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Sexual Health

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Introduction

Sexual health is an important and integral part of overall health.  This is captured in the working definition of sexual health developed by the World Health Organisation (WHO):

‘Sexual health is a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.For sexual health to be attained and maintained, the sexual rights of all persons must be protected, respected and fulfilled’1

The local authority has a mandated responsibility to commission comprehensive, open access sexual and reproductive health services.  Open access services are essential to control infection, prevent outbreaks and reduce unwanted pregnancies and means that non-residents are entitled to use the sexual health services provided in Blackpool.

Sexual ill health is not equally distributed among the population. Those at highest risk of poor sexual health are often from specific population groups with varying needs. These groups include; young people, men who have sex with men (MSM), people from African communities, people living with the human immunodeficiency virus (HIV), sex workers, victims of trafficking, victims of sexual and domestic violence and abuse and other marginalised or vulnerable groups.

The Blackpool Sexual Health Needs Assessment 2016  (pdf 3MB) is intended to present a picture of the sexual health needs and current service provision for sexual health in Blackpool and to support the development of the Sexual Health Strategy and Action Plan for Blackpool 2017–2020 (pdf 1.4MB).

 

 

Facts and figures

Sexually Transmitted Infections (STI's)

In 2015, there were 434,456 new STI diagnoses made at Sexual Health Clinics in England. Of these, the most commonly diagnosed STIs were chlamydia (46%), genital warts (16%), non-specific genital infections (10%), and gonorrhoea (10%)1. The impact of STIs remains greatest in young heterosexuals under the age of 25 years and in men who have sex with men (MSM). Large increases in STI diagnoses have been seen in MSM, including a 21% increase in gonorrhoea and a 19% increase in syphilis. High levels of condomless sex probably account for most of this rise. Testing and partner notification are essential elements of STI management and control, protecting patients/partners from re-infection and long-term consequences from untreated infection, reducing the cost of complications and onward transmission.

There were 1,573 new STIs diagnosed in residents of Blackpool in 2015, a rate of 1120 per 100,000 residents (compared to 768 per 100,000 in England). Blackpool is ranked 26th highest for all new STI diagnoses out of 152 upper tier local authorities. Overall, diagnoses of new STIs have fallen slightly from 2014. The number of people diagnosed in Blackpool has fallen from 1,607 in 2014 to 1,573 in 2015 and the diagnosis rate has fallen from 1144 per 100,000 to 1120 per 100,000.

Figure 1: New STI diagnoses in Blackpool, 2015

STI-New STI diagnoses Blackpool 2015
Source: PHE Sexual and Reproductive Health Profiles and PHE GUMCADv2 Report

However, when looking at new STI diagnoses excluding young people aged under 25 (the age group targeted by the National Chlamydia Screening Programme (NCSP), the number and rate has risen slightly from 2014 to 2015 (figure 2). The trend in new STI diagnoses (exc. Chlamydia <25) in Blackpool has been and still is significantly higher than the national average and while recent years have seen a fall in newly diagnosed STIs, 2015 saw a slight increase from 1063 per 100,000 to 1095 per 100,000.

Figure 2: Trend in new STI diagnosis rate per 100,000, Blackpool compared to England

STI-Trend in new STI diagnoses
Source: PHE Sexual and Reproductive Health Profiles

The 5 main STI diagnoses in Blackpool are chlamydia (51%), syphilis (1.3%), gonorrhoea (8%), genital warts (15%) and genital herpes (9%). HIV (0.8%) and other STIs account for the other 16% of infections. Of the 5 main STIs diagnosed, 99% of females are in the heterosexual population. For males, 78% are heterosexual while 22% are gay, bisexual or other.

Figure 3 shows the trend in specific STI infection rates since 2009. There has been a slight increase in in syphilis following what was a downward trend. While the number of syphilis and gonorrhoea is low, these infections are predominantly in MSM (reflecting higher levels of risky sexual behaviour).

The increase seen in gonorrhoea is in line with the national picture which has seen a sharp rise in recent years, exceeding 40,000 cases in 20152. Although improved test sensitivity and uptake may have contributed, increased gonorrhoea transmission is likely playing a major role. Reversing this trend is a public health priority given the spread of resistance to frontline antimicrobials used for treating gonorrhoea and the depletion of effective treatment options. The Gonorrhoea Resistance Action Plan for England and Wales3 makes recommendations on ensuring prompt diagnosis, prescribing guideline adherence, identifying and managing potential treatment failures effectively, and reducing transmission.

There has been a general fall in genital wart infection and this is expected to continue as a positive effect from the national Human Papilloma Virus (HPV) vaccination programme for young women. MSM HPV vaccine could have an even greater influence if implemented.

Figure 3: Trends by sexually transmitted infection, 2009-2015

STI-Trend in specific STIs
Source: PHE, GUMCADv2 Report, Numbers and Rates of New STIs Diagnoses, HIV and STI Portal

Of the 1,573 new diagnosed STIs in 2015, 61% (953) were in the under 25 age group. Of these 40% were male and 60% female. Conversely, in the 25+ age group, 67% of new diagnoses were male and 33% female. In comparison, across England only 52% of new diagnosed STIs are in the under 25 age group but the gender split is broadly the same as Blackpool.

Figure 4: All new STIs in Blackpool by gender and age group, 2015

STI-New STIs by age sex
Source: PHE, GUMCADv2 Report, Numbers and Rates of New STIs Diagnoses, HIV and STI Portal

Figure 5 shows the breakdown by STI diagnoses for males by sexual risk. It can clearly be seen that while the number of cases of gonorrhoea and syphilis is low, these infections are more predominant in the non-heterosexual community. When an increase in rates of gonorrhoea and syphilis in a population are seen, this reflects higher levels of risky sexual behaviour.

Figure 5: Number and proportion of STIs in males by sexual risk, 2015

STI-STIs in males by sexual risk
Source: PHE, GUMCADv2 Report, Numbers and Rates of New STIs Diagnoses, HIV and STI Portal

For cases in men where sexual orientation was known, 20% of new STIs in Blackpool were among men who have sex with men4.

There is a concern nationally in the rise in syphilis and gonorrhoea among MSM which link with high levels of condomless sex. HIV serosorting, (the practice of engaging in condomless sex with partners believed to be of the same HIV status) increases the risk of infection from STIs, hepatitis B and C, and sexually transmissible enteric infections like Shigella spp, and likely plays a role in the reported STI trends. For those who are HIV negative, serosorting increases the risk of HIV seroconversion as 14% of MSM are unaware of their infection5.

While vaccination is a measure that can be used to control genital warts and hepatitis B, control of other STIs relies on consistent condom use, behaviour change to decrease overlapping and multiple partners, ensuring good access to testing and treatment, and ensuring partners of cases are notified and tested. A large fall in genital warts seen this year in young women is an expected positive effect of the national HPV vaccination programme.

STI testing rates, positivity and diagnoses rates are linked. Figure 6 shows new STI diagnoses (excluding chlamydia in under 25's) positivity rate among people accessing genitourinary medicine (GUM) services expressed as a percentage of the number of STI tests performed.

Figure 6: STI testing positivity rate (exc. Chlamydia in under 25s)-Blackpool and England

STI positivity rates
Source: PHE Sexual and Reproductive Health Profiles

In 2015, Blackpool was higher than the North West and England, with a positivity of 5.9% compared to 5.5% and 5.2% respectively.

Re-infection

Reinfection with an STI is a marker of persistent risky behaviour. In Blackpool, an estimated 9.1% of women and 10.6% of men presenting with a new STI at a GUM clinic during the five year period from 2010 to 2014 became re-infected with a new STI within twelve months. Nationally, during the same period of time, an estimated 7.0% of women and 9.0% of men presenting with a new STI at a GUM clinic became re-infected with a new STI within twelve months4.

