The Government's strategy on the promotion of health in England for the 1990s, entitled The Health of the Nation (HMSO 1991), has been the most influential publication in the UK to use the term sexual health promotion. Subsequent strategy documents have emphasised the importance of sexual health promotion, and in 1998 the Department of Health set targets for reducing the number of teenage pregnancies as one of the key planks of sexual health promotion. There is a reduced emphasis on HIV prevention compared with the 1980s, despite the fact that the rate of new infections continues at approximately 2,500 per year.

In this context sexual health promotion covers prevention activity focused on different topics, but mainly referring to contraception and sexually transmitted diseases including HIV infection. This policy shift has forced many HIV prevention workers to reorientate their work to fit within this wider framework; to coordinate more closely with other prevention activity; to take a more positive health promotion approach, or simply to use different terminology to ensure continued funding. Being aware of this change in emphasis is all the more important because of the likelihood of HIV–specific funding being removed in the near future and, following the NHS reforms, the new contractual requirements of purchasing authorities.

HIV prevention

Traditionally, prevention is described as being at three levels: primary, secondary and tertiary:

• Primary HIV prevention refers to activity focused on preventing uninfected people becoming infected (e.g. through sex education; condom promotional campaigns; needle exchange schemes).
• Secondary HIV prevention refers to activity aimed at enabling people with HIV to stay well (e.g. HIV antibody testing to allow people to know their status; welfare rights advice; lifestyle behaviour change programmes; anti–discriminatory lobbying).
• Tertiary HIV prevention aims to minimise the effects of ill–health experienced by someone who is symptomatic with HIV disease (e.g. the prophylactic use of drugs and complementary therapies; welfare rights advice to maximise benefits; immuno–supportive educational programmes; disability lobbying).

However, such a distinction of activity has been neither so wide nor so obvious in practice; in general terms HIV prevention has implicitly referred only to primary prevention with the additional recognition that people with HIV are themselves involved in ensuring that they do not pass the infection on and that the primary prevention of other sexually transmitted infections (STIs) is in itself important secondary HIV prevention for them. In this way, HIV prevention has mainly focused upon elements of sex education (safer sex promotion) irrespective of HIV status.

Sexual health promotion

Similarly, sexual health promotion can be used to mean a wide variety of things and justify both prescriptive and more liberal approaches.

For example, there have been fears voiced that this term could be used to return to an era of medicalisation as far as the topic of sex is concerned – focusing on disease and the mechanics of sexual behaviour at the expense of sexual pleasure, desire and identity. This is most obvious in situations where sexual health promotion refers to clinic–based contraception and sexually transmitted disease services. However, this need not be the case even where the focus is on medical services; sexual health promotion can be used to widen the approach of such services to include a social dimension and an example of this is given below (see French & George 1994).

In a similar way, sexual health promotion can be used positively to facilitate discussion about sex and encourage the growth of educational and personal development opportunities (e.g. in youth work, with targeted groups). However, this can also be used in a restrictive, medicalised way to allow only the presentation of biology (as in the National Curriculum).

Sexual health promotion could also refer to activities which enable people who identify collectively to express their own needs. Such community–based activity spans a wide range and can be thought of in terms of the amount of real power people have in determining the allocation of resources to meeting needs. The terms community mobilisation and community development have both been used to describe aspects of this kind of work.

Finally, sexual health promotion can also embrace the role of policy-makers and opinion formers in creating a local or national climate which itself promotes sexual health. This can cover anything from liberal or prescriptive mass–media messages, enabling or restrictive legal frameworks or policies and guidelines (e.g. sex education guidelines in schools; age of consent laws; improving the availability of sexually explicit material for 'health' reasons; allowing condom advertising on TV).