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Preventing Sexually transmitted Infections and Teenage conceptions Scope Stakeholder Consultation Table
October 2005
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Department of General Unintended” or “unwanted” under 18 conceptions would be The guidance title reflects the remit
Reproductive Health, preferable that was given to NICE by DH and
Lewisham PCT refers to ‘reducing the rate of under
eighteen conception’. There are
difficulties defining the terms
‘unintended’ and ‘unwanted’, so we
will use the more general one.
Department of 3 The increase in Chlamydia rates has coincided with the introduction Agreed.
Reproductive Health, of more sensitive tests, and this needs to be made clear. If
Lewisham PCT screening is introduced rates will inevitably show an apparent rise
before falling.
There is no study that I know of that has looked at total population Two population-based chlamydia
rates of chlamydia (unlike HIV where unlinked anonymous testing prevalence studies have been
has been possible) and so the rate of undiagnosed chlamydia is not published.
known.
Department of 3 PID and cervical cancer are the consequences of STIs Agreed. We will clarify the scope.
Reproductive Health,
Lewisham PCT
Department of 4.2.3 The chlamydia screening programme is generally under 25s, not Agreed. Scope amended.
Reproductive Health, excluding the under 16s. These very young people are especially
Lewisham PCT vulnerable and have very high rates of infection
Department of 4.4 Can the DH guidance on under 13s (and the involvement of police ‘Working Together’ will be considered
Reproductive Health, or social services) be made explicit? There is great confusion over when it becomes available.
Lewisham PCT this, and serious concerns that very young people will not attend
services if they are not fully confidential, or will do so using false
details
Department of 4.6 Negotiating skills and self-confidence are crucial here, without Agreed. These are included in ‘skills
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Stakeholder Section Comments Response
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Reproductive Health, them knowledge is useless development’.
Lewisham PCT
Department of 4.8 Something is needed here about attracting the right people to this This may arise when we consider the
Reproductive Health, work, in particular paying them adequately. role of the intervener within the
Lewisham PCT research questions.
Deafax Section 3 – We are aware that there is no mention of disabled people especially We agree that it is important to be
Appendix A young deaf people, in your scope. Research has shown that inclusive of people with disabilities.
services currently available in the area of sexual health education, Interventions which target people with
Inequalities in teenage pregnancy issues and support systems focus only upon disabilities will not be excluded from
sexual health HEARING young people. Services currently provided, focus the literature searches.
predominantly upon mothers, with little aimed at fathers. NO
SERVICES are currently provided or exist to our knowledge that are
culturally and linguistically equipped to adequately and
appropriately support young DEAF and HARD OF HEARING
people. A simply internet search reveals that there are no contacts
or specific services provided for this group – almost all young deaf
people rely heavily upon the internet as their source of information
and guidance.
There is also substantial research evidence of incidences where
deaf people have found the process of pregnancy, birth and
parenthood both upsetting and humiliating. Incidences where
individuals have been either misinformed or not informed at all,
where communication support has not been made available,
removing their control and decision making rights and leaving them
feeling distressed and confused about what was happening.
Younger people have demonstrated naivety and ignorance having
never received appropriate education and information regarding
sexual reproductive, in their first language BSL (British Sign
Language), leaving them often grossly misinformed and misguided
about the consequences of their actions. Furthermore, at
heightened risk of placing themselves in unsafe situations where
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Stakeholder Section Comments Response
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they are vulnerable.
The following comments and questions arose form a discussion that
took place September 2004 within a deaf youth group from Norwich
ages 14-22:-
“I didn’t know what contraception was”; “Can I get pregnant from
kissing?”; “I am at risk if I socialise with gay people”; “It’s ok to have
unprotected sex when you have a period”; “I don’t need to worry
about using a condom”. During this discussion over half of the
young people had never heard of ‘the pill’ or knew what a condom
looked like. Those that had thought that the morning after pill could
be taken regularly as a form of preventing pregnancy.
Deafax is currently working upon a programme that aims to impact
Deaf people and communities in 2 ways:
To offer an inclusive and proactive PREVENTATIVE tool to
educate, inform and empower young people to be able to make
responsible and informed decisions about their sexual and
reproductive choices. To offer an inclusive and proactive SUPPORT
system in partnership with primary care service providers to
educate, support and enable young parents and parents to be, to
cope and deal with the progression of pregnancy, birth and
subsequent challenges of change and parenthood in order to move
forward with their lives. For more information see our website
www.deafax.org
Deafax Section 4.3 While Deafax supports one to one initiatives there are enormous While we agree that groupwork can
Interventions benefits to Deaf young people from participating in group based be very important, NICE have decided
which will not workshops and interventions not simply from the educational to prioritise one-to-one interventions in
be included: standpoint but from the positive effect of role models, integration & this particular guidance. There is the
1. Group interaction, discussion and removal of taboos and ignorance. We facility on the NICE website to
based feel very strongly that in order to service communities effectively suggest future projects should you
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Stakeholder Section Comments Response
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interventions and appropriately that groupwork be included in your scope. wish to suggest this, at:
including sex www.nice.org.uk/page.aspx?o=topics
and uggest. We would expect that at some
relationship time in the future NICE will be asked
education. to consider these broader issues.
Royal College of General The RCOG is concerned about both of the issues to be addressed Thank you.
Obstetricians and in this guidance (rising STI rates and unintended teenage
Gynaecologists pregnancies) and welcomes the development of formal guidance in
this area.
Royal College of 4.1 There was much discussion about the scope of “one to one” Agreed. Postal screening will be
Obstetricians and interventions at the Stakeholders Meeting. We wonder whether this included and will be added to the
Gynaecologists would include postal screening by a practitioner. This has been tried scope.
with some success in the UK1 and with more success in Europe.2 It
is clearly not a face to face intervention, but might be a “one to one”
intervention if the invitation to home screen comes from the
patient’s GP.
Royal College of 4.2 Under interventions, the contraceptive advice/provision includes It was not the intention to exclude
Obstetricians and Emergency hormonal contraception. Is the exclusion of emergency IUD. We will clarify this in the scope.
Gynaecologists non-hormonal contraception (e.g. the insertion of an IUCD as a post
coital contraceptive) deliberate?
Royal College of 4.6 Outcome measures: The outcome defined in the draft scope is Thank you for this helpful clarification
Obstetricians and Reduction in the rate of STIs. Does this mean reduction in which will inform the work of the
Gynaecologists prevalence of STIs, or reduction in the number of STIs reported? It Public Health Interventions Advisory
would be worth clarifying exactly which outcome measure is to be Group (PHIAC). However, we will be
used. We feel the guidance should cover both the prevalence and constrained in our research searches
incidence of infection of STIs in the UK. Prevalence and incidence by the outcome measures used in the
of infection is only loosely related to the number of STIs reported primary research reviewed.
(the outcome presented at the Stakeholders Meeting). The number
of STIs reported is heavily influenced by the extent of screening and
the availability of both effective tests and services. These may
change in the time period covered by the guidance, and thus
changes in numbers STIs reported may not reflect changes in
prevalence and incidence of infection. Thus the choice of number of
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Stakeholder Section Comments Response
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STIs reported may not accurately detail how effective the guidance
is in reducing the incidence/prevalence of infection. This is
particularly important with infections like Chlamydia, which are often
asymptomatic. Attention is drawn to the NATSAL survey of Noted.
prevalence of infection.3
Brook General Brook welcomes the opportunity to comment on this scope. We Thank you. We recognise the range of
note that NICE has decided to concentrate on one-to-one interventions which could be
interventions on this occasion. Given evidence to show that considered, but due to time and
combining effective sex and relationships education with access to resource constraints NICE has
confidential services is instrumental in delaying first sex and decided to focus this guidance on
encouraging contraceptive use we would hope for future guidance one-to-one interventions. There is the
to provide a similar assessment of group based interventions. facility on the NICE website to
suggest topics for consideration for
our future guidance. Visit:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Brook 4.2 1. It would be valuable to include help lines and provision of one to Agreed. These will be added to the
one information via email or online enquiry services in the specific scope.
interventions to be considered by the guidance. Substantial
numbers of young people get information and advice in this way.
Data from Brook’s Young People’s Information Service suggest that
the anonymity and confidentiality of this type of communication is
particularly attractive to young men and younger age groups in
general. The provision of confidential email and web-based
services to young people feature in both the Choosi The provision
of emergency contraception presents a key opportunity to provide
advice about prevention of conception and STIs in addition to the
examples given.ng Health white paper and Youth Matters green
paper
Brook 4.2 We welcome the fact that the guidance will include evidence of Noted.
effectiveness as perceived by service users. In particular we hope
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Stakeholder Section Comments Response
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that this will include exploration of the features of the service which
contribute to the user’s perceptions of its effectiveness.
Croydon PCT 4.2.1 We feel provision of emergency intrauterine contraception is also Agreed. This will be clarified in the
and important intervention at which 1:1 health promotion is given. scope.
There are many sites and service providers who do not offer this
method, and it is also important that at the point of referral there is
input to address the issues of STI and future avoidance of potential
unplanned pregnancy.
Croydon PCT 4.2.3 and Evidence around 1:1 input by school nurses if taken in isolation We recognise the range of
‘general’ from SRE and the environment/discussion opportunities from the interventions which could be
education side of the young person’s life will be difficult to interpret. considered, but due to time and
Tensions between what is permitted in schools from the education resource constraints, NICE has
side and what is provided by health workers is an area that decided to focus this guidance on
deserves closer scrutiny. one-to-one interventions. There is the
Peer education/advice in group settings should also be included. facility on the NICE website to
suggest topics for consideration for
our future guidance at:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Croydon PCT 4.3 As indicated in 4.2.3 As above.
Croydon PCT 4.7 If target audience is to include head teachers, teachers and The primary audience for this
lecturers, would be more helpful to have outcomes of their own guidance is the NHS; however it will
opportunities for interventions in classroom settings. be relevant to a wide range of
professionals and others.
Croydon PCT 4.2 Need to evaluate interventions targeting specific vulnerable groups We agree that it is important to be
of young people including the disabled. inclusive of people with disabilities.
Need to evaluate interventions targeting young men and BME Interventions which target people with
communities. disabilities will not be excluded from
the literature searches. Both young
men and BME communities are
highlighted as populations of interest
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Stakeholder Section Comments Response
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in section 4.4 of the draft scope.
Croydon PCT 4.8 Needs to evaluate interventions considering the We recognise that both training and
training/background of professionals involved in 1 to 1 work-linking kitemarking are important, but they
to Government’s Workforce Reform Strategy-childrens’ workforce, are outside of the remit of this scope
around the development of the common core, which will be the which focuses on one-to-one
basis to assess competencies of practitioners in a wide range of interventions.
contexts including providing advice on teenage pregnancy and
sexual health issues.