Also, an estimated 2.9% of women and 6.0% of men diagnosed with gonorrhoea at a GUM clinic in Blackpool between 2010 and 2014 were re-infected within twelve months. Nationally, it was 3.7% of women and 8.0% of men becoming re-infected with gonorrhoea within twelve months.

In Blackpool, an estimated 13.7% of 15-19 year old women and 14.9% of 15-19 year old men presenting with a new STI at a GUM clinic during the five year period from 2010 to 2014 became re-infected with an STI within twelve months. Teenagers may be at risk of reinfection because they lack the skills and confidence to negotiate safer sex.

 

National Chlamydia Screening Programme (NCSP)

The NCSP was established in 2003 to facilitate early detection and treatment of asymptomatic Chlamydia infection. Chlamydia is the most common bacterial sexually transmitted infection in England an up to 70% of women and 50% of men with the infection have no symptoms. If these infections remain undiagnosed and hence untreated, complications such as pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility can develop. Effective screening, when combined with good sexual health improvement messages, contributes to young people having better sexual health, as the offer of a test normalises testing for STIs, doesn't increase risky behaviour and provides a gateway to more comprehensive sexual health services.

The Public Health Outcomes Framework (PHOF) includes an indicator to assess progress in controlling chlamydia in sexually active young adults. This recommends local areas achieve an annual chlamydia detection rate of at least 2,300 per 100,000 15-24 year old resident population to detect and treat sufficient asymptomatic infections to affect a decrease in incidence.

The chlamydia detection rate per 100,000 young people aged 15-24 years in Blackpool was 3,416 (compared to 1,887 per 100,000 in England) in 2015. The rate reflects both screening coverage levels and the proportion of tests that are positive at all testing sites, including primary care, sexual and reproductive health and genitourinary medicine services. Areas achieving or above the 2,300 detection rate should aim to sustain or increase, with areas achieving below it aiming to increase their rate. As shown in figure 7, Blackpool has a higher detection rate than England, though the detection rate has shown a decline. The fall between 2012 and 2013 was due to more targeted screening while the fall from 2014 to 2015 is in line with the national picture, where the rate has fallen by 7.3%.

Figure 7: Chlamydia detection rate per 100,000 aged 15-24 (PHOF indicator 3.02)  

STI-chlamydia detection rate
Source: PHE Sexual and Reproductive Health Profiles

Nationally chlamydia detection rates are higher in females than males reflecting higher testing rates in females. Chlamydia detection rates among young females did not vary greatly between those aged 15-19 years and those aged 20-24years. However, detection rates among males aged 20-24 years were up to 2.4 times higher than among males aged 15-19 years4.

Chlamydia test coverage data represent the number of tests reported, and not the number of people tested. The NCSP recommends that all sexually active under 25 year old men and women be tested for chlamydia annually or on change of sexual partner (whichever is more frequent). There has been a decline in chlamydia testing coverage nationally and Blackpool has shown a similar decline since 2012 (figure 8). The decline is mostly attributable to fewer tests being carried out in non-specialist sexual health services and community venues. Improvements have also been made in data quality which may also account for the decline in data coverage with a reduction in double counting.

Figure 8: Proportion of 15-24 year olds screened for chlamydia

STI-15-24 screened for chlamydia
Source: PHE, HIV STI Portal

The proportion of chlamydia tests that were carried out in in males under 25 years in 2015 was 20% compared to 80% of females in the same age range (figure 9). This demonstrates that work is needed to increase testing in young men in Blackpool.

Figure 9: Proportion of Chlamydia tests by age and gender, 2015

STI-Chlamydia tests by age sex
Source: PHE, HIV STI Portal

The NCSP recommends that local authorities commission services that achieve a positivity rate of 5-12%. In 2014, 28.1% of 15-24 year olds were tested for chlamydia with a 13.4% positivity rate. Nationally, 24.3% of 15-24 year olds were tested for chlamydia with 8.3% positivity rate29.

Partner notification (PN) is a key component in the management of chlamydia. In order to have an impact on the burden of disease, sexual contacts and partners need to be tested and treated.  PN is the process by which sexual partners of individuals with diagnosed STIs are notified, informed of their exposure and offered treatment for infection. The performance standard for chlamydia partner notification is at least 0.4 contacts per index case.  Recent data from April-December 2015 for Blackpool shows a partner treatment rate of 0.8.

 

HIV and AIDS

The North West has a very similar outlook as the rest of the UK when looking at HIV, there has been a gradual decline in cases both regionally and nationally in the last 10 years. Public Health England (PHE) report an estimated 103,700 people were living with HIV in 20145. The overall prevalence in the UK in 2014 was 1.9 per 1,000 people aged 15 years and over. An estimated 18,100 (17%) were unaware of their infection and at risk of unknowingly transmitting HIV.

Figure 10 shows the population prevalence of HIV and AIDS by local authority across the North West, 2014 and demonstrates that Blackpool continues to have amongst the highest prevalence of HIV in the region.

Figure 10: Population prevalence of HIV and AIDS - Number of cases of HIV per 100,000 population by LA, Cumbria and Lancashire, 2014

HIV-Prevalence of HIV and AIDS in the NW
Source: CPH/LJMU, HIV and AIDS in Cumbria and Lancashire,2014

New HIV diagnoses

New HIV diagnosis is not synonymous with prevalence; however, it provides a timely insight into the onward HIV transmission in a country and consequently allows targeting efforts to reduce transmission. Although the majority of HIV diagnoses are made in genitourinary medicine (GUM) services, HIV testing has been introduced in a variety of different medical services and non-medical settings, including the expansion of self-sampling/self-testing6.

In the North West, 590 residents were newly diagnosed with HIV in 2014, a rise of 13% from 20137. The highest proportion (62%) of all new diagnoses in North West residents were in men who have sex with men (MSM), an increase from 61% in 2013 and 42% in 2005. Of the MSM newly diagnosed with HIV, 88% were white and 86% were UK born7. In Blackpool, the new diagnosis rate for residents aged 15-59 years in 2014 was 10 per 100,000, below that of England,12 per 100,000 (Figure 11). Of the 12 new cases in Blackpool in 2014, 80% were male, 40% were aged 25-34 years and 33% were aged 35-44 years, 13% were in the 20-24 and 45-64 year age groups.

Figure 11: New HIV diagnosis rate per 100,000 people aged 15+, Blackpool and England

HIV-New diagnoses trend
Source: PHE, Sexual and Reproductive Health Profiles

Across the North West, the number of new diagnoses was highest in the 25-34 year age group in males and females in 2014. In Blackpool the number is highest in males aged 25-44, with 9 new cases in this age range in 2014.

Figure 12: New HIV diagnosis per 100,000 population aged 15+ by NW local authority, 2014

HIV-New HIV diagnoses NW LAs
Source: PHE, HIV and Aids New Diagnosis Database (HANDD)

Prevalence

In 2014 there were 354 total cases of HIV and AIDS in Blackpool residents. Among these, 93.2% were white, 1.4% black African and 1.4% black Caribbean. With regards to exposure, 79.2% most likely acquired their infection through sex between men and 18.1% through sex between men and women.

The diagnosed HIV prevalence rate was 3.8 per 1,000 population aged 15-59 years, compared to 2.1 per 1,000 in England (Figure 13) . This has increased from the 2013 rate of 3.4 per 1,000 population. Blackpool is the only authority in Lancashire above the threshold whereby testing is recommended in general settings including all medical admissions and all new registrations in general practice (ie, 2 per 1,000 or 200 per 100,000).

Figure 13: HIV diagnosed prevalence rate

HIV-Prevalence trend
Source: PHE, Sexual and Reproductive Health Profiles                                                                                                         

Figure 14 shows that Blackpool is one of only four local authority districts in the North West with a diagnosed HIV prevalence rate in excess of 2 per 1,000 population, which is the threshold for expanded HIV testing. The others were Salford (4.8), Manchester (5.8) and Liverpool (2.1).

