Just two weeks before local authorities take over the
commissioning of sexual health services – and twelve years since a sexual
health strategy was last published – the Department of Health has released a
“framework” which outlines the government’s ambitions for the improvement of
sexual health in England.
Reaction has not been entirely positive. “The framework pays
far too little attention to HIV at a time when infection rates are high, late
diagnosis is common, and almost a quarter of people with HIV in the UK are
unaware of their infection,” said Professor Jane Anderson, chair of the British
HIV Association (BHIVA).
Dr Audrey Simpson of the FPA said that the document lacked "teeth" and that there was no guarantee that local councils would act on it.
“While there is much in this framework to take heart from, unfortunately the
government’s rhetoric for improving the entire nation’s sexual health does not
match up to the reality on the ground,” she said.
Responsibility for planning and purchasing local sexual
health services moves, at the beginning of April, from the NHS to local
authorities (i.e. local councils and boroughs). Sexual health clinics, testing projects,
contraceptive services, teenage pregnancy initiatives and HIV prevention
projects will soon become the responsibility of local authorities, working
under the supervision of elected local councillors. With budgets under pressure,
there is likely to be considerable upheaval and disruption in the coming years.
The Department of Health says that its framework has been published
“to set out for commissioners and providers the government’s ambitions for good
sexual health and to provide information about what is needed to deliver good
sexual health services”.
But as government policy is for decisions to be made at a
local level, the framework does not describe any new programmes, policies or
targets. Instead, it provides a brief overview of some of the issues which
sexual health services need to address, without giving many clear
recommendations for action.
Most organisations that have publicly responded to the
framework have acknowledged that it draws attention to important concerns.
Terrence Higgins Trust said that it treats sexual health as a public health
priority, National AIDS Trust noted that HIV testing and prevention are given
the emphasis they deserve, and Brook commended the document’s ambition that all
young people should have access to confidential services and support.
Moreover, the document acknowledges the role that effective
HIV treatment can have in reducing onward transmission, draws attention to HIV
testing in non-specialist settings, discusses primary HIV infection, briefly
mentions pre-exposure prophylaxis (PrEP), highlights the sexual health needs of
people over the age of 50, and considers the impact of drug and alcohol use on
HIV prevention is clearly identified as needing to be
targeted towards the groups who are most at risk of infection – men who have
sex with men and African communities. The government’s ambition is that
individuals understand what HIV is, how to reduce the risk of transmission, how
to prevent HIV and where to get prompt access to confidential HIV testing.
People diagnosed with HIV should receive prompt referral into care,
high-quality care services should be maintained, and people with HIV should
receive early diagnosis and treatment of STIs.
The framework states that different commissioning bodies
should work together to ensure that close links are made between services
offering testing, prevention and treatment. More generally, in several places
the document says that different commissioners (local authorities, the NHS National Commissioning Board and clinical commissioning groups) should
collaborate so that services are not fragmented.
But whereas local authorities will be required to commission
comprehensive, open-access clinical services for sexually transmitted
infections and for contraception, the document draws less attention to local
HIV prevention and sexual health promotion activities. When they are provided, local
authorities will be the commissioners, but the framework does not establish an
expectation that all local authorities should commission such services.
And although HIV prevention and testing should be targeted
to gay and bisexual men, the particular needs of this group are somewhat
understated in the framework. Most notably, in the section on sex and
relationship education (SRE) for the under-16s, there is no mention of SRE
having to meet the needs of young people who are not heterosexual.
Moreover, while Simon Blake of Brook said that he was “pleased
to see the ambition that all children and young people should receive good
quality sex and relationships education at school”, he was sceptical about
implementation. “This ambition will never be realised whilst the Department for
Education fails to ensure that every school is required to deliver a
comprehensive programme of SRE.”
Deborah Jack of the National AIDS Trust also pointed out
that this is not a comprehensive HIV strategy that addresses the full range of
issues associated with HIV. “Treating HIV as merely a STI is not the whole
picture,” she said. “HIV is not simply a health issue and the responsibility of
the Department of Health. The Department for Education, the Department for Work
and Pensions, the Ministry of Justice, the Home Office and Department for
Communities and Local Government to name a few, all need to consider how their
policies affect people living with HIV.”