Need some assessment of young peoples’ primary, and secondary It is anticipated that confidentiality will
reason for 1 to 1 intervention. Confidentiality issues need to be arise as part of the literature
included. Needs evaluation of badging/kitemarking of accredited searches.
young people friendly services
Association of Medical General; 4.2; Need to emphasise importance of effective communication between We will not be considering diagnostic
Microbiologists (AMM) 4.8 providers of on-to-one interventions and local providers of testing or treatment within this
diagnostic services. Different tests are available which may be more guidance. We would expect that at
appropriate in certain environments. Need to determine what tests some point in the future NICE will be
are provided, for which infections, in which settings. It is important asked to look at these issues.
to consider non-traditional healthcare settings (youth clubs,
pharmacies etc). In most situations samples will be locally collected
and transported to laboratory for testing. In some settings, near-
patient testing may be considered desirable, but any such initiatives
require close collaboration with local microbiologists to ensure
quality assurance.
Association of Medical 4.3 Agree with other professional bodies (RCP etc) that HIV should be Agreed. Scope amended to include
Microbiologists (AMM) specifically included within scope, as this is where greatest potential HIV.
for cost-effective intervention
Association of Medical 4.8 Need to consider how requesters communicate results back to We anticipate considering innovative
Microbiologists (AMM) patient. Innovative means of communication (eg texting) may be means of communication within one-
suitable for negative results for some client groups; some to-one interventions.
experience regarding this has been gained in pilot Chlamydia
screening sites. Positive results will require further face-to-face
follow-up.
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Stakeholder Section Comments Response
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Association of Medical 4.8 Need to consider how treatment, if required, is delivered following This guidance will not consider
Microbiologists (AMM) one-to-one interventions. Effective arrangements for follow-up treatment, although at some point
enable treatment to be offered once results are known, but if follow- NICE may be requested to do so.
up compliance is thought unlikely, empirical treatment or fast-track There is the facility on the NICE
testing may be considered. This may be provided through a local website to suggest topics for
provider, or on-site near patient testing may be desirable (see also consideration for our future guidance
above regarding quality assurance). Such initiatives have resource at:
implications. www.nice.org.uk/page.aspx?o=topics
uggest
Association of Medical 4.9.2 Lack of local funding in some areas has led to inequity of availability Noted.
Microbiologists (AMM) of certain diagnostic tests, particularly Chlamydia nucleic acid
amplification (NAAT) tests. The focus of testing is likely to be on
non-invasive or self-taken samples (urines and vulvo-vaginal
swabs), and all such samples should be tested using optimal
methodology. NAATs are also potentially able to detect gonococcal
infection in addition to Chlamydia (using the same sample); this is
an opportunity for screening to provide valuable epidemiological
information regarding gonorrhoea as well as chlamydia.
Association of Medical General Effective funding streams need to be established to support the Noted.
Microbiologists (AMM) required infra-structure for the initiative. Agreement for such funding
will depend on prioritisation by PCTs and/or other commissioning
bodies
Medical Foundation General The development of evidence based guidance on sexual health Thank you. We agree that there are
for AIDS & Sexual interventions is welcome. However, we hope there will soon be a many factors which influence sexual
Health (MedFASH) further NICE initiative to develop programme guidance. health and a range of interventions for
Sexual health attitudes and therefore behaviour are much prevention of poor sexual health. We
influenced by the social climate, peer norms and stigma, and the recognise the range of interventions
broader determinants of sexual ill-health include economic which could be considered, but due to
deprivation and social marginalisation. These factors cannot readily time and resource constraints, NICE
be addressed by single interventions in isolation, nor is it easy to has decided to focus this guidance on
see how the impact on such variables of single interventions within one- to-one interventions. There is the
a programme could be measured to assess effectiveness. A facility on the NICE website to
comprehensive programme of sexual health promotion is needed suggest topics for consideration for
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Stakeholder Section Comments Response
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and will be more likely to have a measurable impact. our future guidance at:
The recently published and Dept of Health endorsed www.nice.org.uk/page.aspx?o=topics
Recommended standards for sexual health services (MedFASH, uggest We would expect that at some
2005) recommended such a programme and included as its first point in the future NICE will be asked
two ‘key interventions’ for promoting sexual health (Standard 2), to look at these issues.
backed by level 1 and 2 evidence:
- "Programmes and interventions which are multi-component are
most effective in reducing sexual ill health." (I think this is from the
HDA STI prevention effectiveness review)
- "Programmes that focus on strengthening perceived norms that
promote safer sex can lead to reduced sexual risk-taking (for
example, through use of peers or popular opinion leaders)."
In addition, faced with the new challenge of meeting Choosing
Health sexual health targets in the context of NHS financial
pressures and competing priorities, local commissioners will benefit
greatly from guidance which helps them determine what would be
most effective and cost effective to commission. In this context, it
may not seem the right priority for a high profile and highly
resourced national body like NICE to be examining, for example,
the finer detail of whether provider referral is more effective than
patient referral (as partner notification), rather than taking a broader
brush look at what are the elements of an effective and cost-
effective sexual health programme overall and what are their
respective contributions to reducing transmission of STIs and
unintended pregnancies.
Medical Foundation 2 It is stated that the guidance will focus on ‘one to one or face to face See above answer to ‘General’.
for AIDS & Sexual interactive’ interventions. Following on from our comment above,
Health (MedFASH) and for the same reasons, this seems a further regrettable
limitation. According to the paper setting out the NICE Operating
model for the CPHE, ‘interventions’ may be population, community
or individually based. At the least, it would be desirable for the
evidence review and guidance to offer the opportunity to compare
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Stakeholder Section Comments Response
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non-one-to-one interventions such as peer-led group work with
other interventions which are one-to-one.
Medical Foundation 3 A minor point about accuracy: after the table, there seem to be We will check these data.
for AIDS & Sexual conflicting figures for total new STI diagnoses in 2004: 696,419 and
Health (MedFASH) 751,282. Could this be England vs. UK? Or people vs. diagnoses
(as one person may have 2 or 3 STI diagnoses)?
Medical Foundation General There seems to be some confusion about objectives in the Agreed. The scope will be amended
for AIDS & Sexual document. Is the intention to reduce 'teenage' conceptions or accordingly.
Health (MedFASH) 'unintended' conceptions (or 'unintended teenage')? Is teenage
pregnancy undesirable per se? There's virtually nothing in the
earlier sections of the document to argue that it is - in fact the
opposite is argued. However, the national target and DH remit for
the guidance are about reducing the rate of under 18 conceptions
(no mention of unintended). It can help to avoid the term
'preventing' teenage conceptions/pregnancy (because they are not
always bad) in favour of 'reducing the rate of', which could of course
encompass 'prevention' of 'unintended'. The scope document does
this in places, but not everywhere. It will be important to be
absolutely clear about the objectives before starting an exercise to
assess effectiveness and produce guidance.
Medical Foundation 3 Bullet 2 in ‘Inequalities in sexual health’ – a point of accuracy. The Noted. We will amend for accuracy.
for AIDS & Sexual phrase ‘70% of HIV infected heterosexual patients seen for care” is
Health (MedFASH) surely not correct for two reasons. Firstly, the statistics collected by
the HPA record details of the route of transmission (i.e. in this case,
infection believed to be acquired through sex between men and
women) not the sexual orientation (i.e. heterosexual) of the
individuals infected. Aside from being inaccurate, it is hard to see,
in the context of the point being made here (BME populations being
disproportionately affected), why it is actually relevant to specify
sexuality at all.
Secondly, the records of ‘HIV infected. Patients seen for care’
would be the HPA’s SOPHID data. These do not show 70% of
people currently receiving care for HIV to be black African – the
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Stakeholder Section Comments Response
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proportion is still under half (see
http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemio
logy/files/2004_SHA_Web_tables.pdf). However, 70% does look
like a recent figure for the annual number of new HIV diagnoses. It
is very important to distinguish, when assessing needs and
monitoring trends, between the total numbers and characteristics of
those living with diagnosed HIV and of those newly becoming a part
of this cohort each year.
Medical Foundation 3 ‘Trends’. NATSAL surely also shows an increased rate of condom Noted.
for AIDS & Sexual use among young people (somewhat offsetting the other factors of
Health (MedFASH) increasing risk quoted here). As condom use is a key means of
reducing STIs and unintended pregnancy, perhaps the NATSAL
findings should be carefully looked at.
Medical Foundation 4.1 Para 2 i) refers to reducing ‘incidence’. Is this the same as We will clarify these terms in the
for AIDS & Sexual ‘transmission’ (as in the DH remit)? Ii) Refers to ‘teenage’ scope.
Health (MedFASH) conceptions. Is this the same as ‘under 18’ conceptions (as in the
DH remit)?
Medical Foundation 4.2 Para 1. An additional characteristic of effective interventions (Ellis Noted.
for AIDS & Sexual & Grey, 2004) is being multi-component and multi-level. These
Health (MedFASH) characteristics are presumably also not present in one-to-one
interventions (as mentioned in Para 2). See above, for comments
re limitations of addressing only one-to-one interventions. Also,
Para 2 seems confusing, as it appears to be suggesting that NICE
wants to prioritise looking at interventions that don't have the
characteristics of effectiveness, i.e. that are presumably not
effective. Misleading?
Medical Foundation 4.2 and Although mentioned in the statistical appendix about STIs, sexuality We will clarify the inclusion of young
for AIDS & Sexual general is almost invisible in the main document (eg 4.8.8 mentions only men who have sex with men (MSM) in
Health (MedFASH) age, gender, class, ethnicity). Also, by bringing together in one the scope. The focus on STI
'specific intervention' (4.2, point 1) prevention of both under 18 prevention and HIV prevention will not
conceptions and STIs, there is a risk that the STI prevention focus be on under-18’s, but on all age
will be on heterosexual under 18s, paying inadequate attention to groups.
other groups at higher risk, especially gay men. Even in relation to
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Stakeholder Section Comments Response
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young people, there is no reference to young gay men who should
be a key target for condom provision, for example.
Medical Foundation 4.2.2 There has recently been much attention to, and concern among Noted.
for AIDS & Sexual professionals and patient groups about, criminal prosecutions for
Health (MedFASH) HIV transmission. What are the implications for healthcare
professionals in relation to disclosure? This could be a very useful
and interesting aspect of the guidance, but will probably need to
keep constantly up to date with the rapidly moving legal
developments.
Medical Foundation 4.2.3 How can 'screening' be assessed for effectiveness in reducing Thank you for these points of which
for AIDS & Sexual chlamydia transmission in the limited way proposed? Screening we are aware. Effectiveness needs to
Health (MedFASH) can identify those who are infected, but a number of links in the include reduction of transmission and
chain are needed to impact on transmission. Some very crucial sequelae as well as issues to do with
ones appear to be omitted from the NICE scope, begging a lot of uptake of screening and partner
questions about the selection of intermediate indicators and notification etc.
whether 'effectiveness' in terms of health outcomes can be inferred
from them. Crucial among these are the accuracy of the tests used It is not within the NICE remit to
(see Health Select Committee report on sexual health 2003 for consider the efficacy of the screening
slamming criticism re types of test in use with very high rate of false tests.
negatives, since addressed by DH funding for screening
programme, but delivery has been patchy).