Figure 14: Diagnosed HIV prevalence per 1,000 residents aged 15-59 years by district in the North West, 2014

HIV-HIVprevalenceNW
Source: PHE, HIV and Aids New Diagnosis Database (HANDD)

In 2014, 37% of those living with HIV in Blackpool were aged between 45-54 years, 25% were 35-44 years, 24% 55 years and over and 14% 15-34 years. Males represented 92% of Blackpool residents living with HIV in 2014.

HIV testing and uptake

In Blackpool the percentage of eligible GUM episodes where an HIV test was accepted, as a proportion of those offered, was higher than the England average total for men, women and MSM.

HIV test coverage data represent the number of persons tested for HIV and not the number of tests reported. HIV testing is integral to the treatment and management of HIV. Knowledge of HIV status increases survival rates, improves quality of life and reduces the risk of HIV transmission. As figure 15 shows the percentage of eligible new GUM patients who accepted a test, as a proportion of those eligible, is higher than the England average total.

Figure 15: HIV testing uptake and coverage (%) % uptake: 2015
  Uptake    Coverage   
  TotalMen Women MSM  TotalMen Women MSM 
 England  76.2 84.8  69.2  93.4   67.3 78.3  59.2  88.0 
 North West  60.0 77.2  48.9  93.5  51.9  71.1  40.8  87.2 
 Blackpool  81.2 84.3  78.5  95.8  72.8  78.8  68.0  88.7 
Source: PHE, Sexual and Reproductive Health Profiles                           

Figure 16 shows that HIV testing coverage in Blackpool has been consistently higher than the North West average since 2009 and higher than the England average since 2013.

Figure 16: Trend in HIV testing coverage in Blackpool, 2009-2015

HIV-HIVtestingcoverage
Source: PHE, Sexual and Reproductive Health Profiles

Routes of HIV infection

Of the estimated 103,700 people living with HIV in the UK, 45% were infected via MSM. Figure 17 shows that across Blackpool infection from MSM remains by far the highest exposure route (80% in 2014), but has fallen from 83% of all HIV cases in Blackpool in 2013.

While MSM remains the most common route of infection, figure 18 shows that the proportion of HIV infection from a heterosexual route has increased to 18% in 2014 from a constant 15% over the last few years. The recent increase is in male heterosexual diagnoses, a 52% increase from 25 cases in 2013 to 38 cases in 2014. Female heterosexual diagnoses have increased 23% from 22 in 2013 to 27 in 2014. By comparison, MSM increased 9% from 258 to 282.           

Heterosexual contact was the second largest infection route for new diagnoses in North West residents in 2014 (36%). Infections in African born persons accounted for 38% of all heterosexually acquired cases in 2014 compared to 72% in 2005. Infections in UK born persons accounted for 46% of all heterosexually acquired cases in 20147.

The transmission of HIV through injecting drug use is low and accounted for <1% of new diagnoses in Blackpool and across the North West in 20145. However, according to the Gay Men's Survey findings in 2014, 31% of the men diagnosed in the last year indicated other drugs played a part in their acquiring HIV, compared with 22% of those diagnosed for more than 12 months, suggesting that drugs (but not alcohol) are playing an increasing (but still not primary) role in the HIV epidemic8.

Figure 17: HIV Exposure Groups, Blackpool and UK comparison, 2014

HIV-HIVexposuregroups
Source: PHE, HIV and STI Portal

Figure 18: Trend in HIV diagnosed persons seen for care by probable route of HIV infection (excluding MSM)

HIV-diagnosedrouteexcMSM
Source: PHE, HIV and STI Portal

Late diagnoses

In the UK, many people are diagnosed at a late stage of HIV infection - this is defined as having a CD4 count under 350 within three months of a diagnosis. People living with HIV can expect a near-normal life span if they are diagnosed promptly. People diagnosed with HIV late continue to have a ten-fold increased risk of death in the year following diagnosis compared to those diagnosed early5.

Key strategic priorities for HIV are to reduce the proportion of late HIV diagnoses and to increase the proportion of HIV infections diagnosed. Late diagnosis is the most important predictor of morbidity and mortality among those with HIV infection and it is essential to evaluate the success of expanded HIV testing. This indicator directly measures late diagnoses; over time it will show whether there is a trend towards earlier diagnosis.

In Blackpool, between 2012 and 2014, 35% of HIV diagnoses were made at a late stage of infection (CD4 count <350 cells/mm³ within 3 months of diagnosis) compared to 42% in England. Despite late diagnosis rates being slightly better than the England, the rates have not shown the same gradual reduction as in the North West and England.

Heterosexuals were more likely to be diagnosed late (67% of males, 50% of females) than MSM (37%). By ethnic group, black Africans were more likely to be diagnosed late than the white population (63% and 42% respectively)7. Men with a bisexual (60%) or a straight/heterosexual identity (35%) were far less likely to have ever been tested according to the Gay Men's survey carried out in 2014, and yet Blackpool has seen an increase in heterosexual males diagnosed (figure 18).

Men who have sex with men are advised to have an HIV and STI screen at least annually, and every 3 months if having unprotected sex with new or casual partners.

Figure 19: % HIV late diagnosis Blackpool

HIV-late diagnosis trend
Source: PHE, Sexual and Reproductive Health Profiles

The high prevalence and continuing new incidence of HIV in Blackpool suggests a need to ensure the maintenance of services to support people who are living with HIV. However, the higher rates of new infections amongst men who have sex with men in Blackpool suggest there is a need for continuing targeted prevention with this group. Sexual health promotion aimed at the general population should also ensure that a focus on HIV is maintained with the aim of reducing new infections amongst heterosexual people, particularly improving testing in males. Other groups vulnerable to increased higher-risk sexual behaviour should also be considered for targeted HIV testing i.e. substance users, sex workers and swingers. The focus should be flexible to enable targeting to move quickly as new evidence is made available.

Figure 20: Number and percent of late HIV diagnosis Blackpool
  Blackpool North West  England
  Number %
 2009-11 17  32.1 53.3 49.8
 2010-12 13 37.1  52.7  47.9
 2011-13 13  34.2 48.1 45.0
 2012-14 14 35.0 45.8 42.2
   Source: PHE, Sexual and Reproductive Health Profiles  

Importantly, we need to increase awareness and uptake of HIV testing by implementing BASHH testing guidance in primary care, ensuring HIV testing is accessible through secondary care, community settings, integrated sexual health services and on-line self-sampling.

HIV screening in Acute Medical Unit (AMU)

Since November 2013, patients attending the AMU in Blackpool have been offered a HIV test. The service ensures a collaborative and effective operational link with the Blood Borne Viruses (BBV) team and lead consultant.

In 2015/16, 70% of eligible patients were offered a HIV test with 2,577 (51.5%) of patients accepting. As figure 21 shows, following a gap in service provision earlier in the year where there was a significant drop in the number of tests carried out, staff training has had a positive impact on the normalisation of testing and the subsequent uptake in the latter part of the year. This has resulted in a significant improvement in the uptake of tests on the AMU which has carried forward into the first quarter of 2016/17.

Figure 21: Percentage uptake of HIV tests of patients offered in AMU

HIV-UptakeHIVtestsAMU
Source: Blackpool Teaching Hospitals

In total, 6 patients were diagnosed HIV positive in 2015/16 from screening in AMU. These patients were not known to have undergone HIV tests previously. In the previous year less than half the number of screens had been carried out on the unit, with half the number of positive cases diagnosed.

Other key mechanisms in Blackpool are contributing towards the Public Health Outcome Framework (PHOF) indicator to reduce the numbers of late HIV diagnosis. These include testing women in maternity services and those attending for termination of pregnancy:

    • Testing women in maternity services, current uptake of over 95%.
    • Testing women attending for termination of pregnancy has resulted in positive diagnoses.

