The patient population
Sexual health services treat a diverse patient population with differing needs. The population can be subdivided into people at particularly high risk of acquiring sexually transmitted infections and HIV, and those with lower-risk exposures. Epidemiological data on the local population covered by a service indicates the significant sexual health outcomes, such as the prevalence of undiagnosed HIV infections and the proportion of new HIV diagnoses which are considered to be late, based on recorded CD4 counts. This data is published in Public Health England indicators, sexually transmitted infection (STI) statistics and conception rates by age.
Each service’s GUM consultants are usually familiar with these sexual health outcomes and can provide insight into how these are associated with the characteristics of the local areas. They will have established links with local directors of public health to access more detailed population profiles and changing demographics. This will also enable access to information regarding migration, trafficking and child sexual exploitation and sexual assault which can be useful to inform discussions with a full range of commissioners to plan services.
In the clinical context, GUM consultants are able to distinguish between the needs of high-risk and low-risk populations, supporting clinical pathways that address the needs of different groups. In turn these need to be adapted based on the characteristics of the local population and the likely demand for services. For instance, areas with large populations of men who have sex with men (MSM) need to ensure that there is adequate provision of specialist testing and vaccinations such as hepatitis A and hepatitis B. Areas with high rates of under-18 conceptions may need to develop their reproductive health provision. Services for victims of sexual violence (SARCs) need to be commissioned aligned to local GUM services.
Prevention of disease
Through clinical consultations, GUM services identify people at high risk of STI/HIV acquisition, and provide them with personal prevention strategies including vaccination (such as hepatitis A and hepatitis B) as well as behavioural advice and interventions, clinical testing and the introduction of newer interventions such as pre-exposure prophylaxis for HIV (PrEP). Treatment of patients with HIV has been demonstrated to result in reduced complications regardless of CD4 count, and reliable prevention of the onward transmission of HIV infection (TasP) to sexual partners as well as mother-to-child.
While primary and secondary prevention are well established in GUM settings, opportunities have been identified for these in other healthcare settings. For instance, there is evidence that the extension of HIV testing in areas with a high prevalence of undiagnosed HIV infections to settings such as emergency departments and primary care, can effectively detect undiagnosed HIV infections. Furthermore, national data (opens PDF, 1.68MB) indicates that people who test positive are successfully linked into HIV treatment services. Other community interventions for sexual health include chlamydia testing in pharmacies, condom card schemes in youth centres and some sexual health provision and contraceptive provision via general practice. Vaccination against human papilloma virus using the quadrivalent HPV vaccine protects against both HPV-related cancers and genital warts (Joint Committee on Vaccination and Immunisation statement, opens PDF, 110KB).
Partner notification is an additional public health measure that is effective in identifying people at risk of STIs, providing them with relevant information and access to testing. GUM also has wider responsibilities in responding to local outbreaks of STIs in conjunction with public health, monitoring and reacting to trends in antimicrobial resistance of STIs and contributing to the national surveillance of STIs. GUM also provides signposting to relevant services, including drug and alcohol treatment services, SARCs and other agencies, depending on individual needs.
Planning effective services
There is considerable published guidance to inform the commissioning of sexual health services. There is long-established guidance to widen the scope of HIV testing in areas with a high prevalence of undiagnosed HIV infection, so that it is introduced into settings such as emergency departments, primary care and for secondary care medical admissions. This is supported by NICE guidance to inform HIV diagnosis within specific at risk groups, such as men who have sex with men and black Africans. Data from the START study has demonstrated significant benefit in starting HIV treatment in all those diagnosed, regardless of CD4 count and clinical features, which resulted in changes to treatment guidelines in the UK and abroad, and HIV positive individuals in the UK are now encouraged to start treatment as soon as they feel ready after diagnosis.
Two recent trials of daily and on-demand HIV pre-exposure prophylaxis with Truvada (PROUD and IPERGAY) have shown clear evidence of its efficacy, and it is now available to those at greatest risk of HIV in most sexual health services, via a 3-year clinical trial (NHSE/PHE) which started in 2017.
In addition, the following comprehensive guidance has been published by MEDFASH to inform what services, including testing and prevention measures, should be offered to patients attending GUM clinics:
- Making it work: a guide to whole system commissioning for sexual health, reproductive health and HIV (opens PDF, 5.3MB)
- Standards for the management of sexually transmitted infections (STIs) (opens PDF, 1.25MB).
Combined with local level data described in the patient population (see above) this guidance gives an unambiguous recommendation on the services that need to be commissioned locally. There is also guidance on commissioning sexual health services in prisons (opens PDF, 105KB).
Contraceptive care provision is funded by local authority budgets in England, via block contracts in many areas (as opposed to payment by results tariffs for sexual health). There are reports of variation in access and the range of methods available. Consistent service provision is recommended by the Faculty of Sexual and Reproductive Healthcare (FSRH) standards of care.
Through two national professional associations, the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA), local sexual health services participate regularly in national audits on the quality of services provided and their outcomes.