Another is the appropriateness of the treatment given. There are
also big questions about how to ensure the partner is treated, to This is an important point of relevance
prevent re-infection - not only the partner notification options, but when making recommendations.
also whether it is possible and more effective to give the patient Partner notification will be considered
antibiotics to give to her/his partner (technically illegal). How about within this scope.
questions regarding whether it is more effective to treat at the site of
testing or after referral to GUM?
It seems strange in a way to select chlamydia screening when it has
already received so much attention in relation to evaluation - i.e.
the original CMO expert report, assessment by national screening
cttee, pilot screening programme, roll-out with elements of The title of the scope reflects the
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evaluation (eg recently announced Boots contract which I believe referral from the Department of Health
includes evaluation). On the other hand, this could make it really to NICE. This included chlamydia
important to get past the excitement about innovative ideas and screening. The review of chlamydia
focus on identifying the real evidence for effectiveness and cost- screening will certainly focus on the
effectiveness of different approaches. Selection of indicators will be ’real evidence for effectiveness and
vital - eg how can you assess the differential impact on chlamydia cost-effectivesness’ rather than
transmission of screening in different settings (which may, for respond to hype or excitement. The
example, have very different characteristics such as choice of indicators used will depend
space/time/skills for a confidential chat or not)? to a large extent on the literature that
is reviewed. We are clearly only able
Overall, guidance on STI screening (for Chlamydia or other to report on the indicators used in the
infections) seems to provide an ideal opportunity for the joining up studies.
of NICE’s role in relation to public health and treatment (see
Operating model for the CPHE, para 4.4). However, on the NICE is developing integrated ways of
evidence of this ‘scope’ document, the barriers remain firmly and working between the preventative and
regrettably drawn within NICE between the different but closely treatment elements of its remit. This
related areas of prevention and treatment – both of which impact, of scope reflects the remit from
course, on public health. Ministers, not the internal structure of
NICE.
Medical Foundation 4.2 and 4.3 HIV is very little mentioned in the draft ‘scope’, despite it being The scope will be amended to include
for AIDS & Sexual arguably the greatest threat to public health and the biggest drain HIV more clearly.
Health (MedFASH) on the public purse within the sexual health field. Death and ill-
health resulting from HIV are not even mentioned in the
consequences of poor sexual health. There is no mention of
working with HIV-positive people to prevent transmission. This
omission needs to be rectified and the assurances of NICE staff at
the 23 September stakeholder meeting that it will be were very
welcome.
Medical Foundation 4.2 and 4.3 GUM 'sexual health screens' and of 'screening for HIV, syphilis and Other than chlamydia, screening and
for AIDS & Sexual hep B' are explicitly excluded. Clarity is needed regarding testing will be excluded, although the
Health (MedFASH) wording... is the reference to 'screening' or 'testing'? Chlamydia one–to-one prevention interventions
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screening (which is to be covered in the scope, outside GUM) is which are delivered alongside
taken to be ‘opportunistic’ screening. What about the 'routine offer' screening/testing, will be included.
of testing, eg of an HIV test at first GUM visit? What about when a
patient attends to request testing? Or when a doctor suggests a
syphilis test in view of risk factors identified? The professionals are
not always that clear either about wording, but NICE needs to be.
It would appear that the diagnosis and treatment of symptomatic Agreed, but this is outside the remit of
STIs are also excluded. Effectively dealing with those who have this scope.
symptomatic STIs is at the core of prevention of STI transmission.
Only those infected can transmit, and many infections are quickly
curable, eliminating the risk of transmission by that individual.
Questions about the relative effectiveness and cost-effectiveness of We recognise the range of
diagnosis and treatment in different settings, by different interventions which could be
professionals, within different time-spans, etc, could potentially be considered, but due to time and
extremely valuable. Partner notification (included in the NICE resource constraints NICE has
scope) is part of this but many other aspects are also important, decided to focus this guidance on
and it is regrettable that NICE is choosing to exclude them. (The one-to-one interventions. There is the
purely clinical aspects of treatment may be less important to facility on the NICE website to
address, because already the subject of clinical effectiveness suggest topics for consideration for
guidelines from BASHH). our future guidance at:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Medical Foundation 4.2 Evidence, as suggested, and guidance for provision in different Noted. Thank you.
for AIDS & Sexual settings, including schools, would be very helpful.
Health (MedFASH)
Medical Foundation 4.6 Para 4. As a primary outcome measure, what exactly is the 'rate' of The outcome measures used will be
for AIDS & Sexual STIs? Normally, surely, 'rate' implies prevalence or incidence as a those found in the literature reviewed
Health (MedFASH) % of population. How will this be measured for STIs and is that the for this guidance.
intention. There are limited studies using this kind of measure
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(except national HIV prevalence estimates based on anonymous
screening programme) and at a population level, the best readily
available statistics on STIs are numbers of new diagnoses (in
GUM).
Care is always needed when interpreting the meaning of rises or Noted.
falls in new diagnoses. They can be a measure of success in
encouraging testing as much as of real incidence of infection. The
term 'incidence' (also used in the scope document, apparently as a
synonym for 'transmission') is sometimes used as shorthand for
number of diagnoses, but clearly this is not the same as actual new
infections. NB There are many undiagnosed STIs, so the task of
assessing 'rates' of prevalence or incidence is much harder than for
conceptions, which almost all eventually end in a baby or an
abortion, both recorded in the official statistics.
Also, until a new common sexual health dataset is finally
introduced, the only nationally available STI data come from GUM
clinics. There is surely no reliable source of statistics for chlamydia
diagnoses in general practice, let alone pharmacy, unless special
arrangements have been made as part of NCSP roll-out.
Medical Foundation 4.9.2 How does the approach used 'to account for the complexity and See above response to 4.2 and 4.3.
for AIDS & Sexual multidimensional character of public health interventions' square
Health (MedFASH) with the intention to focus on specific 1-to-1 interventions in this
NICE guidance?
Health Protection General A clear methodology is needed to review the evidence. Much of the NICE has consulted on its operating
Agency--LARS published literature is written by people with great enthusiasm for model. Specific methods and
their own interventions, and little examination of the “confounding” procedures for reviewing the evidence
variables that may have led to change. This is particularly important will be provided in detail in the
in sexual health as so many variables, and combinations of forthcoming methods and procedures
variables, can lead to change. A further difficulty is that of applying manuals, due to be published in
results from one population to another, and of that of trying to November.
measure impact on a sub-population at total population level.
Brighton & Hove City 4.1 The emphasis in this review is on delivery of one to one direct We will consider a range of settings,
15
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
PCT sexual health interventions. However, this mainly targets those both those where people access
accessing services. In GUM people who receive negative results services and those based on outreach
will be given advice on staying negative [though this as a strategy models.
for keeping those negative needs strengthening]. However in opt-
out services such as through ANC only those found to be positive
for HIV, hepatitis B or syphilis will be given thorough advice,
missing an opportunity for advising those at risk such as African
origin women, how to stay negative. This missed opportunity needs
evaluation.
Brighton & Hove City 4.3 In addition, late presentation for diagnosis is a concern for African We agree that there are many factors
PCT origin people. Stigma is a major barrier for individuals’ self that influence sexual health and a
identifying as being at risk. One of the ways of addressing this and range of interventions for the
awareness of risk of HIV and STIs in these communities is through prevention of poor sexual health. We
community education, for instance through faith based recognise the range of interventions
organisations. This does not fit into the one-to-one health which could be considered, but due to
professional model. If it is not included in this review the time and resource constraints, NICE
opportunity for addressing this problem for heterosexual has decided to focus this guidance on
transmission among new migrants with urgency will be lost. one-to-one interventions. There is the
facility on the NICE website to
suggest topics for consideration for
our future guidance at:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Brighton & Hove City 4.2 Much of the literature on what works with communities within local NICE literature searches include world
PCT Interventions African contexts would be relevant to African people living here, literature.
especially new migrants, who represent a microcosm of the society
they have come from rather than where they are living now. The
literature review on ANC, VCT, stigma, economic evaluation etc
needs therefore to include world literature pertinent to African
societies.
Brighton & Hove City 4.8 research Research questions that emerge from the evidence should also be The guidance will include
16
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
PCT questions considered. recommendations for future research.
Brighton & Hove City General Grey literature publications should also be considered. How to Grey literature is included in the list of
PCT integrate education given in the various vertical strands of sexual evidence which NICE will consider.
health programmes would be an important component of improving
services.
Nottingham University General The basis for restricting the scope to one-to-one interventions is not We will make the focus explicit in the
Business School clear. There seems to be no such specific direction in the Brief final edition of the scope.
from Ministers and this was clearly causing some confusion at the
Stakeholder Meeting in London. If the Brief was not intended to
restrict the guidance to one-to-one interventions, then thought
should be given to revising the scope to take account of this. If the
restriction is maintained, then its rationale should be made explicit.
Nottingham University 4.2 Specific Intervention number 1 is framed very tightly. It gives the Delay of sexual activity and reduction
Business School impression that that contraceptive advice and provision is the only of partners will be included as
intervention aimed at reducing teenage pregnancy. Although interventions to be considered to
alternatives are hinted at in bullet point 3, it should be made more reduce under 18 conceptions and
explicit that NICE will examine interventions aimed at, for example, prevent STIs.
delaying sexual activity or reducing the number of partners.
The nature and possible impact of interventions post-conception
should be made more explicit. Most importantly, the nature of
termination provision (which would clearly fall within the scope of a
one-to-one intervention) may have an impact on decisions taken
prior to conception and, consequently, on pregnancy and STIs.
There is considerable research from the States on, for example, the It is likely the issue of confidentiality
impact of removing confidentiality in abortion provision for minors will be raised in the literature.
on conception rates. Confidentiality is usually removed with the Literature from the USA will be
intended aim of reducing teenage pregnancy rates and this would included in the review.
therefore be an important body of evidence for the NICE guidance
to cover. Although the issue of mandatory confidentiality may lie
outside the scope of the NICE guidance, an assessment of this
body of evidence is likely to be useful in formulating NICE guidance
on best practice for doctors providing terminations to minors.
17
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Nottingham University 4.4 It is unclear why the NICE guidance should necessarily reflect the Wording in the scope will be amended
Business School Department of Health guidance on the provision of advice and to ‘guidance from the Department of
treatment to young people under 16 on contraception, sexual and Health and DfES will be taken into
reproductive health (see paragraph 2 of 4.4). Presumably it is account’.
possible that a review of the evidence by NICE would suggest that
the DOH guidance needs re-visiting. This may just be a problem
with the current wording of this paragraph.
Nottingham University 4.6 The interim measures suggested for pregnancy/STI are very The outcome measures used will
Business School imperfect and uncertain indicators. For example, several reflect those which are found in the
programme evaluations have found increases in condom use & no literature reviewed.
change (or even delayed) sexual activity but no reductions in
pregnancies. A possible reason may be changes to the nature of
sexual activity associated with increased condom use. In almost
every case, it is impossible to be certain how changes in the interim
measures will map onto the primary health outcomes.
Consequently, I think the scoping document should be explicit that
much greater weight will be placed on research that evaluates
primary health outcomes. It may be that a consequence of this is
that the guidance will be characterised by a high level of uncertainty
regarding the weight of evidence.
