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Sexual Health

Introduction

This summary has been produced to accompany the 2017 Berkshire Sexual Health Needs Assessment. It aims to provide an overview of the key findings from the needs assessment relating to: the current sexual health of people resident in Reading; and the sexual health services used by people resident in Reading. The needs assessment and accompanying summary will be used to identify priority areas of need; to identify what is working well and where improvements can be made, in order to inform the commissioning of local sexual health services in Reading.

The current main provider of sexual health services in Reading is The Royal Berkshire Hospital (RBH). They provide an integrated service covering both Sexual and Reproductive Health (SRH) related care and Sexually Transmitted Infection (STI) related care. The current provider contract will end on the 31st March 2020.

National commentaries around the current sexual health commissioning arrangements express concern around their fragmented nature with commissioning split between local authorities, clinical commissioning groups (CCGs), and NHS England. There is concern that services are not accessible to all, particularly those at greatest risk; that contracting problems are arising through patients attending services out-of-are; that there is a lack of clinical expertise both in service delivery and commissioning. There is also a general increase in demand for services occurring at the same time as budgetary restrictions.

Reading's population

Reading has a total population of 161,739 (ONS, 2016). A number of population groups have been highlighted as been at a higher than average risk of poor sexual health outcomes. It is not always possible to count and map the numbers of people from these groups. However, we can estimate that in Reading there are;

  • 12,166 females and 11,716 males ages 15 to 24
  • 56,609 people from Black, Asian, and Minority Ethnic (BAME) backgrounds
    • Reading has an ethnically diverse population with just over 60% coming from White British backgrounds
  • 6,428 living in the most deprived areas of Reading
  • 613 users of adult specialist substance misuse services
  • 1,016 men who have sex with men (MSM)

When Reading's population structure is compared to the overall population structure for England, there is a higher proportion of people age 20 to 44 living in Reading; and a lower proportion of those aged 45 and over. In terms of predicted change in population size, we can expect an increase across all age groups and, in particular, in those aged 45 and over.

Reproductive health

All- age conception rates in Reading are higher than national and regional averages and have shown a slight increase in recent years. There has been a large percentage decrease (65%) in the rate of teenage pregnancies between 1998 and 2015. Current rates are comparable to national and regional averages. There has also been a steady decrease in the rates of conceptions to under 16 year olds.

Over 20% of all age conceptions in Reading lead to abortion. The percentage of conceptions leading to abortion Reading is comparable to the national average and higher than the regional average. We can also look at the number of abortions as a rate of the total female population aged between 15 and 44. The abortion rate in Reading is higher than the national and regional rates.

Women under the age of 18 are much more likely to have an abortion than average. The percentage of under 18 conceptions in Reading which lead to abortion is around 60% and is higher than the national and regional averages although this is not a statistically significant difference. The percentage of under 18 conceptions leading to abortion in Reading has significantly increase overtime: a pattern that has been seen nationally. This is suggestive that the numbers of unplanned pregnancies are decreasing at a slower rate than planned pregnancies.

The birth rate in Reading is approximately 70 per 1,000 females aged 15 to 44 and is higher than national and regional averages (approx. 60 per 1,000).

Reading residents have contact with sexual health services for Sexual and Reproductive Health (SRH) related care significantly less than the national and regional averages. When looking at the key 15 to 24 year old age group, both males and females aged 15 to 24 from Reading are significantly less likely to attend sexual health services for SRH care than national and regional averages with male attendances been particularly low.

The vast majority of contacts made by Reading residents occur in clinics located in Berkshire. The majority of those choosing to go out of area go to St Mary's in Westminster (1.6% of all Reading residents' contacts for SRH related care).

Just 4% of all contacts made by Reading residents are made by males. This is lower than the national and regional average of 12%. As a proportion of all SRH-related contacts made by females from Reading, a higher proportion of contacts are made by those aged less than 25 than are made by this age group on average nationally and regionally. When we look at female SRH-related contacts as a proportion of the total population aged 13 to 54, just 6% of the female 25 year plus population from Reading attend services compared to 15% of this age group on average nationally. 50% of the female under 25 year old population from Reading attend services compared to 60% nationally.

Around 50% of SRH-related contacts are for contraceptive care. This is followed by attendance for sexual health advice with make up just fewer than 50% of contacts. One contact may be made up of more than one activity so it is likely that those attending for contraception will also be coded under sexual health advice.

