Written evidence from the Terrence Higgins Trust [WRH0042]

About Terrence Higgins Trust

Terrence Higgins Trust is the UK’s leading HIV and sexual health charity. We support people living with HIV and ensure their voices are heard, provide testing services for HIV and other sexually transmitted infections, and help the people using our services to achieve good sexual health.

Our vision is a world where people with HIV live healthy lives free from prejudice and discrimination, and good sexual health is a right and reality for all.

Introduction

This is a welcome inquiry. There is an urgent need for clear, strategic direction from government on sexual and reproductive health in England.

A national strategy is long overdue: the government first promised a Sexual and Reproductive Health Strategy in 2019, following a recommendation from the Health and Social Care Committee.[1] This commitment was reiterated in December 2021 in the Government’s National HIV Action Plan and again in August 2022 in the Women’s Health Strategy.[2]

Everyone should be able to access reproductive healthcare in a timely manner from services that meet their needs. Our evidence highlights the need to improve access to reproductive health care through sexual health clinics, ensure these services are holistic, and prevent the burden of responsibility for sexual and reproductive health from being solely placed on women.

We recommend:

1.                                            In light of significant increases in chlamydia diagnoses, the National Chlamydia Screening Programme returns to recommending proactive screening of all young people.
2. Sexual health appointments should be bookable via relevant NHS apps in addition to the option of booking an appointment anonymously via the phone or online.
3. A 48-hour waiting time target for access to sexual health appointments should be implemented and monitored as an indicator for demand that central government, health boards and local authorities can use for planning purposes.
4. National governments in England, Wales and Scotland must ensure there is increased funding, rising yearly by at least the rate of inflation, specifically for sexual and reproductive health services in order to meet the rising demand and deal with rising STI rates and unplanned pregnancy.
5. The UK government should explore options for awarding multi-year Public Health Grant settlements in England specifically for sexual and reproductive health, to enable commissioners to ensure longer-term strategic service delivery in their areas and reduce the administrative burden of regular retendering.
6. Commissioners should ensure that service specifications for sexual health clinics require STI and HIV testing on an opt-out basis and conversations about PrEP as part of reproductive health appointments.

Changes to the National Chlamydia Screening Programme (NCSP)

In 2021 UKHSA announced changes to the National Chlamydia Screening Programme that place the burden of chlamydia testing solely on women and girls. Previously, it was recommended that all sexually active men and women aged 15-24 be tested for chlamydia annually or on change of sexual partner (whichever is more frequent). This made chlamydia a shared responsibility between women and men.

The shift has meant that now only young women are proactively offered a chlamydia screening in community settings.

The changes were framed as a strategic re-focus, from preventing transmission of chlamydia and early detection, to reducing the reproductive harm of untreated infection in young women. However, by putting the burden of testing solely on women and girls, the programme sends a message about who should (and shouldn’t) bear responsibility for sexual and reproductive health and prevention. Losing this focus on informing all young adults about chlamydia and normalising the idea of regular chlamydia screening for young men is detrimental for all young adults.

This is particularly harmful as there was a 24% increase in chlamydia last year, with nearly 200,000 chlamydia diagnoses in 2021[3]. Given 70% of women and 50% of men with chlamydia show no symptoms, opportunistic screening of all young adults is an essential approach to early diagnosis and preventing onward transmission. The new approach to NCSP does not seem to have increased the number of chlamydia tests carried out among young women: last year there was a small decrease compared to 2021.[4] Emphasis on preventing pelvic inflammatory disease and infertility that results from some untreated chlamydia infections is important, but only testing women and girls is not the answer.

We recommend:

•                                              In light of significant increases in chlamydia diagnoses, the National Chlamydia Screening Programme returns to recommending proactive screening of all young people.

Access to reproductive health services through sexual health services

Our research suggests that sexual health services are the second most common way of accessing reproductive and sexual health care, following GP surgeries.