Nottingham University 4.6 & 4.2 Following on from the previous point, using increased condom use As above response to 4.6.
Business School as an interim measure has particular problems in the context of
STIs. Specifically, its use is only appropriate for those infections
against which condoms provide significant protection. The existing Noted.
evidence base suggests that the extent of protection provided by
condoms varies quite significantly across different infections and, in
some cases, the evidence on the level of protection is simply very
limited.
It would be inappropriate to use this as an intermediate measure Noted.
without some reference to and assessment of the evidence on the
efficacy of condoms in preventing each STI. In turn, this suggests
that the final sentence of Specific Intervention 1 (in Section 4.2)
needs re-phrasing.
18
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Nottingham University 4.9.2 QUALYs are a useful tool but their application in the context of Agreed. The NICE Health Economics
Business School health outcomes that potentially lead to a new life would raise some team will need to consider this issue.
particularly tricky methodological issues. It would be useful to have
some indication in the Scope that these issues have been thought
through.
Darlington PCT 3 general When identifying those most at risk of poor sexual health could you The scope includes a full list of
also reference the evidence base that leads you to mention these references.
groups
Darlington PCT 4.1 Identifies that those involved in delivering sexual health The issue of a knowledge/skills
interventions come from a range of organisations – should this framework is an important one.
guidance therefore also identify (somewhere within the paper) a However, it is outside the remit of this
baseline skills/knowledge/framework for practitioners which would scope which focuses on one-to-one
include legislation to ensure consistency, less risk of mixed interventions. There is the facility on
messages, poor practice and negative full blown media interest that the NICE website to suggest topics for
sexual health services sometimes attracts consideration for future guidance at:
www.nice.org.uk/page.aspx?o=topics
uggest
Darlington PCT 4.2 Not sure how many years of evidence is being considered but could Specific methods and procedures for
there also be some indication as to how work is carried out to reviewing the evidence will be
enable young people/other high risk groups to make the transition provided in detail in the forthcoming
from specialist outreach/screening etc interventions to accessing methods and procedures manuals,
mainstream providers (e.g.: sexual health issues including due to be published in December.
termination of pregnancy for groups in their early 20’s is increasing)
This group may have been targeted in their mid teens when the Thank you for this observation.
teenage pregnancy strategy first began but seem to have missed
the message.
This question is therefore raised ‘has increased prevention/sexual
health intervention services reduced STI’s/pregnancies etc’? what
would NICE forecast be for reduction in demand with a timeline in
light of increased activity in prevention
Can there be some clarification as Chlamydia Screening The NCSP is an opportunistic
Programme (CSP) does not include those aged 25 screening programme targeting
sexually active young women and
19
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
men under 25 years of age. (DH
(2004) NSCP in England Programme
Overview. P13.)
Darlington PCT 4.3 Appreciate that not all interventions can be covered in one This will depend on the Department of
document – could there be some indicator as to when these Health referring the work to NICE.
interventions will be covered.
Point 3 in this section is a priority and should be covered
Darlington PCT 4.4 Can the assessment also include clear guidance for those working It is anticipated that this will be
for or in education regarding the provision of information and included in the guidance.
referring on of young people to sexual health services?
Darlington PCT 4.6 Could the outcome measures also identify: Outcome measures as identified in
Sexually diverse groups lesbian, bisexual and transgendered the scope will be looked at in relation
to any groups identified in the
literature.
The involvement and retention of young men within a service The scope has been amended to
include uptake of services as an
outcome measure for both men and
women.
Darlington PCT General I could not see any mention of young people with disabilities/sen’s We agree that it is important to be
Comment inclusive of people with disabilities.
Interventions which target people with
disabilities will not be excluded from
the literature searches.
RCGP General The RCGP welcomes the fact that the proposed guidance focuses Thank you.
on broad sexual health issues encompassing both STIs and
pregnancy. The DOH has been expressing concerns for many
years on the rising incidence of STIs as well as under 18
pregnancies, and with good reason. The UK has the highest
incidence of teenage pregnancies in Europe, with levels twice those
of Germany, thee times those of France and six times those of
Holland.
However the advantages of this approach are limited due to the Noted. The referral from DH specified
differential age range under consideration. Unintended under 18 conceptions.
20
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
pregnancies are not restricted to under 18 year olds, and sexual
behaviour associated with unintended pregnancy is also associated
with increased rates of STI. An alternative approach might be to
amend the scope to include unintended pregnancy and STIs in
young people up to the age of 25.
RCGP General It is also important that we don't stigmatise teen pregnancies any Agreed.
more than they are already and that we don't use a medical model
for trying to reduce burden of STIs and unwanted pregnancy here:
the reason why far more social class five girls get pregnant more
than social class ones are multiple and are not all to do with access
to contraception.
We recognise that this scope is for Public Health Intervention We recognise the range of
Guidance and focuses on one to one interventions (2). Whilst we interventions that could be
welcome the fact that this will be specifically relevant to the general considered, but due to time and
practice, we would emphasise that such interventions will only have resource constraints NICE has
limited impact in relation to the broader social, cultural and cultural decided to focus this guidance on
environment. We would advocate the production of Public Health one-to-one interventions. There is the
Programme Guidance to complement this approach and to provide facility on the NICE website to
the context for successful face to face interventions suggest topics for consideration for
. The scope recognises that under 18 pregnancies may not be our future guidance at:
unintended or unwanted, but it is not clear about how these will be www.nice.org.uk/page.aspx?o=topics
distinguished, and the scope still identifies overall conception rates uggest
as the primary outcome. Where possible we would recommend
that the outcome used should be unintended pregnancy. Rates of Noted. The measures used will be
termination of pregnancy can be used as a surrogate marker of this dependent on the measures used in
within some research. the reviewed literature.
RCGP General There is little emphasis on young heterosexual men within the draft We agree and note the paucity of
scope. Whilst young heterosexual men are at less direct risk of the research with young heterosexual
complications of high risk sexual behaviour, they are key to the men. We will examine this group very
transmission of STIs and initiation of pregnancy! Moreover they are carefully.
difficult to engage in a one to one setting and require a different
approach to that for young women. It is important that the guidance
explicitly acknowledges these differences and examines the
21
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
research evidence for effective interventions in this group. Due to limitations in resources it was
The guidance needs to explicitly include screening for other decided not to cover screening other
sexually transmitted infections in individuals diagnosed as having than for chlamydia. Screening is
one. The importance of this is emphasised by the fact that co- currently outside the remit of NICE
morbid HIV infection is less frequently detected in individuals and is overseen by the National
diagnosed as having chlamydia infection in general practice Screening Committee.
compared with GUM clinics.
RCGP 3 In addressing the rate of under 18 pregnancies, it is essential to Noted.
consider the evidence relating to limiting factors for seeking
contraception (eg lower use in lower socio-economic groups (1),
anxiety about confidentiality and confusion over legal issues (2).
1)http://www.statistics.gov.uk/StatBase/ssdataset.asp?vlnk=4985&
More=Y
Krishnamoorthy N, Ekins-Daukes S, Colin R Simpson C et al.
Adolescent use of the combined oral contraceptive pill. A
retrospective observational study. Arch Dis Child.2005; 0:
200405917
It could be noted that homes without a father also have an Noted.
unusually high burden of teen pregnancy.
There is also evidence that contrary to intuitive inclinations,
increasing provision of inappropriate services may make sexual
health & inequalities worse.
E.g. Paton D Journal of Health Economics
2002 21 207-225
RCGP 4.2.1 Through EC intuitively seems an effective approach to date no Noted.
research has shown any benefit in lowering unplanned pregnancy
rates.
See Glasier A et al
“Contraception” 2004 69 361-6
Raine T et al
JAMA 2005 293 54-62
Glaasier A et al
NEJM 19996 339 1-4
22
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Condoms only offer substantial protection against some STIs Noted.
notably HIV. However they offer little or no protection from eg HPV.
HPV vaccination is important here as well as education about the
high risk of inconsistent condom use, as well as non use.
See e.g. Genuis SJ et al
AM J of O&G 2004 191 1103-1112
Consideration should be given to the problem that the best Noted.
contraceptives (COC, Depos etc) do not protect against STI’s
Conversely condoms & other barriers though offering some
protection against STI’s, have a higher failure rate for pregnancy
than other methods.
The committee must consider the evidence on whether allowing
GPs to prescribe condoms will improve the uptake of condom use
and a thereby reduction in rates of STIs.
The scopes states that it will not look at the efficacy of individual
methods of contraception. However, it should consider the effect of
limited availability of the whole range of contraception methods on
uptake and pregnancy rates.
RCGP 4.2 Consideration should be given to the problem that the best Noted.
contraceptives (COC, Depos etc) do not protect against STI’s
Conversely condoms & other barriers though offering some
protection against STI’s, have a higher failure rate for pregnancy
than other methods.
RCGP 4.2.2 The issue of confidentiality and partner notification should be Agreed.
considered in the guidance as more and more G-U work is being
transferred from STI clinics to primary care.
RCGP 4.2.3 (4.3). The scope covers screening for Chlamydia and specifically Due to limitations in resources it was
excludes screening for HIV, syphilis and hepatitis B. decided not to cover screening other
It is unclear why these other infections are excluded, and screening than for chlamydia. Screening is
for gonorrhoea is not specifically addressed. currently outside the remit of NICE
The role of screening for infections as part of routine antenatal care and is overseen by the National
needs to be considered. Screening for chlamydia should not be Screening Committee.
confined to patients over the age of 16.
23
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
RCGP 4.2.3 Some research has shown high recurrence rates after screening, & Noted.
intervals of 6-12 months are recommended, if no change in sexual
behaviour occurs concurrently with screening.
See Lee VF, Tobin JM
Int J of STD & Aids 2004 15 944-6
RCGP 4.4 We would welcome the emphasis on the populations suggested. Thank you.
RCGP 4.8.5 In addition to those proposed, research questions need to be We anticipate that to some extent this
included: will be covered in considering the role
Evaluation of the level and nature of training of the intervener of the intervener.
RCGP 4.8.5 Integration and communication between complementary services We agree that this is more appropriate
(e.g. co-location of school / GP / GUM services) – i.e does to programme guidance.
improved integration of services influence effectiveness? (this may
be more appropriately covered within Programme Guidance)
RCGP Section 4.8.5 Acceptability and accessibility - relating to willingness of young Noted.
people to attend services for sexual health advice. This is likely to
depend on a variety of factors including setting and type of service,
but also choice of gender of the intervener (not necessarily gender
per se).
Holistic approaches – whether interventions that include broader
aspects of health care (such as alcohol / drug misuse and mental
health issues) are more effective than those that focus on sexual
health in isolation.
RCGP Section 4.8.5 There are specific issues regarding repeat unintended pregnancy Noted.
and STIs. The research evidence in this area is limited but needs
to be considered separately to primary prevention and first
presentation.
Faculty of Family 4.2 It is not clear to me whether you plan to include so-called ‘novel’ We will only consider screening for
Planning & Interventions strategies for screening for STI such as postal testing kits or chlamydia, but within this we will
Reproductive internet invitations. It would be most helpful if an evaluation of these consider novel approaches.