Screening in the community

The National Institute for Health and Clinical Excellence (NICE) has advocated for expanding testing outside clinical settings by engaging community organisations, developing local strategies to increase testing, and by providing rapid HIV tests. Testing in non-medical settings such as community HIV testing, self-sampling and self-testing for HIV broadens the options available to people wishing to take an HIV test.

    • The Harm Reduction Service in Blackpool (Renaissance) offers point of care testing within the Blackpool locality, with a focus on MSM.
    • The HIV home self-sampling service enables people to order tests online. This service is available to groups at higher risk such as MSM, Black African and Caribbean communities and sex workers. Tests are mailed to people's address of choice, with self-taken samples of blood or saliva returned to the provider's laboratory. Confirmatory testing is undertaken by local clinical services for all reactive tests. To date none of these have been positive locally, though there have been positives nationally. Since the introduction of the service in November 2015, 92 kits have been ordered, with a return rate of approximately 50%.

 

Sexual Health Services (SHS) - mapping demand

The majority of Blackpool residents use sexual health services within Blackpool. In 2015, only 3% of Blackpool service users attended clinics outside of Blackpool. However, of all patients using services within Blackpool, 41% come from outside the local authority (Figure 22).

Figure 22: Patients attending clinics in Blackpool by residency status, 2015

Service-Clinicattendancesbyresidency
Source: GUM Clinic Activity Dataset report, HIV and STI Web Portal

Genitourinary Medicine (GUM) clinic

There has been a 15% increase in the number of Blackpool residents attending the GUM service at Whitegate Drive Health Centre from 2011 to 2015 (figure 23). 97% of Blackpool residents choose to attend the GUM service in Blackpool, making up 58-60% of patient flow throughout the year. The majority of the remaining patients attend from the Fylde and Wyre area.

Figure 23: Attendances to Whitegate Health Centre GUM by Blackpool residents 2011-2015
 Patients   Attendances  
  Patients from Blackpool % of patients seen at clinic New attendancesFollow-up attendances Total attendances 
 2015  4,947 58.0%   6,395  2,553  8,948
 2014  5,123  58.5%  6,655  2,613  9,268
 2013  5,142 60.4%   6,494  2,118  8,612
 2012  4,665 60.2%   6,006  1,540  7,546
 2011  4,557  60.2%  5,766  1,828  7,594
   Source: PHE, HIV/STI Portal, GUMCADv2 Report   

Sexual Health Screens

There were 6,597 first attendances at all sexual health services by Blackpool residents in 2015, a decrease from 6,840 in 2014. First attendances are new and re-booked 'face-to-face' attendances at the start of a new sexual health episode. 45% of these first attendances were male and the over 25's made up just over half (54%) of all attendances. Almost three quarters (74%) had a sexual health screen, that is where a combination of 2 or more of the following tests are taken; chlamydia, gonorrhoea, HIV and/or syphilis. Approximately 32% were diagnosed with a STI (figure 24). Sexual health screens taken at a follow-up attendance are not included in these figures.

Figure 24: Number of first attendances, screens and STI diagnoses, Blackpool residents, 2015

Service-1stattendances-screens-STIs
Source: PHE, HIV/STI Portal, GUMCADv2 Report

While the number of first attendances decreased from 2014, the number of screens taken has increased 3% from 4,745 in 2014 to 4,899 in 2015. The biggest increase in the number of screens has been in males aged 25-34 and females aged 20-24, though proportionally males aged 65+ and females aged 45-64 have seen the biggest rise (31% and 20% respectively).

Figure 25: Trend in sexual health screens by age and gender, 2013-2015

Service-trendbyagesex
Source: PHE, HIV/STI Portal, GUMCADv2 Report

Tier 2 STI testing in Primary Care

The Tier 2 General Practitioner (GP) led Sexual Health Service was developed in 2007/08 to provide testing and treatment of sexually transmitted infections in the community - Level 2 STI services. The service was designed to complement the sexual health service available through GUM, with GUM taking on the role of training and governance and the treatment of the more complex sexual health conditions.

The service is currently provided by the following GP practices:

    • Harris Medical Centre (part of Adelaide St Surgery)
    • Gorton Street Practice
    • Waterloo Medical Centre
    • Stonyhill Medical Centre

Figure 26: Location of each primary care Tier 2 service provider, including Connect and all age Sexual Health Services (Whitegate Health Centre)

Service-locationmap

The service is open to any resident, whether registered at the practice or not. Patients testing positive at the Tier 2 service are treated, with partner notification undertaken. However, those testing positive for more complex conditions such as HIV, Syphilis and Gonorrhoea would be referred to the Tier 3/Level 3 service for treatment.

There are different models of delivery depending on the service provider - for example, GP-led or nurse-led, offering booked appointments and/or drop-ins. During a 'new appointment' (patient's first appointment), patients are offered a full STI screen.

Practitioners at all the delivery practices will manage symptomatic MSM and practitioners at all the practices will manage pregnant women with STIs. These are traditionally not managed in primary care but practitioners will consult with the Level 3 service and refer when necessary.

Figure 27: Number of new appointments (when the patient is tested), 2014/15, 2015/16 and 2016/17 (April - August)
 No. of new appointments Type of STI/BBV found Average positivity rate 
 2014/15 785   Chlamydia, Genital Herpes, Genital Warts, Gonorrhoea, Trichomonas, Syphilis 23.0% 
 2015/16  816   Chlamydia, Genital Herpes, Genital Warts, Gonorrhoea, Hepatitis B, Hepatitis C  14.5%
 2016/17 (Apr-Aug)  290  Chlamydia, Genital Herpes, Genital Warts, Gonorrhoea  6.5%

The most commonly diagnosed infections are Genital Warts, Chlamydia and Genital Herpes. Although the overall positivity rate for the service has dropped from 2014/15, the positivity rate for 2015/16 was still significantly high for a sexual health service delivered through primary care. All five service providers now record and upload data for GUMCADv2 but this data is not yet available.

Tier 2 contraception in primary care

The Department of Health's Framework for Sexual Health Improvement in England includes the ambition to reduce unwanted pregnancies among all women of fertile age through:

    • increased knowledge and awareness of all methods of contraception among all groups in the local population,
    • increased access to all methods of contraception, including long-acting reversible contraception (LARC) methods and emergency hormonal contraception, for women of all ages and their partners.

The PHOF indicator of GP prescribed LARC (excluding injections), replaces an earlier indicator which included injections, because:

    • injections rely on repeat visits/administration within the year and have a higher failure rate than the other LARC methods,
    • injections are easily given in primary care and do not require the resources and training that other LARC methods require,
    • injections are outside local authority contracts.

The rate per 1,000 women on long acting reversible contraception (LARC) prescribed in primary care was 19.5 for Blackpool, 23.1 for North West and 32.3 per 1,000 women in England (figure 28). However, this is prescribing data and may not include implants purchased through central supply of implants provided to the practices by the Integrated Sexual Health Service at Whitegate Drive.

Figure 28: Rate of GP prescribed long acting reversible contraception (LARC) excluding injections, Blackpool and England

Service-GP-LARC
Source: PHE Sexual and Reproductive Health Profiles

Figure 29: Number and types of contraception provided by SHS and general practice in Blackpool: 2014

Service-Contraceptiontype
Source: SRHAD, Sexual and Reproductive Health Services and PACT NHS Prescription Services' Prescribing Databa
 
 

Contraceptive services

Emergency hormonal contraception (EHC)

Emergency contraception can be used following unprotected intercourse, contraceptive failure, incorrect use of contraceptives, or in cases of sexual assault. It is intended for occasional or emergency use, not as a primary contraceptive method for routine use. Use of EHC is closely linked to a reduced rate of unplanned pregnancies for women of all ages and the availability of EHC is essential in reducing the teenage conception rate and also the number of unplanned pregnancies which result in termination.