Long Acting Reversible Contraception (LARC) is available via GPs and via the integrated sexual health service. Total rates of Long Acting Reversible Contraception (LARC) prescribing across both GP and SRH services are higher than national and regional averages for females resident in Reading. There has been a non-significant increase in prescribing between 2014 and 2015. The vast majority of LARC is prescribed in GP Practices which is the pattern seen nationally and regionally. However, the increase in LARC prescribing described above appears to be driven by a significant increase in prescribing in SRH services with no change seen in prescribing in GP Practices.

79% of contraception prescribed in South Reading CCG, and 77% of contraception prescribed in North and West Reading CCG is for short-acting hormonal contraception. LARC prescribing as a rate of population is lower than the Berkshire average in South Reading CCG; both short-acting hormonal contraception and LARC prescribing is higher in North and West Reading CCG than the Berkshire average. It should be noted that the Berkshire rates are skewed downwards due to particularly low rates of prescribing in Slough.

When LARC provided in GP Practices (including the contraceptive injection) is broken down by LARC type, it can be seen that the most common LARC used by patients registered at North and West Reading and South Reading CCGs is the contraceptive implant followed by the contraceptive injection. There are higher than average rates of prescribing of the IUS in North and West Reading CCG.

Sexually transmitted infections

In 2016 rates of new STI diagnoses in Reading in 2016 were higher than the national and regional averages. Rates have showed a decreasing trend both nationally and regionally which has also been mirrored in Reading between 2013 and 2016.

Rates of all-age chlamydia diagnoses are similar to the national average in Reading and higher than the Regional average. They have shown a significant decrease over recent years. Diagnosis is most common in people aged less than 25, particularly amongst females in this age group. However, diagnosis rates are increasing amongst those aged 25 and over nationally and in the South East Region.

Rates of newly diagnosis HIV in Reading are higher than they are for the South East Region and comparable to the national average. Rates have shown a decline nationally and regionally. A non-statistically significant downward trend can also be seen in the rates of new diagnosis in Reading over recent years with rates previously been higher than the national average. HIV prevalence rates in Reading are higher than national and regional averages. Although not significant, and upward trend can be seen in the prevalence rates indicating an improvement in HIV care and an increasing life expectancy for those with the condition.

Rates of gonorrhoea diagnosis in Reading were higher than the national average in 2015 after a significant increase in rates. In 2016 rates dropped back in line with the national average but still remain higher than the regional average.

A non-significant increasing trend is seen in syphilis diagnosis rates in Reading between 2013 and 2016. This mirrors the increasing trend seen nationally and regionally. Rates in Reading in 2016 are comparable to national and regional averages.

Diagnoses of genital warts and herpes have been decreasing nationally. A significant change has not yet been detected in the Berkshire local authorities. However, a slight non-significant downward trend can be seen in the diagnosis of genital warts in Reading since 2013. Rates of genital warts and herpes in Reading in 2016 were higher than national and regional averages and have been so consistently over recent years.

When looking for inequalities within STI diagnosis rates, data has been aggregated across all Berkshire local authorities due to small numbers at individual local authority level. This analysis shows that types of diagnosis differ between males and females with males receiving more diagnoses of gonorrhoea, syphilis and genital warts and females receiving more diagnoses of chlamydia and herpes. Diagnoses are most common in younger age groups and peak in the 25 to 34 age band. More Gay and Bisexual men are diagnosed with an STI than would be expected given the relative population size. Lesbian, Gay, and Bisexual (LGB) women make up a very small proportion of diagnoses. People from 'Black' or 'Other' ethnic backgrounds are more likely to be diagnosed with an STI than would be expected given the relative population size.

During 2016, First attendance rates for STI related care for people resident in Reading were approximately 10,000 per 100,000 resident population. This is the second highest attendance rate out of the six Berkshire local authorities.

When looking for inequalities amongst first attendance for STI-related care, data has been aggregated across all Berkshire local authorities due to small numbers at individual local authority level. Gay and bi-sexual men are more likely to attend for STI-related care then would be expected given their relative population size. This is a similar pattern to that which we see in the numbers of new STI diagnoses. Also similar to the pattern in the diagnosis data is the fact that people from 'Black' and 'Other' ethnic backgrounds are overrepresented given the relative population sizes of these groups.

The vast majority of residents from Reading attending clinics for STI related care attend clinics within Berkshire (96%). People from Reading who go out of area for STI related care are most likely to attend the Dean Street Clinic in Westminster (0.8% of all Reading residents' attendances for STI related care).

Around 78% of Reading residents who attend a clinic for STI related care receive a sexual health screen at their first attendance. Females are slightly more likely to be tested then males.