Healthcare could be included (including cost-effectiveness)
Faculty of Family 4.5 It is vital to look at data from other countries since little exists from NICE will consider data from
Planning & UK studies. Data from developed countries may be more useful worldwide literature.
Reproductive than from developing country settings.
24
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Healthcare
Jewish AIDS Trust General NICE is developing guidance on public health, recommending types Due to limitations of resources this
of activity usually provided by local health organisations to help Intervention guidance will not look in
promote and maintain a healthy lifestyle, or reduce the risk of depth at the broader determinants of
developing an STI. sexual health, a task which is more
appropriate to Programme Guidance.
But the wider determinants of health, including education and The topic referral from the Department
cultural differences are not included in the research. of Health specified that ‘interventions’
should be the focus of this guidance
The Influence of culture and religion must be take into the equation, (see scope section 1). There is the
when looking sexual health. People who adhere strictly to their facility on the NICE website to
faith may have little if any sexual health education. If they then fail suggest topics for consideration for
to follow the strict teaching of their faith they become vulnerable. our future guidance at:
www.nice.org.uk/page.aspx?o=topics
Providing one-to-one interventions without considering the uggest We would expect that at some
influences of culture and religion amongst many other social issues, point in the future NICE will be asked
which affect an individual will greatly reduce the effectiveness of the to look at these issues
intervention. Human beings are complex. More than most other
issues, sexual health interventions cannot be looked in isolation One-to-one educational interventions
from the influences that affect a person's life. will be considered.
The Royal Society for 4.1 The RSPH considers the intended audience as appropriate, Thank you
the Promotion of particularly where it includes non-professionals and those working
Health in non-health specific services.
Considering evidence on inequalities in health, particularly Agreed.
regarding social class and ethnicity will be of benefit. It would also
be of benefit to look at social exclusion factors, not solely social
class, including for example, educational attainment levels.
The Royal Society for 4.2 Could direct one-to-one intervention not include testing as well as This guidance will not cover testing
the Promotion of screening, or is this assumed. For example, pregnancy and STI and screening, other than for
Health testing? chlamydia, however, prevention
In addition to intervention in non-NHS settings it may be necessary interventions delivered at the time of
and beneficial to consider non-statutory services including testing will be considered.
25
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
community (both geographical and of interest) and youth based
organisations and their interventions.
The Royal Society for 4.4 The RSPH considers the population appropriate. Thank you.
the Promotion of
Health
The Royal Society for 4.6 The RSPH considers the use of research on both intermediate and Thank you.
the Promotion of primary health outcomes to be appropriate in this instance.
Health
The Royal Society for 4.7 The RSPH considers it essential that the audience for this guidance Agreed. NICE anticipate that the
the Promotion of extend beyond health professionals and that the final guidance be guidance will be useful to a wide
Health appropriate to those without medical knowledge and knowledge of range of practitioners.
technical medical language and terminology. This is due to the
multi-disciplinary nature of the sexual health workforce.
The detailed list of target audiences is appropriate and in the case
of schools and colleges and voluntary services may also consider
counsellors and psychologists. Those working on helplines in
community and voluntary settings would also be of benefit to
include.
Health Trainers, currently operating in pilot areas, will also be an
appropriate audience.
The Royal Society for 4.8 The RSPH considers the overarching research question to be Thank you.
the Promotion of appropriate.
Health The ten elements identified to examine effectiveness of
interventions are considered appropriate by the RSPH .
Family Education General The character and context in which one-to-one health interventions Noted.
Trust take place is of crucial importance. It should not be assumed that
any targeted intervention is better than none.
Given that sexual abstinence is the only sure way to meet both of
the aims, one-to-one interventions that encourage sexual
relationships outside the context of a lifelong committed marriage
and encourage patients to understand the physical and emotional
benefits of exercising self-restraint should be included within the
scope.
26
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Within a climate which has cheapened sex and presented it as a
casual activity, practitioners and educators in one-to-one
interventions are well-placed to raise the attitudes and aspirations
of their clients/patients.
Our leaflet, Sexual Spin (copy to follow in the post), may serve as a Thank you.
useful guide to practitioners in this area and is suitable for passing
on to clients/patients for further reflection and consideration.
Family Education Section 4.2 The emphasis on condom provision in this section implies a level of It is outside of the remit of this
Trust reliance on this method of contraception that is not supported by the guidance to consider the effectiveness
data. We would suggest that the scope should take account of the of condoms. Resource and time
user and method failure rates associated with condom usage and constraints mean that we can only
the evidence which indicates that condoms provide less protection consider the interventions themselves.
against some STIs than others. However, this background information
will be used to frame the
recommendations.
Family Education Section 4.4 The statement that the resulting guidance ‘will reflect the guidance Wording in the scope will be amended
Trust provided by the Department of Health’ appears to prejudge the to ‘guidance from the Department of
outcome of the exercise and possibly render it superfluous. It Health and DfES will be taken into
appears to preclude the possibility that NICE’s analysis might draw account‘.
different conclusions from those previously reached by the
Department of Health.
Family Education Section 4.6 We suggest that knowledge and access to resources are not The outcome measures used will be
Trust necessarily measurements of success. Consideration needs to be dependent on those used in the
given to possibility that the perceived reduction in risk afforded by reviewed literature.
contraception and emergency hormonal contraception may provide
some young people with an incentive to become sexually active.
Particular attention should be given to the operation of the risk
displacement principle where contraceptive advice and provision is
offered to a minor in the context of a confidential one-to-one
intervention.
27
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Roche Diagnostics Ltd General Section 2.0 of the draft scope states that the intervention guidance The scope has been amended to
will focus on “one to one or face to face interactive interventions.” include all approaches to chlamydia
This point is repeated in section 4.1. However, section 4.2 states screening.
that the scope will include chlamydia screening of young men and
women in a range of non-GUM settings, including opportunistic
screening.
We are concerned that there is a potential conflict between these
two statements, and that the review of chlamydia screening may
only focus on one to one interventions instead of examining the full
range of options for delivering the screening programme. The
opportunistic nature of the programme – and that the fact that it is
designed to reach a target population which can be difficult to
contact – mean that one to one interventions may not be the most
appropriate or effective way of communicating with this audience.
Given this, we would strongly recommend the following:
The Centre for Public Health Excellence does not just consider
one to one interventions when assessing the chlamydia
screening programme, so that it can provide the most
comprehensive and useful advice to underpin the roll out of the
programme.
It specifically examines the role that pharmacies can play in
delivering chlamydia screening services, given the pilot scheme
that will be starting shortly in London. This will ensure that the
NHS receives co-ordinated and up to date advice on the options
available for rolling out the programme and achieving the best
possible results.
We hope that NICE will also assess the other pilot projects that
have recently taken place in primary care settings, such as the
Men and Chlamydia Project run by the Men’s Health Forum in
Telford which was highlighted in Choosing Health Through
Pharmacy published by the Department of Health in April 2005
(http://www.dh.gov.uk/assetRoot/04/10/74/96/04107496.pdf
28
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
fpa (Family Planning 3 The need p4 ‘other consequences of poor sexual health’: this section comes Agreed. We will amend the scope to
Association) for guidance across as very female-oriented; it needs to be clearer that the reflect these points.
effects of poor sexual health also impact on men, and have
negative consequences for male sexual health and fertility
p5 inequalities in sexual health:
bullet 1: need to be clear which data referring to, as only 2003 data
available for HIV but 2004 data for other STIs (which are referenced
on pages 3-4)
p5 inequalities in sexual health:
bullet 2: why does this point mention NI but omit reference to
Scotland? It should either include Scotland (now covered by HPA
data) if giving a UK-wide picture, or just refer to England and Wales
if the guidance is for these countries only
fpa (Family Planning Trends p6: this should also reference drug and alcohol misuse and its Agreed.
Association) impact on sexual behaviour and risk-taking
fpa (Family Planning 4.2 p8:paragraph 3: must be clear how ‘brief advice’ is defined in the Agreed.
Association) Interventions context of direct one-to-one interventions
p8:section 1, bullet 1: this should refer to ‘advice on and provision of Agreed.
the range of contraceptive methods, including both methods of
emergency contraception’ Agreed.
p8:section 1, bullet 3: this should be rephrased ‘e.g. at pregnancy
testing, at pregnancy counselling and at antenatal checks’ – it is not
the time to have these interventions at abortion (NB please also
note for reference that it is now more commonly accepted to use
the term abortion rather than termination of pregnancy), but
pregnancy counselling would cover discussions which lead to aborti
p9: section 3: need to add pharmacy to list of NHS and non-NHS Agreed.
settings where interventions take place, as pharmacists play an
important role in the provision of one-to-one advice
fpa (Family Planning 4.5 Will cross country comparisons be within the UK or across a wider We are keenly aware of the
Association) Comparators geographical remit/worldwide? If worldwide data is used it will be complexities, but to a large extent the
important to take into account cultural differences which will have data used for comparison will depend
an impact on the effectiveness of different interventions on the data revealed by the literature.
29
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
fpa (Family Planning 4.6 Outcome paragraph 3, intermediate outcome measures: this should also Noted.
Association) Measures include increased and effective use of emergency contraception
paragraph 4, primary health outcomes: it will be important to take
care when considering the primary health outcomes of interventions
– both teenage pregnancy rates and rates of sexually transmitted
infections are affected by a complex range of factors, and it may Noted.
therefore be difficult to draw a direct link between specific
interventions and rates of TP and STIs
fpa (Family Planning 4.8 Research There should be a question here that addresses the provision and Noted.
Association) Questions role of ‘back up’ information, which supports improved
understanding and use of contraceptive methods, for example (for
reference, the Fertility Regulation Group has just done a Cochrane
Review in this area which addresses interventions around
improving adherence to contraceptive use)
fpa (Family Planning General There is a notable lack of patient voice within sexual health; it will NICE involves the public and patients
Association) therefore be vitally important to engage the public/patients in a in all of its consultation phases.
sensitive way to ensure their involvement in the development of this
guidance
Durham Dales Primary Appendix A Pleasing to see this paragraph as it outlines the groups with the Thank you.
Care Trust greatest burden of sexual ill health. National guidelines should allow
flexibility so that sexual health services can be targeted to specific
local communities within a locality. E.g. Nationally we are told of
new diagnosis of HIV within the straight community have overtaken
new infections within the gay community, however within County
Durham and Darlington men who have sex with men are still the
highest group affected by HIV.
Durham Dales Primary 4.1 Mentioned in this section but throughout the document. Recognition Agreed.
Care Trust of other organisations that deliver sexual health services is vital
especially as PCTs are envisaged to become commissioner rather
than provider organisations. Quality assurance / standards will have
to be reflected within Service Level Agreements between PCTs (as
commissioners) and sexual health services (as providers).