Figure 30: Number of Blackpool female residents prescribed emergency contraception by age group and frequency at SHS: 2014

Service-EHCbyageandfrequency
Source: SRHAD. Data from Sexual and Reproductive Health Services

A service review was undertaken as part of a programme of reviews of all Public Health services to establish whether the Pharmacy EHC scheme was meeting the needs of the population and to consider the comparative benefits of alternative service models.

Figure 31: Access to EHC by age group and service, 2014/15

Service-EHCbyageandservice
Source: Blackpool Public Health, EHC in pharmacy review, 2016

EHC in pharmacy settings offered opportunities for easier access when young women may have been at risk from an unplanned pregnancy and sexually transmitted diseases (STIs). However, findings from the review showed that few patients accessing community pharmacy were given the wrap around service they would receive from their GP or sexual health service, particularly STI screens and follow-on contraception. Not only are the majority of young people screened for STIs at the sexual health services, they also receive the contraception of their choice; with nearly 50% taking up long acting reversible contraception (LARC). Essentially, the demand for EHC from pharmacies from those under the age of 19 was found to be low in Blackpool, with most young people accessing EHC for free through Connect Young Peoples service (figure 31). Following the review it was decided to discontinue the provision through pharmacies and provide all EHC through sexual health services and primary care.

Contraceptive care

Good contraception services have shown to lower rates of teenage conceptions. Knowledge, access and choice for all men and women to all methods of contraception to aid in the reduction of unwanted pregnancies is supported by the government and the Faculty of Sexual and Reproductive Healthcare (FSRH).

In 2014, of 1.5 million attendances at sexual health services by residents in England where regular contraception was prescribed, 6,005 were by residents from Blackpool.

Compared to the national average, a greater proportion of attendees at contraception services are in the younger age groups, eg. 32% of Blackpool attendees are aged under 20, compared to only 24% nationally. This may go some way to explaining the declining teenage conception rate; fewer births indicate more young people are on contraception.

Figure 32: Proportion of SRH services attendees by age group, Blackpool and England: 2014

Service-ProportionSHSattendeesbyage
Source: PHE, SRHAD. Data from Sexual and Reproductive Health Services

Long Acting Reversible Contraception (LARC)

In 2014, the rate of LARCs prescribed in SHS to women aged 15 to 44 years was 65.6 per 1,000 for Blackpool and 31.5 for England. This does not include LARCs that may have been prescribed in other services, such as termination of pregnancy (TOP) services, which may account for a significant amount.

Figure 33 compares proportions of each contraceptive method prescribed to residents in Blackpool and England. Of all contraceptive methods prescribed, the main methods of contraception for residents in Blackpool were 29.7% LARC, 21.1% injectable contraception and 49.2% user dependent method (UDM), compared to 23.0% LARC, 12.3% injectable contraception and 64.7% UDM, for residents in England.

Figure 33: Proportion of LARC, injectable and UDM contraception prescribed by age group among residents of Blackpool and England: 2014

Service-Contraceptionmethodbyage
Source: Blackpool Laser Report 2014

The number of LARCs reported is not indicative of compliance as data on LARC removals are not available. However, Blackpool sexual health service data (figure 34) shows that since 2012/13, a significant number of women in Blackpool have had the hormonal contraceptive implant removed compared to other LARC methods. In 2014, Blackpool SRH services showed a higher proportion of women were having the implant removed, 5.5 compared to 2.3 and 2.7 in the NW and England respectively4.    An audit of the number of early removals will be required to better understand compliance with the method compared with reasons such as family planning/referrals for removal from primary care.

Figure 34: Contraception prescribed in SRH services
 2012/13 2013/14 2014/15 
 Contraceptive injections administered  315  274  313
 Hormonal contraceptive implants fitted  590  553  624
 Hormonal contraceptive implants removed  405  548  609
 IUD's fitted  117  124  128
 IUD's removed  62  68  61
 IUS fitted  149  125  126
 IUS removed  71  78  97
 Source: Blackpool Teaching Hospitals sexual health service data   

Figure 35: Number* of contraceptive methods prescribed and interventions at SRH Services by age group (years), Blackpool residents: 2014

Service-Contraceptionprescribedtable
* To prevent deductive disclose the number of contraceptive methods prescribed has been rounded to the nearest 5. Therefore the totals may not equal the sum of their parts.
Source: PHE, SRHAD, Sexual and Reproductive Health Services.

LARC Incentive Scheme

Women with substance misuse issues are often socially marginalised, with poor access to general and reproductive healthcare, particularly evident with females who inject drugs9. One of the objectives of Blackpool's Sexual Health Action Plan 2013-15 was to prioritise prevention by targeting preventative initiatives at key groups, ultimately reducing the number of children in care.

 In 2014, a local audit10 was undertaken looking at contraceptive use and parental responsibility in female clients of drug and alcohol treatment services, with responses from 19% (111) of women in treatment at the time. The work was undertaken to help inform the feasibility of developing an incentive scheme to promote long acting reversible contraception in chaotic drug and alcohol users.

Key results of the audit were:

    • 68% of women taking part were in treatment for heroin use,
    • 77% of women had children, with most women having 2 or more,
    • 56% of children were living with people other than their mother; 8% with their father or stepparent, 13% with their extended family and 12% in foster care, children's home or adopted,
    • 71% of women were still menstruating,
    • 32% of women had had unprotected sex - 35% of those in the previous 12 months,
    • Only 26% of women were using contraception, with 58% of these relying on condoms or oral contraceptives, methods which rely heavily on correct usage and compliance.

Respondents were asked about what kind of incentive would work best for LARC, the majority of respondents selected shopping vouchers. This was further discussed during a focus group with female service users, though some women felt that a small cash incentive would be more practical than a shopping voucher.

All the women in this focus group felt that offering an incentive for LARC would be a positive development and that it would encourage them to access more reliable contraception. All the women in the focus group were aware of LARC methods as were the majority of Horizon staff members interviewed as part of this work.

Uptake of LARC in Horizon Drug and Alcohol Integrated Treatment Service

Approximately 68% (124 individuals) of eligible females in treatment were referred for LARC in the period April 2015- March 2016, with 31% of those referred receiving LARC as a contraceptive method. Eleven women were pregnant or became pregnant when they entered the treatment system.

Figure 36: Uptake of LARC in Horizon
 No. of females in treatment No. eligible for referral for LARC No. who received LARC Pregnant or became pregnant 
 2015/16 183  124  38  11 

 

Prevention and Harm Reduction

Attitudes to Sexual Health - National Survey of Sexual Attitudes and Lifestyles (Natsal)

Due to the cost and complexity of such studies, limited work has been undertaken locally to determine the trends in attitudes to sexual health. Hence, information is drawn from national studies, such as the National Survey of Sexual Attitudes and Lifestyles (Natsal) 2013. This was the third survey carried out in Britain and the researchers interviewed 15,162 men and women aged 26-74 between September 2010 and August 2012.

Over the 1990's, there was an increase in the number of opposite sex partners people reported and more people reporting same sex experience. Over the last decade there have been further increases for women, so the gender gap is narrowing. The percentage of people reporting sexual intercourse with someone of the opposite sex before the age of 16 has not increased substantially since the mid 1990's (figure 37), with approximately 1 in 3 young people reportedly having sex before the age of 16.

Figure 37: Percentage of the population who have ever had same sex experience and sexual intercourse with someone of the opposite sex before age 16

Prevention-Natsalinfographic1
Source: NATSAL Survey 2013

Data from the survey provides the first population prevalence estimates of non-volitional sex in Britain. Non volitional sex is a term which includes coercion, sexual assault and rape by friends, partners or strangers, i.e. sex against your will since the age of 13. In most cases the person responsible was someone known to the individual (figure 38). This was the first of the NATSAL surveys to include questions on sexual violence (outside the context of crime) and was strongly associated with a range of adverse health outcomes in both men and women.