When looking at data aggregated across Berkshire, people identifying as heterosexual are more likely to be tested for an STI than those identifying as Gay, Bisexual, or who do not specify with rates of uptake highest in heterosexual males. Males across all other groups are less likely to be tested for STIs than females. People from Black ethnic backgrounds are significantly less likely to take up an STI test (58%). These patterns are a reversal of what we can see in both the first attendance rates and in the STI diagnosis data: although Gay and Bisexual men and people from Black ethnic backgrounds are over-represented in the attendance and STI diagnosis rates, they are less likely to receive an STI test at their first attendance for STI related care. This means that it is more likely that people within these groups have an undiagnosed STI.

Sexual health services

In the West of Berkshire level 3 STI and level 2 SRH services are provided as an integrated service by the Royal Berkshire Hospital (RBH). The service is characterised by a 'hub-and-spoke' model. The hub is based in Reading (The Florey Clinic) and spoke services operate at West Berkshire Community Hospital and Wokingham Community Hospital. Level 2 services operate at Whitley Health and Social Services in Reading. Young people's services called Healthpoints also operate out of the following locations;

Reading - Reading Adviza (Contraception only)
Reading - Prospect Park School
Reading - Reading College
Reading - Whitley Health and Social Services Centre
Wokingham - Woodley Centre Surgery
Wokingham -Wokingham Community Hospital
West Berkshire - Newbury College
West Berkshire - Waterside Youth Centre

In 2016/17 15,119 attendance episodes at RBH integrated sexual health services were made by Reading residents which is an increase from 14,835 in 2015/16. Reading residents make up 53% of all attendance episodes at RBH integrated sexual health services made by Berkshire residents. The majority of these (8,341) were first episodes. 71% of episodes were for STI related care.

STI-related care episodes can be further analysed by diagnosis/condition/disease and services provided. The data does not currently provide details of the activity recorded against SRH related care episodes so we are not able to further analyse these.

2,886 STI diagnoses were made at first attendances at RBH sexual health services where the patient was a Reading resident with (50% of all diagnoses made in RBH clinics amongst Berkshire residents). The number of diagnoses made has decreased from 3,322 in 2015/16. This is the pattern we are seeing at a national level in the new STI diagnosis data. Numbers of all diagnoses have decreased with the exception of chlamydia for which numbers have increased from 482 to 576 between 2015/16 and 2016/17. This increase may be due to the decrease of the NCSP (see below) meaning that a higher proportion of people are now been tested for chlamydia in sexual health services. The most common diagnosis amongst Reading residents attending RBH clinics is for chlamydia (20%) followed by genital warts (17%).

20,226 services were provided at first and follow-up attendances at RBH sexual health services where the patient was a Reading resident (52% of all services provided in RBH clinics to all Berkshire residents). The numbers of services provided has decreased slightly from 20,236 in 2015/16. This decrease is driven by a decrease in services provided at follow-up attendances with an increase seen in the numbers of services provided at first attendances. This could be indicating an increase in the efficiency of the service: providing more services at first attendances is reducing the need for follow-up appointments. It could also be reflective of the decrease in STI diagnoses at first appointments which is reducing the need for treatment and follow-up. For first episodes, there has been some increase in all services provided and a decrease in the numbers coded as 'HIV test - not appropriate'. When testing activity at first attendance is grouped by STI type, it shows an increase in testing for all conditions between 2015/16 and 2016/17. For follow-up episodes, there has been some decrease across all services provided between 2015/16 and 2016/17 with the exception of Partner Notification.

When we look at the proportion of episodes of care at RBH sexual health services that are coming in from out of area (Berkshire), just over 400 attendances at RBH clinics in Reading for SRH related care are made by people coming in from out of area with the majority coming from Oxfordshire or an 'Unknown' local authority. 3,882 attendances at all RBH sexual health services for STI-related care were made by people coming in from out of area: the majority were from South Oxfordshire, Basingstoke and Deane, or from elsewhere in the UK (not England and Wales).

Benchmarking of STI testing data is shown in Public Health England reports. Rates of testing for all STIs (excluding chlamydia <25) in Reading are higher than the national and regional average. Rates of testing in Reading are increasing over time in line with the national trend. Although testing rates are increasing, positivity rates are decreasing in Reading, again, following the national trend but being significantly lower than the national and regional averages.

