sexual health care, such as contraception and gynaecology, whilst at the same time accessing sexual health care in genitourinary medicine (GUM), around sexually transmitted infections (STIs) and HIV. Indeed, there can be no high quality sexual and reproductive healthcare without high quality STI and HIV care.

• Currently, barriers in the way services are developed and funded impede a more joined up approach to women’s sexual and reproductive health. For example, many sexual health services do not receive funding for genital dermatology and psychosexual services, leaving gaps in service provision. Similarly, many contraceptive services will not discuss or offer PrEP (treatment to prevent HIV transmission) to women as part of their routine care.

• Integrated Care Systems provide an opportunity to address some of the longstanding challenges and complexities in the commissioning of SRH services, such that services are made easier to navigate and better equipped to meet the needs of specific demographics, including women.

• Other initiatives to support women’s health, particularly the introduction of Women Health Hubs, should ensure that women can access sexual health services and receive care from GUM specialists as required. BASHH emphasises that any model for the implementation of Women’s Health Hubs should not impede access to specialist GUM services. Access to STI care for women must be assured either within integrated sexual and reproductive services or alongside them in order to offer the best access for women.

• GUM services are particularly significant in relation to HIV care and this must be considered in relation to the specific needs of and outcomes for women, namely HIV testing and PrEP access. In addition, integrated approaches to access to routine contraception and other sexual services should effectively utilise GUM specialists in a patient-centred and joined up way.

• Additionally, in determining the model of care available to women, it should be acknowledged that dedicated services for STI care offer a higher level of confidentiality than elsewhere in the health system. By assuring patient confidentiality, these services enhance access to healthcare for women.

HIV Care for Women

• Women make up one third of people living with HIV in the UK.[1] It is important that women are offered appropriate care and interventions, to tackle current inequalities. For example, women are more likely to be diagnosed late with HIV – of the total number of people diagnosed with HIV in England in 2021, 44% were diagnosed late, whilst 50% of women were diagnosed late.[2] Late diagnosis increases the risk of dying by 8-fold and it is estimated that someone who is diagnosed very late with HIV has a life expectancy at least 10 years shorter than someone who starts treatment earlier.1 Late diagnosis of women living with HIV also increases the risk of harm to their children who may be diagnosed late with HIV too.

• HIV testing is a critical tool for the prevention of HIV transmission and for diagnosis and management of HIV infection. In order to achieve the ambitions set out in the HIV Action Plan, committing to achieving zero HIV transmissions in England by 2030, it is important that testing is offered to women at appropriate points, including through engagement with services for sexual and reproductive health.

• It is important to note recent trends in HIV transmission in relation to women’s health. The recent decline in new HIV diagnoses has largely been driven by reductions in diagnoses in gay and bisexual me, who accounted for 41% of all new diagnoses in England in 2019. However, newly diagnosed HIV infections first made in England have declined less steeply among women (and heterosexual men).[3] In England in 2021, the number of new diagnoses increased by 9% in women exposed by heterosexual contact.5

• Almost 2,000 people living with HIV and Hepatitis who were previously undiagnosed have been identified by the NHS over the last year, thanks to the emergency opt-out testing pilot.[4] Not only does this pilot facilitate diagnoses, it also works to normalise HIV testing, supporting de-stigmatisation. Women should be enabled to effectively engage with programmes such as the opt-out programme.

• Notably, opt-out HIV testing coverage for pregnant women remains high at over 99% and has been highly effective in reducing mother to baby transmissions.1 This underlines the value of interventions for women along specific pathways.

• On HIV prevention, more work is needed to define and identify women at risk of HIV. Recent analysis from the Terrence Higgins Trust highlights that nearly half of the women they spoke to (42%) felt that barriers prevent them from testing for HIV, underlining the difficulty women can experience in accessing appropriate HIV care.1

• Furthermore, nearly one fifth of women (18%) reported that in the past five years there had been times when they had wanted to use an HIV prevention method but had not felt able to.1

• Not only do women experience barriers in accessing HIV care, but their HIV status often negatively impacts on other aspects of their health care, for example, the Terrence Higgins Trust found that nearly one third (31%) of women had avoided or delayed attending healthcare out of fear of discrimination.1 Furthermore, women living with HIV are known to experience inequalities in access, for example, a significant number of women living with HIV do not attend routine cervical screening.

• A key aspect of the Zero 30 ambition is the use of PrEP to reduce HIV transmission. PrEP access for women is relatively recent in the UK and there are significant barriers for women in relation to being offered or even considered for PrEP.

• Recent data on PrEP access has found that no local authority in England had reported more than 5 women using their PrEP services.[5] This underlines significant gaps in access. Additionally, supporting evidence from a community survey led by the Sophia Forum, found that only 12 respondents (1%) were women. This suggests that women’s engagement with PrEP services remains poor, and there is more work for service commissioners and providers to do to engage with women specifically.1

Sexually Transmitted Infections

• Alarmingly, recent data demonstrates significant increases in rates of STIs including chlamydia, gonorrhoea, and syphilis. It is important that women are able to access sexual health services that can treat and support prevention of these STIs. Data from the UK Health Security Agency highlights that rates of both syphilis and gonorrhoea have risen compared to the previous year across women in multiple age categories (15-19, 20-24, and 25-34).[6]

• These STIs can have serious implications for women’s reproductive health, if left untreated or diagnosed late, with risks such as pelvic inflammatory disease, infertility, and chronic pelvic pain. It is important that women are able to access services as early as possible and receive specialist care.

• In addition, data in recent years has underlined increasing rates of congenital syphilis[7], a key indicator of challenges in diagnosing and treating women for STIs as early as possible, which has wider implications for women’s reproductive health.

Access to routine contraception

• In 2020, the APPG on Sexual and Reproductive Health published the findings of its inquiry into access to contraception following the response of 60 written evidence submissions from individuals and organisations involved in the sexual and reproductive healthcare (SRH) sector. This found that women are finding it harder and harder to access contraception that suits them.[8]

• Government data outlines that 45% of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence.[9] It is important that services are available to support women around their reproductive health, and that barriers to access are addressed.

• Some specific challenges, such as meeting the demand for Long-Acting Reversible Contraception (LARC) must be addressed. Whilst demand for LARC is increasing, provision has still not returned to pre-pandemic levels.[10]

• The Faculty for Reproductive and Sexual Health has advocated for the introduction of a Women’s Health Hub model – which could be used to support improvements in access to contraception and contraceptive counselling.[11] BASHH is supportive of the prioritisation of women’s health and underlines that any model should ensure that women can access appropriate sexual health care.