The research, conducted in November and December 2022, examined barriers to sexual and reproductive health in the UK and gaps in service provision. It comprised a survey that received over a thousand responses and 60 follow-up interviews.

Sexual health clinics had the highest satisfaction ratings, above GPs, shops or community pharmacies, with two-thirds of people who used a sexual health clinic saying it was “very helpful” in accessing contraception or protection, as compared to 37% of people who went to their GP. For one respondent who wasn’t registered with a GP in the city she was studying, accessing contraception through their sexual health service was the preferred option. There was also a strong perception of gatekeeping by GPs around contraception options, with some respondents claiming they were denied their preferred option due to not having given birth. Some respondents had experienced or feared judgement from pharmacy staff if they asked for contraception.

However, rising demand for sexual and reproductive health services, combined with a 29% decrease in funding for sexual health between 2015/16 and 2023/24[5] has left services in England under significant strain. Our Mystery Shopper research found that nearly half of clinics didn’t have appointments for booking available by the telephone for asymptomatic service users, with waiting times averaging 13 days.

This is likely exacerbating existing inequalities in access to reproductive and sexual health services.

We found that:

• Young people (16-24) continue to face the greatest difficulties accessing sexual and reproductive health care. 
• There are clear geographic inequalities in provision. People in the North East, London and the West Midlands also reported higher levels of difficulty obtaining contraception or protection.
• Transgender men and non-binary people were more likely to report difficulties in access than any other group: 38% and 29% respectively, compared to 12% of cis women and 6% of cis men.

Inability to get an appointment was by far the most common reason people faced difficulties in accessing contraception and protection, followed by long waiting times. Many people elaborated that they found it difficult to get an appointment to get an IUD or coil fitted or replaced, with several respondents relating this to lack of local sexual health clinics. 2 out of the 6 respondents who attempted to obtain a diaphragm in the past year were unable to do so, and a fifth of respondents who tried to have a coil fitted failed. Ten respondents were unable to get hold of the morning after pill, with one non-binary respondent elaborating that when they tried to access emergency contraception, they were told that “men can’t get pregnant” by their pharmacist.

In addition to being key to preventing the circulation of infections that can cause reproductive harm in women, such as chlamydia, sexual health clinics are a popular and trusted way of accessing reproductive health services. For girls and women, every delayed or unavailable appointment at a sexual health clinic may be a missed opportunity to discuss reproductive health options. Sexual health services can play a crucial role in ensuring everyone can access contraception in a timely way, but must be properly resourced to do so.

We recommend:

• Sexual health appointments should be bookable via relevant NHS apps in addition to the option of booking an appointment anonymously via the phone or online.
• A 48-hour waiting time target for access to sexual health appointments should be implemented and monitored as an indicator for the demand that central government, health boards and local authorities can use for planning purposes.
• National governments in England, Wales and Scotland must ensure there is increased funding, rising yearly by at least the rate of inflation, specifically for sexual and reproductive health services in order to meet the rising demand and deal with rising STI rates and unplanned pregnancy.
• The UK government should explore options for awarding multi-year Public Health Grant settlements in England specifically for sexual and reproductive health, to enable commissioners to ensure longer-term strategic service delivery in their areas and reduce the administrative burden of regular retendering.

Opportunities for wider sexual health and HIV prevention during reproductive health care

Often sexual and reproductive health services operate as parallel services provided in one building and so prevention opportunities are missed. Consultations about contraception provide the perfect opportunity to have wider conversations about sexual and reproductive health with people who are sexually active or thinking about being sexually active.

Perceptions of who is likely to be affected by HIV mean that women are significantly less likely to be offered an HIV test or have their PrEP need identified during a sexual health consultation. There is an urgent need to increase the number of women accessing PrEP: only 2% of PrEP users in England in 2021 were women, despite making up 21% of new HIV diagnoses. Reproductive health services could and must play a central role in this.

We recommend:

• Commissioners should ensure that service specifications for sexual health clinics require STI and HIV testing on an opt-out basis and conversations about PrEP as part of reproductive health appointments.

September 2023