Figure 38: Person responsible at most recent occurrence of sexual violence

Prevention-Natsalinfographic2
Source: NATSAL Survey 2013

Over the past decade, national sexual health strategies in Britain have aimed to increase access to sexual health services and STI/HIV testing. Compared with previous surveys, more people reported having an HIV test or going to a sexual health clinic in the past 5 years. It is encouraging to see that these increases were even larger in those at highest risk, such as people who reported multiple partners.

The researchers found that unplanned pregnancy was less common than has been found in studies done in some other high income countries such as the USA. This may in part reflect the fact that contraception is provided free of charge in Britain under the NHS.

Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour ostensibly more evident in women than men. The continuation of sexual activity into later life emphasises that consideration of sexual health and wellbeing is needed throughout the life course.

Condom use and the use of contraception had increased over the period of the three studies. The main source of sexual health education is now schools. In the 1990 survey most advice was sourced from friends.

While most people have had vaginal sex in the past year, other practices are less common, especially anal sex. Anal sex was most frequently reported by young people. This is important in relation to communicating the risk of HIV in both the younger heterosexual population and men who have sex with men.     

According to the survey, overall, around one in a hundred people aged 16-44 had Chlamydia, although this varied by age, peaking at almost one in twenty women aged 18-19 and one in thirty men aged 20-24. Although people who reported more partners in the past year were more likely to have Chlamydia, Chlamydia was found in people who reported only one partner in the past year.

The percentage of men reporting the use of sex workers in the past five years was 4% with 0.1% of women (4 in 100 men and 1 in 1,000 women).

The key issues raised by the NATSAL survey will be addressed by this action plan, alongside the findings of the needs assessment.

Renaissance at Drugline Lancashire: Sexual Health Services in Blackpool

Renaissance at Drugline Lancashire provides a range of harm reduction services including non-clinical, co-ordinated support for individuals who are living with or who are affected by HIV, Hepatitis C or affected by sexual violence. This includes the lesbian, gay, bisexual and transgender (LGBT) community and populations at high risk of poor sexual health, for example, sex workers and men who have sex with men (MSM). As part of the Horizon Project, Renaissance at 102 Dickson Road have 2 dedicated LGB&T Development Leads who have been working in Blackpool for many years. They each support the needs of the LGB&T community, particularly around sexual health issues and have targeted work with peer support groups for Trans community members as well as LG&B social and support groups. The LGB&T Development Leads also coordinate a team of sexual health outreach workers that offer community interventions in LGB&T focused venues as well as saunas and public sex environments.

The sex worker community in Blackpool has changed over recent years. In 2006, the service worked with mainly English parlours and a few Thai. Since 2012, three Polish parlours have been established whereby sex workers come to Blackpool for eight weeks and then return to Poland. The women inform their families they are working in factories and return with the money they have made in Blackpool.

Polish sex workers are engaging with services, however language barriers have been encountered as some of the women can only speak a small amount of English, or none at all. In the last 3 years, there has been an influx of women needing specific support, with Polish women also coming to Blackpool to organise a termination. However, they are being asked to return to the city they have travelled from (e.g. Manchester) to access the pregnancy advisory service there. Horizon, Dickson Road has had an information list translated into Polish and a Polish drop-in has been set up, where a translator is employed to help the Sexual Health worker converse with the sex workers. Recently a small number of Romanian women have commenced work at one of the Polish parlours and this will need to be monitored with liaison with the police as and when required.

The service expanded its offer of HIV tests in 2014 to include dry blood spot testing and 135 tests were carried out in 2015/16. Of those which were reactive and referred for a confirmatory serological test, less than 5 were positive. However, there were 12 Hepatitis C positive results. These were undertaken in the needle exchange at Dickson Rd, by assertive outreach workers at the Salvation Army and church soup kitchens, in hostels and in saunas by the sex worker outreach.

Renaissance, under GUM governance, now provide HIV insti-testing as part of the Public Health England MSM testing programme in venues throughout the town. The 'Insti' 60 second HIV tests carried out during the same period resulted in <5 people reactive tests. The tests were undertaken at Dickson Road or in a sauna. Sixty five 'insti' tests were undertaken in the year.

Sexual exploitation, violence and abuse

Sexual and domestic violence and sexual exploitation and abuse can be issues for men, women and children. More than one-third (38%) of all rapes recorded by the police in England and Wales in 2010/11 were committed against children under 16 years of age, and 49% of gay and bisexual men have experienced at least one incident of domestic abuse from a family member or partner since the age of 16. Service providers should be alert to these issues and be able to provide support and make onward referral for victims including to the police, social services and specialist health and third sector services. Although routine enquiry about domestic violence in pregnancy has been undertaken for a number of years in antenatal settings, there has been less focus on screening in women having an abortion. Studies show an association between domestic violence and termination (and repeat termination) of pregnancy17. Evidence shows that such violence can severely affect the mental and sexual and reproductive health of victims18.

Across Blackpool:

    • Abuse and neglect represent the biggest need areas for safeguarding children in Blackpool and proportions of children in need are higher than seen elsewhere;
    • Early findings from the PAUSE project have indicated a significant number of women have had multiple children removed and taken into care. Early indications estimate approximately 140 women and 380 children are in the cohort identified. Although these figures may change as the scoping exercise develops.
    • Although low in volume, rape has the greatest impact in terms of harm in Blackpool. The number of recorded rapes has been increasing during the last 3 years;
    • Mental illness can impact on sexual behaviour, impairing judgement, especially for individuals dependent on alcohol and other substances;
    • Self-report of STIs, termination of pregnancy and sexual assault are high in sex workers;
    • Poor access to sexual health services for sections of our society who need it the most.

It is widely acknowledged reliable information on the volume of sexual offences is difficult to obtain because a high proportion of offences are not reported to the police. However, we need to ensure that sexual violence pathways are available to all agencies, and there is equity of provision. Rape is not a gender specific issue but evidence does suggest it disproportionately affects females. The Ending Violence against Women and Girls Strategy 2016 -202019 aims to increase awareness in children and young people of the respect and consent in relationships and that abusive behaviour is wrong - including abuse taking place on line.

Overall, there is a correlation between sexual health and other key determinants of health and wellbeing, such as alcohol and drug misuse, mental health and violence (particularly violence against women and girls), contributing to a reduction in health inequalities.

Sexual assaults and rape offences are significantly higher in Blackpool than the Lancashire and national average. Although low in volume (average of 115 offences per year over the last three years), rape has the greatest impact in terms of harm in Blackpool, accounting for 39% of the total20. The number of recorded rapes has been increasing during the last 3 years.

    • Increasing trend over the last 4 years.
    •  Issues around young victims and inter-relationship offences. 
    • Increase in the number of historical offences being reported.
    • 90% of victims are female
    • 87% victims knew the offender

Figure 39: Key harm categories for Blackpool

Prevention-keyharmcategories
Source: Safer Lancashire Strategic Assessment, 2015, Blackpool District Profile

              

New and emerging trends and developments

'Chemsex'

An emerging trend of sexualised drug use has been identified. Chemsex is a commonly used term to describe sex under the influence of drugs taken immediately before and/or during sexual contact. It is a rapidly emerging pattern of drug use, not just amongst men who have sex with men as often assumed, but heterosexual patients as well21. The main drugs chemsex refers to are GHB/GBL22, mephedrone, crystal meth, cocaine and ketamine. Use of these drugs by gay men in London appears to have risen sharply from relatively low levels and, as yet, there is little data to inform appropriate harm reduction services. Chemsex is changing the way some gay and bisexual men socialise, including the organisation of private parties online or via smartphone apps and sourcing sexual partners with the explicit intention to use drugs together.

The risk of chemsex drugs can be:

    • having sex with more people than planned to
    • Within the gay community there is an increased risk of unprotected anal and rough sex
    • Chemsex can prolong sex sessions giving an increased opportunity for infections to be passed on, so people may be at risk of getting an STI
    • Sharing of needles to inject with can spread diseases and injecting may increase risk of overdosing
    • Shigella is a bacterium which has been linked to gay men who use chemsex drugs.