Durham Dales Primary 4.2 Clarification needed regarding Chlamydia screening age range – The NCSP is an opportunistic
30
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Care Trust 16-25? The national screening programme is 16-24. screening programme targeting
sexually active young women and
men under 25 years of age. (DH
(2004) NSCP in England Programme
Overview. P13)
Durham Dales Primary 4.3 Slightly concerned that the numbered interventions that will not be We agree that this is important. But
Care Trust covered – especially point three. Tackling the wider determinants of because of resource and time
Sexual ill health is essential from a prevention perspective – we will constraints, we are unable to cover
not stem the flow of increased STI/HIV rates if this is left out of the this area. There is the facility on the
guidelines. NICE website to suggest topics for
consideration for our future guidance
at:
www.nice.org.uk/page.aspx?o=topics
uggest
Durham Dales Primary 4.6 Reflecting on the points made with Appendix A. Could there be The outcome measures will
Care Trust outcome measures to encompass the Lesbian Gay Bisexual and encompass all of these populations.
Transgender communities and people affected by HIV?
National Aids Trust General HIV needs to have a stronger profile in the scope document. Agreed. The scope has been
Elsewhere it is often identified separately to other STIs and as a amended to clarify this.
result some interpret the phrase 'STIs' to mean STIs other than HIV.
National Aids Trust Section 2 To clarify the place of HIV, as discussed above, we propose in the Agreed.
paragraph marked 'a)', that the phrasing be amended to read, "to
develop public health intervention guidance on the reduction of
sexually transmitted infections (STIs), including HIV".[Bold to
identify addition]
31
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
National Aids Trust Section 2 and The paragraph marked 'b)' states that a second function of the Noted. We do not wish to de-prioritise
3 guidance, in addition to providing recommendations for good HIV.
practice [see 'a)'], will be to "support measures to achieve the
government targets..".There then follows an extended section on
the national targets around sexual health. HIV is not included either
in the national PSA targets nor in National Standards, Local Action,
and this omission has been a matter of some controversy. It would
be wrong for the NICE assessment to mirror recent targets in
deprioritising HIV. The current place of the 'targets section' in the
scope document inadvertently suggests this might happen.
The seriousness of HIV as a condition, the steep rise in new
diagnoses and the urgency of the need for an effective response all
mean that the opening sections of the report need to highlight the
importance of HIV in the assessment which is to be undertaken by
NICE. To that end, we propose that Section 2 'Background' consist
simply of the two paragraphs currently marked 'a)' and 'b)'. Section
3 'The need for guidance' should have at the end the paragraphs on
targets currently found in Section 2. It is striking that the first part of
Section 3 gives epidemiological data on all STIs apart from HIV -
another example of sidelining of HIV in the document. Information
and data on HIV must be added to make clear the need for
guidance in this area.
National Aids Trust Section 4 The capturing of research on health inequalities is welcome. There Noted.
[4.1] has been important recent work by organisations such as Sigma
Research on social class and ethnic inequalities within gay men's
sexual health work1, and these should be reviewed.
32
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
National Aids Trust Section 4 Interventions assessed should include counselling/discussion Noted.
[4.2] around Post Exposure Prophylaxis; one-to-one
counselling/discussion on helpline or by email; one-to-one
interventions as part of the ongoing clinical management of people
living with HIV. It should be made clear that interventions include
opportunities linked or related to the HIV screening process, even if
the screening itself is not included. The description of under 18
interventions at '1.' of 4.2 biases the assessment towards a
contraceptive and heterosexual model e.g. "Advice about the use of
condoms plus other forms of contraception for the prevention of
conception and STIs". There has to be consideration of
interventions aimed at gay young men in particular around STI and
HIV prevention, a group who are at present very poorly served and
invisible in the current scope document. Interventions in the primary
care setting are particularly important given the ambitions of the
'Choosing Health' White Paper to roll out sexual health services into
the primary care setting. Interventions relating to prevention of HIV
will for the most part involve linking information and referral on
sexual health services to the contraceptive services currently
provided in primary care settings. There has recently been
interesting work on HIV and wider sexual health service provision in
primary care and GP settings and this should be captured.
We regret that group based interventions are not to be covered
since this effectively excludes an important forum for African people
especially, and one where guidance is urgently needed.
Consideration should be given to information available on other
one-to-one interventions which can have a sexual health dimension
for Africans in the UK, including discussions with faith
leaders/pastors and the role of immigration professionals in health Thank you. These observations will be
screening advice. Interventions should not be considered too very helpful for the PHIAC in
'vertically' and solely in terms of the express and immediate aims of developing the recommendations.
the intervention. Particularly around sexual health, interventions
around Chlamydia or conception, for example, could well have
implications or opportunities for HIV.
33
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
National Aids Trust Section 4 There is often an assumption in prevention work that interventions Interventions targeting people with
[4.4] target those in vulnerable groups who are currently uninfected. In HIV will be considered.
the case of an incurable, long-term condition such as HIV there is a
growing belief in the HIV sector that some of the key interventions
to prevent further infection should be targeted at people living with
HIV, and there has been interesting work internationally, including
in the USA, on this basis ("Positive Prevention"). This is not limited
to partner notification or post-test discussion, and the scope
document could usefully make clear that effective one-to-one
interventions are for both infected and uninfected people.
As has been stated above, it will be important in looking at the
various population groups identified in this section to be sensitive to
the way they interrelate e.g. BME young gay men.
The category of 'refugee and asylum seekers' needs to be We will reconsider the wording used
reformulated or added to. One of the groups where there is most for this.
concern at present is that of failed asylum seekers and other
undocumented migrants who, though they are living here, are
ineligible for free HIV treatment on the NHS with implications for the
interventions which they can access to reduce the likelihood of
onward transmission of HIV. A word such 'migrant', or something
similar, would capture this key vulnerable population and not limit
interventions to those the Government recognises as having a legal
right to be here.
National Aids Trust Section 4 Another intermediate outcome measure could usefully be The outcome measures used will
[4.6] 'appropriate and timely treatment of STIs and HIV'. reflect those found in the literature.
British Psychological 4.2 Mention “counselling (including CBT)” & 1:1 interventions. Will One-to-one interventions in GU and
Society Interventions counselling & Clinical Psychology interventions in the GU clinics & other areas will be considered, but not
& Whole HIV centres be looked at of interventions aimed at reducing the group interventions. There is the
document behaviours behind the transmission of STI & Pregnancy. facility on the NICE website to
Psychologists are behavioural scientists who have much to offer suggest topics for consideration for
both directly and indirectly in the above through staff training and our future guidance at:
research and consultation. www.nice.org.uk/page.aspx?o=topics
uggest.
34
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
London Network for 1 We feel that the proposal should better reflect that it also refers to Agreed. The scope will be amended
Nurses and Midwives: HIV, therefore we request that it is made more explicit in the to clarify this.
Sexual Health Group document
London Network for 2 It mentions in the document that it is focusing on ‘face-to-face The focus is on one-to-one
Nurses and Midwives: interactive interventions. However there are two points we would interventions, rather than face-to-face
Sexual Health Group like to make: which has now been removed from
1) There may be aspects of group work or techniques, which the scope. Group interventions will not
may have been appraised in the literature, which could be considered in this guidance. There
prove beneficial and could be applied in a face-to-face is the facility on the NICE website to
consultation. suggest topics for consideration for
It might be useful to follow up your initial assessment of face-to-face our future guidance at:
interventions with group work, as this is a very important and often www.nice.org.uk/page.aspx?o=topics
affective intervention especially with minority populations who are uggest We would expect that at some
disproportionally affected with poor sexual health. point in the future NICE will be asked
to look at these issues.
London Network for 4.3 The public health role of GUM clinics needs to be acknowledged as Agreed. The scope has been
Nurses and Midwives: a lot of work is done face-to-face with the patients in the clinic amended.
Sexual Health Group setting PEPSI should be seen as a opportunity for interventions as
this group of patients may be more open to behaviour change
Royal College of General With a membership of over 370,000 registered nurses, midwives, Noted.
Nursing health visitors, nursing students, health care assistants and nurse
cadets, the Royal College of Nursing (RCN) is the voice of nursing
across the UK and the largest professional union of nursing staff in
the world. The RCN promotes patient and nursing interests on a
wide range of issues by working closely with Government, the UK
parliaments and other national and European political institutions,
trade unions, professional bodies and voluntary organisations.
Thank you for the opportunity to comment on the draft scope of this
guidance. As an overall outcome the scope does not seem to
include examining ease of access to 1:1 interventions. There are
disparities not only nationally but also within Strategic Health
Authorities and this will prove important when trying to determine
why target groups do not access services.
35
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Royal College of 1.1 and For clarity - would suggest that the short title reads “….under 18 Noted. NICE housestyle spells
Nursing general year old” Note that there are a number of typing errors throughout chlamydia with a lower case ‘c’.
the document. Throughout the document STIs are mentioned but
Chlamydia is the only one mentioned in detail. Chlamydia is
generally spelled with capital C, whereas chlamydial is lower case.”
new STIs were diagnosed” Technically, this is “new incidence (or
new cases) of STIs were diagnosed”, as it reads as though they are
new infections per se. In collaboration with the Department of
Health and University of Greenwich, the Royal College of Nursing
runs a distance learning course in Sexual Health Skills
(www.rcn.org.uk/sexualhealthlearning ) which captures much of
what the scope of the guidance is aimed at. A copy of the course Thank you.
flyer is attached for your information.
Royal College of Page 4 New 696,419 unsure where these figures came from and need checking. Figures will be checked and amended
Nursing STIs if necessary.
Royal College of Primary This will increase during the next 2-5 years as GU clinics all move Noted.
Nursing outcomes to NAAT tests for chlamydeous.
Reduction in
no of STIs
reported
Royal College of 3 (page 5) Inequalities in sexual health: target group should also include Noted.
Nursing teenage parents.
Royal College of 4.1 &4.2 And including repeat pregnancies Excellent to see condoms being Thank you.
Nursing promoted as contra-infection as well as contraception.
Royal College of 4.3.2 Interventions which will not be included - General - Missed Noted.
Nursing opportunity to exclude the interventions around sex and relationship
education and role of the family.
Royal College of 4.3.5 and 4.4 These are in conflict with each other, as targeting gay, bisexual and Interventions for HIV prevention will
Nursing other men who have sex with men for STIs but not HIV would be considered. HIV screening will not
probably be unethical, given: a) the current trends in encouraging be considered as this is outside the
HIV testing and b) the availability of HAART for those deemed remit of NICE.
necessary (obviously more beneficial through early testing)
36
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Royal College of Page 10 The Sexual Health Strategy gave clear markers/targets for these Screening for these two infections is
Nursing Screening for two infections and a missed opportunity if not excluded. outside the remit of this guidance.
HIV and Hep
B
Royal College of General Other conception rates nationally are at < 19 and the current data Noted. The referral from the DH
Nursing available is under 19. specified that the guidance should
cover under 18 conceptions.
Royal College of Page 10 4.3 Interventions which address the wider determinants of poor sexual Although we are unable to address
Nursing No 4 health – another missed opportunity. interventions which tackle the wider
The majority of clients attending GUM receive 1-2-1 interventions determinants (other than on a one-to-
and it would be a missed opportunity if GUM were omitted one basis), GU clinics will be included
in the revised scope. There is the
facility on the NICE website to
suggest topics for consideration for
our future guidance at:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Royal College of Page 10 no Appears to conflict with no 3 in 4.3 stating that reference will be One-to-one interventions can be
Nursing 4.4 given to those groups who are at the greatest risk of STIs and consistent with addressing the wider
teenage pregnancy and yet fails to address the wider determinants determinants of health.
of poor sexual health.