HIV testing coverage as a proportion of those attending sexual health services for STI related care is decreasing in Reading and is lower than the national and regional averages. This decrease in testing and lower total coverage seems to be mainly driven by low and decreasing testing amongst women attending services. Testing coverage is increasing amongst males, and amongst MSM with testing amongst MSM being higher than the national and regional averages. 46% of new diagnoses of HIV in Reading are diagnosed at a late diagnosis stage. This figure is similar to the national average and had remained relatively static over recent years.

The National Chlamydia Screening Programme (NCSP) which aims to test sexually-active people under the age of 25 was decommissioned in Berkshire from 31st March 2016. Chlamydia screening coverage in Reading during was lower than national and regional averages for the first time having been historically higher than these averages but decreasing each year. Across Berkshire, the majority of tests that are taken are; taken by females (72%); taken by people aged 20-24 (67%); taken in sexual health services (75%). Positivity rates in Berkshire are 7% and tests are more likely to be positive; amongst males: amongst those aged 15 to 19; when taken in sexual health services. This is reflected in the significant decrease in Reading of the chlamydia detection rate (diagnoses per 100,000 population aged 15 to 24) which is now lower also lower than the national average.

Emergency Hormonal Contraception (EHC) is available via GPs, pharmacies, and via the integrated sexual health service. Data available from pharmacies as recorded in the 'PharmOutcomes' system appears to be incomplete across some Berkshire local authorities; 153 prescriptions were recorded in Reading pharmacies in 2016/17. Rates of EHC provided to Reading residents in SRH services are the same as national averages, and higher than regional averages. Prescriptions of EHC in GP Practices for patients registered in both North and West Reading CCG and South Reading CCG are comparable to the Berkshire average. However, these two CCGs have the highest rate of prescribing out of the seven Berkshire CCGs with the highest rate of prescribing coming from South Reading CCG.

Support for those living with HIV is provided by Thames Valley Positive Support; a charitable organisation with bases in Reading and Slough. They support approximately 25 people across Berkshire per month. The numbers of people supported by local authority varies with more people supported in Reading and Slough. Thames Valley Positive Support also provide a service for those engaging in Chemsex.

A Termination of Pregnancy Service (TOPS) is provided by the British Pregnancy Advisory Service and is commissioned by the Reading CCGs. Percentages of repeat abortions amongst females aged less than 25% trend towards been higher than national and regional averages in Reading. However, numbers are too small to say that this is a significant difference.

The nearest Sexual Assault Referral Centre (SARC) is based in Slough and commissioned by NHS England. Trust House is a charitable organisation based in Reading offering specialist support services for people affected by rape and sexual abuse in Berkshire.

The Safe Sex Berkshire website is available as a central, web-based information resource on sexual health services across Berkshire. There were a total of 34,861 visits to the website during 2016/16 with a monthly average of 2,905 visits. Visits peaked around the times of promotional activity. A user survey showed that the majority of users of the site are; aged 15 to 24, are female, are from White ethnic backgrounds, and visit the site for advice around contraception and STIs. 80% of those who access the site do so from mobile devices so work is currently underway to improve the look and feel of the site for those using these media.

Key points

Population key points

  • Reading has an ethnically diverse population with people from BAME backgrounds known to be at an increased risk of poor sexual health
  • Reading has a high proportion of resident who are aged 20 to 44 with those in younger age groups known to be particularly vulnerable to poor sexual health
  • Reading has a high number of people from groups that are known to have some of the poorest sexual health outcomes including MSM and adults who misuse substances

Reproductive health key points

  • A dramatic decrease in teenage pregnancy highlights the Teenage Pregnancy Strategy as an exemplary sexual health promotion programme and a caution against subsequent complacency in this area in order to keep rates of unplanned pregnancy low
    • Although not statistically different to national and regional averages, the increase proportion of under 18 conceptions leading to abortion suggests that there are groups of young women who are remaining vulnerable to unplanned pregnancy
  • The abortion rate is higher than the national average in Reading
    • Repeat abortions in under 25 year olds are higher than national average although this is not a statistically significant difference
  • Reading's higher than average birth rate and large population of reproductive age indicates a higher than average need for sexual and reproductive health care
    • The trend towards females giving birth at older ages highlights the importance for women to continue to use contraception until after the menopause
  • Despite this higher level of potential need, people from Reading are less likely than national and regional averages to attend sexual health services for SRH related care
    • This is true across all age groups and is particularly marked in the low rates of males attending services
      • Potential reasons for low attendance amongst males are:
        • Provision of condoms to young men outside of SRH services could reduce the numbers attending SRH services
        • Some service models may not attract males
        • Some integrated service models may record certain contraceptive models only as part of the GUM data set
    • Just 6% of the female population who are aged 25 and over are attending services for SRH related care
      • RBH not commissioned to provide LARC to those aged 25 and over
  • Total Rates of LARC prescribing are higher than national and regional averages and are increasing
    • LARC prescriptions higher in GP Practices than in SRH services
      • Though increase in prescribing driven by increase in SRH service prescribing
  • GP prescribing of short-acting hormonal contraception and LARC as a rate of the population is higher than the Berkshire average in North and West Reading CCG
    • LARC prescribing is lower than average in South Reading CCG