Pre-exposure prophylaxis (PrEP)

The new HIV initiative is joint between NHS England and Public Health England, and follows the recent Court of Appeal ruling that NHS England, alongside local authorities, has the power, although not the obligation, to fund the provision of anti-retroviral drugs for the prevention of HIV, known as pre-exposure prophylaxis (PrEP). PrEP is a course of HIV drugs taken before sex to reduce the risk of getting HIV. The UK's PROUD study reported an 86% reduction in HIV infections in gay men taking PrEP23. NHS England is working in partnership with PHE to run a number of early implementer test sites to research how PrEP could be commissioned in the most clinically and cost effective way.

HPV Vaccine for MSM

PHE is currently piloting the new human papillomavirus (HPV) vaccination programme for MSM in selected clinics across England.  HPV is one of the most common sexually transmitted infections in the UK.  Following reviews of all the epidemiological and economic evidence, as well as vaccine safety and efficacy, a targeted HPV vaccination programme for MSM is considered an effective way to reduce the number of preventable HPV infections and their onward transmission in the MSM population24.

 

High Risk Groups

Looked After Children (LAC)

Blackpool has the highest rate of LAC within England and has far higher rates than similar local authorities. Data for 2014 showed 445 children were looked after in Blackpool. The rate of LAC was 152 per 10,000 children compared to the national average of 60 per 10,000 in 2014. The number of children in care has risen almost every year from 2008 with nearly double the amount from 2008 to 2014.

The available evidence shows that children in care often have a higher rate of poor sexual health and may be more prone to involvement in risky sexual activity, exploitive and abusive relationships and early parenthood. Many looked after young people in Blackpool may also have come to Blackpool from other areas in the region and beyond and as such are likely to have little or no knowledge of local services.

Parents with multiple children in care

A number of expectant mothers would be eligible for the PAUSE project in Blackpool, most of whom had had a number of children taken into care previously. PAUSE works with women who have experienced, or are at risk of, repeat removals of children from their care. It aims to break this cycle and give women the opportunity to develop new skills and responses that can help them create a more positive future.

Early findings from the project in Blackpool have indicated a significant number of women have had multiple children removed and taken into care.  It is estimated approximately 140 women and 380 children may be in the cohort identified, though these figures may change as the scoping exercise develops. Sexual health services will need to consult with service users to support effective marketing/promotion of LARC to complex women.

Child Sexual Exploitation (CSE)

Blackpool experiences considerable levels of disadvantage with many families who are from socially and economically deprived backgrounds and who often have an array of complex needs that require additional support from a range of service providers. The proportion of 'looked after children' is high compared to many other authorities in England and Blackpool has the 10th highest rate of 'children in need' in England. Abuse and neglect represent the biggest need areas for safeguarding children in Blackpool and proportions of children in need under these categories are higher than seen elsewhere.

Figures reported by Lancashire Constabulary show that there were 144 reports of crimes with a CSE element in Blackpool in 2015/16, a rate of 1.0 per 1,000 population and is significantly higher than the Lancashire average of 0.4 per 1,00011.

Child Sexual Exploitation (CSE) in Lancashire is an operational priority area that represents a county wide threat. The Awaken Project is run jointly by Blackpool Children's Services and the police, based at Bonny Street Police Station. Its aim is to safeguard vulnerable children and young people under the age of 18 who are sexually exploited and to identify, target and prosecute associated offenders. Blackpool Safeguarding Children Board (BSCB) has a safeguarding policy in place to assist practitioners working with sexually active under 18s to identify and assess where relationships may be abusive and the young people may be in need of protection and/or additional services

There is a requirement for sexual health services to attend BSCB and to ensure that it has safeguarding policies and procedures in place and to comply with the Blackpool Safeguarding Adult and Children Board's guidelines. The service is also required to undertake the CSE Toolkit (developed by Brook) with all relevant users of the service and refer to other agencies such as child protection as per safeguarding policies.

Sex workers

Blackpool has a number of sex workers operating on the street, as well as in venues such as massage parlours and saunas. Sex workers as a group can be characterised by multiple vulnerabilities, for example, having been a looked after child or young person12 or having drug or alcohol problems13. Self-report of sexually transmitted infections (STIs), termination of pregnancy and sexual assault are also high in this group14. It is vital that the sexual health needs of this vulnerable group are prioritised in any sexual health strategy.

Operation Azure is a multi-agency partnership formed to tackle issues around sex work in Blackpool. This includes preventing the sexual exploitation of women and children and dealing with premises which are nuisances to the public.

The Sex Workers Outreach and Support Service (SWOSS) project is funded by Blackpool Council and provided by Renaissance at Drugline, Lancashire. The service supports all those over the age of 18 involved in the sex industry in Blackpool. This includes the provisions of free condoms, help with accessing sexual health and other health services, support with substance misuse issues and promotion of personal safety, sexual health and emotional health and wellbeing. Additionally, the service promotes the Ugly Mugs scheme, allowing sex workers to circulate descriptions of dangerous customers nationwide.

Lesbian, Gay, Bisexual and Transgender

Blackpool has a large lesbian, gay, bisexual and transgender (LGB+T) community. Accurate estimates of the numbers in the population are difficult to arrive at, although sexual orientation is now recorded in the national census. Local estimates have provided a figure of 7-8% of the population in Blackpool being lesbian, gay, bisexual or transgender (national estimates based on the Integrated Household Survey 2012 are 1.5%) which would give a figure of around 10,500 LGB+T people in Blackpool. Blackpool has a large number of LGB+T businesses such as entertainment venues, hotels and guesthouses, all of which attract visitors from outside of the area. It should also be noted that Blackpool's LGB+T population is as likely to be affected by issues of transience and migration in and out of the area as is the rest of Blackpool's population.

Lesbian, gay, bisexual and transgender people experience a number of health inequalities which are often unrecognised in health and social care settings. Research suggests that discrimination has a negative impact on the health of LGB+T people. Many people are reluctant to disclose their sexual orientation to their healthcare worker because they fear discrimination or poor treatment. Healthcare and other professionals commonly assume that LGB+T people's health needs are the same as those of heterosexual people. The sexual health needs for LBG+T people are not homogeneous. Lesbians, gay men, bisexual men and women, transgender men and women, young LGB+T people and older LGB+T people will all have differing needs. Research commissioned by Stonewall indicates that a high proportion of lesbian and bisexual women15 and gay and bisexual men16 have never been tested for STIs.

Evidence also suggests that gay and bisexual men who use particular illegal drugs (as well as alcohol) are more likely to engage in risky sex. Stonewall's research found that 51% of gay men had taken illegal drugs in the previous year, compared with 12% of men in the wider population.

Services should ensure that they are accessible and welcoming to LGB+T people. Services should ensure all staff undertakes training to understand the varying needs and potential barriers to access for LGB+T people and are able to actively challenge homophobia. Services should outreach to LGB+T groups and venues to increase awareness of their services. All sexual health services should maintain close links with local LGB+T community groups, youth groups and voluntary sector organisations. There is a particular need for sexual health materials such as posters and leaflets specifically for young LGB+T people in Blackpool. Much of the available materials are not age appropriate or are specific to other areas of the country.

All sexual health services should give careful consideration to routinely monitoring the sexual orientation of their clients. This will enable services to ensure they are accessible to this group.

Prison Population

Blackpool does not have a prison, though Kirkham prison is located close by. This presents a number of challenges particularly related to sexual health for our prisoners who are on day release and choose to spend their time in Blackpool. This has placed a significant burden on prison health care in treating associated infections.