Royal College of 4.4 final Special mention could be made here for the innovative work of Noted.
Nursing paragraph many school and young people’s nurses, for those working with all
the groups identified here, especially young men in Young
Offenders Institutions.
Royal College of 4.6 paragraph Measuring knowledge is one thing, but what about (negative) Noted.
Nursing 3 attitudes towards such issues as condom use?
Royal College of Page 11 4.7 Sexual Health Leads at strategic health authorities should be Guidance will be appropriate for the
Nursing Target included as they receive all new modernisation money for sexual full range of practitioners both inside
audience health. and outside of the NHS.
37
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Royal College of 4.7 In NHS: Teenage Pregnancy Co-ordinators sometimes sit within the Guidance will be appropriate for the
Nursing NHS rather than local authorities. Should it not include health full range of practitioners both inside
promotion specialists? and outside of the NHS.
Royal College of 4.7 bullet School heads and teachers – to also improve the knowledge of Guidance will be appropriate for the
Nursing point 3 young people - But best practice suggests this is an up-hill struggle full range of practitioners both inside
without engaging the help of parents (who have already been and outside of the NHS.
excluded in 4.3.2).
Royal College of Appendix 2 – Given what is said on HIV above, HIV cannot be ignored in the We will not ignore HIV. The scope is
Nursing “syphilis” transmission of other sexual infections, most particularly to gay, being amended to reflect HIV more
bisexual and other men having sex with men. If this group shows clearly.
such high incidence of other sexual infections, then obviously they
are having unprotected sex, which is, by definition, open to the
transmission of HIV. Statistical evidence also shows that in the UK,
it is mainly white, under 24 year old males in this group acquiring
HIV. It cannot and must not be missed out!
Royal College of 4 Questions – Appropriate communication methods are essential in order to reach Noted.
Nursing delivery/mode this targeted age group in the population. We would expect to see
included in this review, appropriate use of language for young
people and especially when English is not their first language.
Royal College of Lack of There is a lack of published qualitative research, which may NICE considers a wide range of
Nursing research highlight positive outcomes of interventions, which work, therefore evidence which stretches beyond
the scope, may not get what they are looking for. ’published research’ and includes grey
literature.
38
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Teenage Pregnancy General We very much welcome the proposed guidance in helping to Thank you. We agree that we should
Unit, DfES strengthen implementation of the Teenage Pregnancy Strategy and take a broad as view as possible to
improvements to young people’s sexual health. assess indicators of success and will
International research evidence underpinning the Strategy makes consider all those outcomes that are
clear that reducing teenage pregnancy relies on a multi-faceted reported in the literature.
approach, involving a range of partners. Further evidence on the
ingredients of effective face to face interventions by health and non-
health professionals, will be extremely helpful in the planning and
development of integrated targeted support for the most vulnerable
groups. However, as teenage pregnancy and poor sexual health
result from a complex array of causal factors, evaluation of single
interventions can be very challenging. We would therefore NICE does not currently consult with
encourage NICE to take as broad view as possible to assess end users. However, as part of the
indicators of success, rather than rely solely on rates of under 18 fieldwork phase of the guidance
conception or STIs as outcome measures. development, we do consult with
We would also be keen that the proposed testing of the guidance frontline workers who have a good
with frontline practitioners, also includes testing with young people. knowledge of users’ views.
39
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Teenage Pregnancy 4.2.1 We would recommend including the following within the scope: Thank you. We expect that all of these
Unit, DfES *Interventions focused on addressing young people’s concerns interventions will fall within the
about specific contraceptive methods and improving their parameters of the literature searching
understanding and confidence in method use. For example, it is of ─ however, it is impossible at this
concern that a significant percentage of teenagers who have stage to predict what the literature will
received the pill from their GP become pregnant and that show.
awareness of the full range of methods, including long-acting
contraception remains poor.
*identifying the effective ingredients of successful referral to
contraceptive/sexual health advice services. For example, non-
health professionals such as youth workers, Connexions PAs and
teachers are in touch with young people most at risk and need to
know the most effective ways of referral.
*effective face to face work with under 16s, both on encouraging
delaying early sexual activity and effective contraceptive and
condom use by those who are sexually active. Research evidence
identifies that young people who have sex before 16 are at
significantly higher risk of regret, non-use of contraception and
pregnancy before 18.
*interventions to reduce second unplanned pregnancies after a)
abortion and b) birth.
*interventions with boys and young men about understanding
contraception and sexual health issues and effective condom use.
Teenage Pregnancy 4.4 Please also reflect the Teenage Pregnancy Unit Best Practice Noted.
Unit, DfES Guidance on the Provision of Effective Contraception and Advice
Services for Young People (2000) which sets out the criteria, based
on research with young people, against which services are
expected to be commissioned.
Teenage Pregnancy 7 Please amend the reference to Guidance for Youth Workers to: Noted. The scope has been amended.
Unit, DfES Enabling young people to access contraceptive and sexual health
advice: guidance for youth support workers. DfES/Teenage
Pregnancy Unit, 2005.
40
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Maranatha 1 There has been a massive increase of sexually transmitted Thank you. The guidance will be
Community/Council for diseases (STIs) in the UK over the past years. Diagnoses of developed on the basis of the best
Health and Wholeness gonorrhoea and chlamydia have all more than doubled between available evidence. The scale of the
1995 and 2004. Syphilis cases rose by a staggering 1500%. Cases problem, we agree, is considerable.
of HIV and AIDS are set to rise almost 10 per cent a year and have
more than doubled between 1993 and 2002. There has been a
record numbers of HIV infections in 2001, with 5393 newly
diagnosed cases. This was the highest number of new diagnoses
recorded in a single year since the beginning of the AIDS epidemic.
(Draft NICE guidance; MW Adler, Sexual health – health of the
nation. Sexually Transmitted Infections 2003; 79: 85-87; Written
answer; Sexual Health; Miss Melanie Johnson: Sexually
Transmitted Disease data for England; as at 28 November 2003
Maranatha 2 The number of lifetime sexual partners had increased from 8.6 to Noted.
Community/Council for 12.7 for men and from 3.7 to 6.5 for women over the past 10 years.
Health and Wholeness Britons also have sex at an earlier age now. For over 55s the
average age of losing their virginity was 19, within the 25-34 age
group it was 16 and among the 16-24 year olds it is only 15. Over
the past 10 years, there has been a “considerably higher rate of
new partner acquisition among those younger than 25 years and
those not cohabiting or married. These strong age effects are
reflected in the substantially higher incidence of STIs in those
younger than 25 years, compared with older people.” (The
Observer, Sex uncovered, result of a poll of 1027 adults aged 16 or
over; 27 October 2002; Johnson AM et al. Sexual behaviour in
Britain: partnerships, practices, and HIV risk behaviours. National
Survey of Sexual Attitudes and Lifestyles; Natsal 2000; Lancet
2001: 358; 1835-42
41
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Maranatha 3 Between 1991 and 2001, attendances at GU (genito-urinary We agree the problem is
Community/Council for medicine) clinics in England, Wales & Northern Ireland rose from considerable. We reserve judgement
Health and Wholeness 669,291 to 1,332,910. In 2004, there were 1.5 million appointments as to cause and effect until the
at GUM clinics. At the same time, there has been a dramatic reviews of evidence are complete.
increase in all STIs. The government’s drive to further increase
access to GU clinics will therefore not stop the epidemic of STIs.
(Draft NICE guidance; Sexually Transmitted infections in the UK:
new episodes seen at Genitourinary Medicine Clinics, 1991 – 2001;
Public Health Laboratory)
A small increase in condom use has been observed over the past If the evidence shows that current
10 years in the National Survey of Sexual Attitudes and Lifestyles. methods and approaches are
This survey concludes that, due to the increase in risky sexual ineffective, NICE recommendations
behaviour the ‘benefits of condom use were offset by increases in will reflect this.
reported partners’. To rely on condoms without emphasis on
reducing casual sex – as the government seems to be doing – will
not stop the epidemic of STIs. (Johnson AM et al.; Natsal 2000;
Lancet 2001: 358; 1835-42. The Medical Institute for Sexual
Health: Sex, condoms and STI’s – what we now know. 2002)
There is a strong positive correlation between increased condom
use at first sexual intercourse and increased teenage pregnancy. If
the traditional approach – to encourage increased uptake of
condoms – were effective, an increased use of condoms would be
associated with a decrease in unwanted pregnancies. However, this
is not the case since condom distribution may be associated with
increased sexual activity and condom use may give a false sense of
security, which increases sexual risk-taking and casual sex. Finally,
condom distribution does not ensure condom use: In a recent
survey, ¾ of male students reported having sex without condom
when they felt one should have been used to protect against
pregnancy or infection. (Williams ES. Contraceptive failure may be
a major factor in teenage pregnancy. British Medical Journal 1995;
311: 806-7. United States Agency for International Development:
The ‘ABCs’ of HIV prevention. ‘ABC’ Expert Technical Meeting
September 17, 2002. Warner L. Condom access does not ensure The remit of this scope goes beyond
42
condom use: you’ve got to be putting me on. Sexually Transmitted the benefits or otherwise of condom
Infections 2002; 78: 225.) use.
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Maranatha 9 The current UK policy on sexual health is based on the National Noted.
Community/Council for Strategy for Sexual Health and HIV, (Department of Health 2001)
Health and Wholeness and the Teenage Pregnancy Strategy in 1999. The government has
been attempting to tackle high teenage pregnancy rates and
increasing rates of STIs in the UK. The aim is to halve teenage
pregnancy rates by 2010. The Teenage Pregnancy Strategy policy
initiatives are very similar to those introduced by the Conservative
Government in 1992 with the aim of halving the underage
pregnancy rate by the year 2000. The National Strategy for Sexual
Health nor the draft NICED guidance does not promote the only
evidence-based definition of safe sex, which is (apart from
abstinence) mutual monogamy among uninfected partners. The
National Strategy nor the draft NICE guidance does not even
mention the word marriage, even though the majority of the
population – 83% - still considers monogamy and marriage as the
preferred form of relationship. Reduction in casual sex does not
even feature in the National Strategy for sexual health and HIV nor
the draft NICE guidance. These guidance’s are therefore doomed
to fail, since it does not address the underlying problem, the
dramatic increase in casual sex. (In a recent poll 83% of
respondents aged 16 or over believed that monogamy is desirable.