STI key points

  • Diagnosis rates of all new STIs are higher than national and regional averages in Reading potential driven by higher rates of genital warts and herpes; rates of all new STIs are decreasing in line with the national and regional pattern
    • All age chlamydia showing a decreasing trend and in 2016 was similar to national average having been historically much higher
    • Newly diagnosed HIV showing a non-significant downward trend and in 2016 was similar to the national average having been historically higher
      • Prevalence rates are higher than national and regional averages and are showing a non-significant upward trend
        • Indicating an improvement in healthcare and life expectancy
    • Rates of gonorrhoea in Reading also returned to the national average in 2016 after a significant increase in rates prior to 2015
    • Rates of genital warts and herpes are higher than national and regional averages
      • A slight non-significant downward trend is seen in the diagnosis of genital warts in Reading since 2013
  • Gay and bi-sexual men and people from 'Black' and 'Other' ethnic backgrounds are overrepresented in STI diagnosis figures given their relative population sizes
    • Although these groups are also overrepresented in the data showing first attendance for STI related care they are proportionally less likely to receive and STI test at this first attendance
      • Estimates suggest a high number of people from these groups are resident in Reading
  • New diagnosis and re-infection rates are highest amongst younger adults
  • Attendance rates at sexual health services for STI related care are the second highest after Slough when compared to other Berkshire local authorities
    • Females are slightly more likely to attend than males
  • 4% of Reading residents attend clinics out of Berkshire for STI related care
    • Majority attending out of area go to Dean Street in Westminster
  • Around 78% of people from Reading receive a sexual health screen at their first attendance
    • Females are more likely to be screened than males

Sexual health services key points

  • Reading residents make up 53% of all Berkshire residents' episodes of care at RBH sexual health services
  • There has been an increase in people from Reading attending integrated sexual health services provided by the RBH between 2015/16 and 2016/17
    • The majority of attendances are first attendances
    • 71% were for STI-related care
  • The total number of diagnoses made in RBH clinics amongst Reading residents has decreased between 2015/16 and 2016/17
    • This pattern can be seen across all diagnoses with the exception of chlamydia for which diagnoses have increased
      • Chlamydia testing and diagnosis in sexual health services may have increased following the de-commissioning of the NCSP as testing is no longer available via this programme
  • Chlamydia is the most common diagnosis followed by genital warts
  • 52% of services provided to Berkshire residents by the RBH integrated sexual health service were provided to Reading residents
    • There has been a decrease in the number of services provided at follow-up attendance accompanied by an increase in the number of services provided at first attendances
      • The decrease in services provided at follow-up appointments can be seen for all types of activity with the exception of partner notification which has increased
      • The increase in services provided at first appointments can be seen for all types of activity
      • STI testing has increased across all STI types
      • This could be indicating an increase in the efficiency of the service with more services been provided at first attendances reducing the need for follow-up appointments and/or be reflective of the decrease in STI diagnoses at first appointments reducing the need for treatment and follow-up
  • There is a need for further detail to be provided with the RBH contact monitoring reports around SRH related care activity types in order to have a complete picture of the integrated service
  • The majority of out of Berkshire contacts at RBH integrated sexual health services are for STI related care with people coming in from South Oxfordshire, Basingstoke and Deane, or from elsewhere in the UK (not England and Wales)
  • Testing rates for all STIs (excluding chlamydia in people aged less than 25) in Reading are higher than national average
    • Testing rates in Reading are increasing in line with the national trend
    • Although testing rates for all STIs are increasing; the positivity rate is decreasing and are lower than national and regional averages
  • Testing rates for chlamydia in people aged less than 25 in people in Reading in 2016 are lower than national and regional averages for the first time
  • HIV testing coverage lower than national and regional averages and decreasing
    • Driven by low and decreasing testing coverage in women
    • Testing coverage in men and MSM is increasing
      • Higher than national average in MSM
  • Rates of EHC prescribing are higher than regional and Berkshire averages

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