Vulnerable Adults (including Learning Disabilities)

Coping with puberty, sexual identity and sexual feelings can be more difficult for people with learning disabilities who might be struggling to understand their emotions and their body. The sexual needs of people with learning disabilities have historically been ignored and often, sexuality only becomes an issue to be discussed when there is a problem.

Sexual health services in Blackpool aim to improve access to service for people with a learning disability/mental health issue by working with mental health and learning disability teams to develop domiciliary care pathways for vulnerable groups not accessing services.

Service provision is also targeted at groups with particular needs who may be vulnerable and at risk from poor sexual health, including young people, gay and bisexual men, some black and minority ethnic groups as well as people with learning disabilities.

 

Current Services

Blackpool's main clinical sexual health service is delivered from Whitegate Health Centre. This includes the provision of an open access Tier 1,2 and 3 service which is open to anyone of any age, irrespective of where they live.  Elements of a Tier 1 service include the provision of emergency oral contraception, sexual history taking and Chlamydia testing, with Tier 3 management of complex contraceptive problems and specialised infections management.

Connect Young People's Service provide a Level 2  open access clinical service for anyone aged under 25, which includes STI screening, contraception and management of uncomplicated infections.  Four GP Practices have also been commissioned to provide Tier 2 sexual health services for Blackpool residents.

In recent years, investment has been made through Public Health to improve access to Blackpool sexual health services, including easier access for high-risk groups.  This investment includes the development of the following:

    • Staff in Primary care have been trained to fit and remove contraceptive implants, intrauterine systems/devices and local enhanced service agreements are in place with a number of GP practices in Blackpool for both their registered and non-registered patients.  These LARC (long acting reversible contraceptive) are more reliable than user-dependent methods like oral contraceptives and less likely to lead to unintended conceptions
    • A young people's sexual health/substance misuse harm reduction service has been commissioned, which includes training on risky behaviour for frontline workers working with young people and provision of a bus to enable young people to access harm reduction messages and Chlamydia testing
    • Chlamydia testing is offered by harm reduction and other services accessed by people aged under 25
    • A condom distribution scheme is in place, with a particular focus on men who have sex with men (MSM) by providing free condoms and lubricant through outreach in public sex environments and pubs and clubs
    • Outreach visits to children's homes to enable Looked After Children to access contraception and sexual health services
    • Targeted work with sex workers to facilitate access to sexual health services
    • Sexual health services are delivered through non-clinical settings such as saunas and within Horizon drug and alcohol treatment services
    • A PSHE incentive scheme is being piloted to encourage secondary schools to add  PSHE, including SRE to their curriculums with many schools delivering this from Autumn 2015 onwards
    • Access to HIV testing is being increased through the Acute Medical Unit (AMU), GP practices, point of care testing in community venues and home self-sampling

 

National and local strategies

    • A Framework for Sexual Health Improvement in England (2013) sets out the Government's ambitions for good sexual health and provides evidence, interventions and actions to improve sexual health outcomes.
    • Blackpool Health and Wellbeing Board Sexual Health Action Plan 2013-15 - This document outlines the strategic intentions of the Blackpool Health and Wellbeing Board as commissioners and providers of services for the residents of Blackpool.
    • The joint NICE and PHE guideline [NG60] HIV testing: increasing uptake among people who may have undiagnosed HIV (December 2016) covers how to increase the uptake of HIV testing in primary and secondary care, specialist sexual health services and the community. It describes how to plan and deliver services that are tailored to the local prevalence of HIV, promote awareness of HIV testing and increase opportunities to offer testing to people who may have undiagnosed HIV.
    • PHE, Sexual and reproductive health in England: local and national data - Guidance to help health professionals including local government, service providers and commissioners understand the sexual health data that is available across England and how the data can be accessed. It includes data collected by Public Health England (PHE) and other organisations (December 2016)
    • NICE guidance [PH51] Contraceptive services for under 25s (March 2014) emphasises the need to offer additional tailored support to meet the particular needs and choices of those who are socially disadvantaged or who may find it difficult to use contraceptive services.
    • Blackpool Health and Wellbeing Board Sexual Health Strategy 2017-2020 sets out Blackpool's actions to deliver their objectives of improving sexual health and reducing sexual health inequalities (still to be finalised)

 

Recommendations

Based on the needs assessment, the following recommendations have been highlighted for consideration. Further detail is available in the  Blackpool Sexual Health Strategy and Action Plan 2017-2020 (pdf 1.4MB)

    • Reduce unplanned pregnancies among all women of fertle age
    • Reduce the rate of sexually transmitted infections and re-infections
    • Improve detection rate in chlamydia diagnosis in 15-24 year olds
    • Reduce the onward transmission of, and late diagnosis of, HIV
    • Reduce inequalities in sexual health outcomes, including sexual violence
    • Effectively promoting all sexual health and harm reduction services in Blackpool

 

 


[1] WHO (2006) Defining sexual health: Report of a technical consultation on sexual health, 28-31 January 2002, Geneva, http://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf

[2] PHE, Health Protection Report, Vol 10 Number 22. Sexually transmitted infections and chlamydia screening in England, 2015

[3] PHE, Gonococcal resistance to antimicrobials surveillance programme (GRASP) report

[4] PHE, Blackpool Local Authority sexual health epidemiology report (LASER): 2014

[5] PHE, HIV in the UK – Situation Report 2015. Incidence, prevalence and prevention https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/477702/HIV_in_the_UK_2015_report.pdf

[6] PHE, Sexual and Reproductive Health Profiles https://fingertips.phe.org.uk/profile/sexualhealth

[7] PHE, Annual epidemiological Spotlight on HIV in the North West, 2014 data

[8] State of Play: Findings from the England Gay Men's Survey, Sigma Research 2014, London

[9] S. Pinkham, C. Stoicescu, B. Myers (2012) Developing effective health interventions for women who inject drugs: Key areas and recommendations for programme development and policy. Advances in Preventative Medicine Vol 2012 Hindawi Publishing Corporation.

[10] Blackpool Council, Contraceptive use audit in female clients of Horizon substance misuse treatment service and exploration of the use of a potential incentive scheme, September 2014

[11] Safer Lancashire, MADE database, District Profile v15.1

[12] Jeal N. and Salisbury C (2004) Health Needs Assessment of Street-based Prostitutes. Journal of Public Health (Oxford) 2004 Jun;26(2):147-51

[13] Pinkham S. Stoicescu C. and Myers B. (2012) Developing Effective Health Interventions for Women who Inject Drugs: Key areas and recommendations for programme development and policy. Advances in Preventative Medicine, 2012 Vol 2012 Hindawi Publishing Corp.

[14] Edelman L. Patel H. Glasper A. and Bogen-Johnston L. (2014) Original Research Sexual Health Risks and Health-seeking Behaviour among Substance-misusing Women. Journal of Advanced Nursing. John Wiley and Sons Ltd

[15] Stonewall (2013) Lesbian and Bisexual Women's Health Survey

[16] Stonewall (2013) Gay and Bisexual Men's Health Survey

[17] Aston G and Bewley S, Abortion and domestic violence, The Obstetrician and Gynaecologist 2009; 11:163-8

[18] Dept of Health, A Framework for Sexual Health Improvement in England (2013)

[19] HM Govt, Ending Violence against Women and Girls Strategy 2016-2020, March 2016

[20] Safer Lancashire Crime Report 2015

[21] BMJ Editorial, What is chemsex and why does it matter? BMJ 2015; 351:h5790

[22] GHB (gammahydroxybutrate) and GBL (gammabutyrolactone), are closely related, dangerous drugs with similar sedative and anaesthetic effects. GBL is converted to GHB shortly after entering the body. Both produce a feeling of euphoria and can reduce inhibitions and cause sleepiness.

[23] Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial McCormack, Sheena et al.The Lancet , Volume 387 , Issue 10013 , 53 - 60

[24] PHE, HPV vaccination pilot for men who have sex with men (MSM) 2016 Information for healthcare professionals