Source: The Observer, Sex uncovered. 27 October 2002; National
Strategy for Sexual Health and HIV, Department of Health, 2001)
43
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Maranatha General The graph below shows that there has essentially been very little or To date NICE has not made any
Community/Council for no impact of increased access to family planning clinics on recommendations and will not do so
Health and Wholeness underage conceptions. It is of interest to note, that, despite a until after the consideration of the
massive increase in family planning clinic attendances, underage evidence.
conceptions have remained unchanged. The previous Conservative
government tried to reduce underage conceptions with the ‘Health
of the Nation’ programme in 1992, which contained very similar
policy measures to the currently adopted teenage pregnancy
strategy. This programme failed to reach its target, to halve teenage
pregnancies by the year 2000. Since this previous programme
failed to significantly reduce teenage pregnancies, it is very likely
that the currently adopted strategy – as recommended by the NICE
guidance - will not make much difference either.
North West Public 4.1 (page 7) Re: the text, “Activities provided by local health organisations” – this At the moment NICE intervention
Health Team, work will be influencing a wide range of practitioners eg. Local guidance is primarily for healthcare
Government Office authority staff and not just NHS staff. Maybe “health” could be practitioners, however we
North West removed or revised to “health in it’s broadest sense” acknowledge that this guidance has
relevance to a broad range of other
staff and these are outlined in 4.7.
North West Public 4.2, Section 3 National Chlamydia screening upper age limit is 24 not 25 The NCSP is an opportunistic
Health Team, (page 9) screening programme targeting
Government Office sexually active young women and
North West men under 25 years of age. (DH
(2004) NSCP in England Programme
Overview. P13)
44
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
North West Public 4.4 (page 10) The section lists guidance that the scope will reflect which is Thank you. The scope has been
Health Team, welcomed. However, it should also reflect the guidance in “Working amended to include: ‘Working
Government Office Together” when it is published at the end of the year which is a Together’ when it is available and
North West document that aims to provide a sensible and agreed way forward other DH/TPU guidance.
for a range of agencies and practitioners re: sex and under 13s. In
addition to the TPU/ DH guidance on Sexual Health and Youth
Workers (2001) and Social Care workers (revised in 2004) there is
also TPU guidance on working with Boys and Young Men and
working with BME groups, two groups highlighted in the scope as
being disadvantaged so maybe these pieces of guidance should
also be included?
North West Public 4.5 (page 10) What is meant by “routine care”? “Interventions will be compared Although potentially difficult, we want
Health Team, against each other” – does that mean the same intervention but the economic models to compare
Government Office conducted by a different practitioner i.e. two GU nurses doing the interventions that are special or
North West same thing with one in one part of the country and one in another. different, with normal care. We will
Or does it mean comparing the intervention of, for example, a see how feasible this is as we
young person’s health adviser with the intervention of a GU nurse – proceed.
or does it mean both?
North West Public 4.6 (page 11) “Intermediate outcome measures” – while I don’t disagree that We appreciate that many of the
Health Team, measuring intermediate outcomes is important, my concern is that measures are problematic; however to
Government Office for some of the measures, the data doesn’t actually exist so it will a large extent the outcome measures
North West be very difficult to measure distance travelled/ change in behaviour which are used will reflect those in the
before and after an intervention has taken place. literature.
North West Public 4.6 (page 11) “Primary outcomes” – again, don't disagree with these measures Please refer to response given above.
Health Team, but need to be mindful of the timeliness of the current data that we
Government Office have eg. Teenage Conception data is always two years out of date
North West so the impact of interventions taking place now in 2005 may not be
realised until 2007/ 08. Some data is collected at the local level in
real time but this may make comparisons between different parts of
the country difficult. At least the advantage of using national data is
it is collected in the same way across the country……
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Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
North West Public 4.7 (page 11) Re: who the guidance is aimed at, “The guidance is aimed at At this stage NICE intervention
Health Team, healthcare professionals working in the NHS……..It will also be guidance is primarily for healthcare
Government Office relevant to professionals and lay people……” This contradicts practitioners, however we
North West section 4.1 (3rd paragraph) which states that the focus is on a range acknowledge that this guidance has
of professionals, not just NHS ones. It also contradicts Professor relevance to a broad range of other
Kelly’s presentation on 23rd September where he highlighted that staff and these are outlined in point
the guidance is for non-NHS professionals too. I think we need to 4.7 of the scope.
be explicit that this is going to be guidance for all practitioners,
wherever they are based who undertake one to one interventions.
Otherwise, it just compounds the fact that this is a “NHS” issue and
we know that the
North West Public 4.7 (page 11) current evidence, especially around Teenage Pregnancy supports a Noted.
Health Team, continued multi-faceted approach by a range of professionals who work with
Government Office vulnerable groups to improve their sexual health and well-being.
North West
North West Public 4.7 (page 12) The second bullet point states “In local authorities it includes: Thank you. The scope has been
Health Team, teenage pregnancy co-ordinators”. Not all Tics are based in Local amended to include TPCs in
Government Office Authorities, some are employed by the NHS and in other whichever organisation they are
North West organisations, for example, the Connexions service. If this guidance employed, plus housing support
is aimed at all practitioners who may undertake one to one work workers and learning mentors.
with young people, the following should also be included: housing
support officers (particularly for those who are supporting young
people making the transition to an independent tenancy of their own
as this is often the point when a young person is most vulnerable)
and learning mentors who should also be included for those local
authorities who still employ them
North West Public 4.11 (page “Outputs of this work will include…..Information for the general The final NICE recommendations.
Health Team, 14) public” - about what? The final NICE recommendations, the
Government Office scoping exercise or both?
North West
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Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
North West Public General Need to be mindful that many non-clinical practitioners eg. Youth Noted.
Health Team, comment workers and teachers operate a policy where they are always
Government Office accompanied by a co-worker to ensure that they and the young
North West person are not in a vulnerable position and so will not actually
deliver one-to-one work re: sexual health with young people
North West Public General Many young people ring “Sexwise” for information over the phone Agreed. The scope will be amended
Health Team, comment from trained advisers – is this considered to be a one to one to include helplines, web-based
Government Office intervention and if so, will this type of intervention be included? In advice and other ‘remote’ services.
North West addition to this, Choosing Health refers to the development of web-
based advice for young people re: sexual health so it may be
helpful to include any services that are currently offering this facility
to ascertain the effectiveness of this approach
North West Public General Is there any mileage in the implementation of the final NICE The implementation of NICE guidance
Health Team, comment guidance to be included as a performance indicator eg. Within NHS in the NHS will be monitored.
Government Office targets, PSAs or Local Authority Best Value reviews? Discussions are currently ongoing at
North West government-level to determine the
status of NICE guidance outside of
the NHS.
North West Public General How will the interventions for inclusion in the study be selected? Clear review parameters will be
Health Team, comment How can representative geographical and demographic spread be agreed at the outset of the work. A
Government Office ensured? range of different study types will be
North West included in the search. The
recommendations will be tested
across a range of geographical sites
as part of the fieldwork phase of
guidance development to ensure its
relevance to local areas.
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Stakeholder Section Comments Response
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North West Public General In addition to looking at the effectiveness of the intervention, will the One of the research questions asks
Health Team, comment receptiveness of the young person also be looked at? A young about how effectiveness varies in
Government Office persons background will affect uptake and compliance following an relation to age, gender, class and
North West intervention i.e. the same intervention undertaken by the same ethnicity.
practitioner may have a completely different outcome for each
young person who works with the practitioner and this should be
considered
Terrence Higgins General THT welcomes the formulation of this guidance as an opportunity to Thank you.
Trust (THT) construct a comprehensive framework to support delivery of sexual
health services. Commitment to an examination of a variety of
types of evidence for interventions that take place in different
settings and which are delivered by a range of service providers is
vital.
Terrence Higgins 4.1 Areas that will be covered Agreed. The scope has been
Trust (THT) Consideration of the impact of interventions on inequalities in amended to include these categories.
sexual health should be a high priority. In addition to reference to
social class and ethnicity, it may also be useful to examine data on
inequalities relating to sexual orientation and educational
achievement.
Terrence Higgins 4.2 Interventions Agreed. Interventions that develop
Trust (THT) Sexual ill health and unwanted pregnancies can often be a self-esteem, confidence and
consequence of high-risk behaviours. Such behaviours themselves negotiation skills are included in this
can often spring from a lack of confidence or self-esteem, or an scope.
inability to negotiate behaviour within relationships. It is therefore
important to examine evidence for those interventions that seek to
build personal skills in these areas.
Post exposure prophylaxis (PEP)
PEP is a month-long course of anti-HIV medication that since the We agree. We will examine this issue
mid 1990s has been given to health workers thought to have been in so far as the literature permits.
at risk of HIV. Some sexual health and accident and emergency
settings are now offering PEP to people who believe they may have
been exposed to HIV. It might therefore be timely to examine the
available data in relation to the targeted use of PEP as a sexual
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Stakeholder Section Comments Response
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health intervention.
Telephone and email interventions Agreed. The scope has been
Increasingly, clients seek advice and support on sexual health and amended to include telephone help
contraception through telephone or internet services, it will therefore lines and the use of the internet.
be important to assess the efficacy of such one-to-one interventions
within this guidance.
Opportunistic Interventions Agreed
The discussion of specific interventions rightly highlights the
opportunity for health promotion messages to be communicated
during pregnancy testing, termination of pregnancy and antenatal
care. Clients who have already presented for treatment or care in
such situations are often more receptive to further messages about
health, and the connection between treatment, health promotion
and avoidance of re-infection is very important. It might therefore be
helpful to more explicitly specify the inclusion of opportunistic
interventions that can take place in a sexual health screening or
treatment setting, either within GUM clinics or in a community or
voluntary sector setting.
Partner Notification
In addition to examining partner notification mechanisms for STIs in This will be included within the partner
general, it would also be useful to examine methods of partner notification. The scope has been
notification that are specific to HIV, as the evidence base for these amended.
may be separate.
Service user experience
THT strongly supports the commitment within the scope to consider
the effectiveness of interventions as perceived by the people to We agree, and hope that the literature
whom they are offered. A qualitative examination of the service will reflect this.
user’s experience is crucial to an assessment of the long-term
effectiveness of health promotion interventions.
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Terrence Higgins 4.3 Interventions that will not be included The guidance will consider the
Trust (THT) THT is aware that responsibility for assessing the effectiveness of prevention interventions which take
screening activity currently rests with the National Screening place within the screening process;
Committee. However, within sexual health, screening and health however it will not consider screening
promotion activity are often conducted together and should be in itself. The scope will be amended to
viewed as a holistic package of interventions. In order to allow a reflect this. We acknowledge this
more comprehensive analysis of the effectiveness of both types of important point.
work, it would be helpful to take a more inclusive approach and
examine them together. The exclusion of screening for HIV,
Hepatitis B and Syphilis is of particular concern, as these infections
are targeted within the National Strategy for Sexual Health and HIV.
It should also be noted that many clinics commonly offer a range of
tests, rather than testing for one infection such as Chlamydia, and
this often includes an offer of an HIV test.
A comprehensive analysis of interventions in a range of settings
would be helpful, and the exclusion of sexual health screens in GU
departments may lead to certain key health promotion interventions
being omitted from this guidance. If it is not possible to include
such interventions in this assessment, inclusion in a later set of
accompanying guidance would be helpful.
Although PSE and group based interventions will not be covered in PSE will not be covered in this
this guidance, it will be essential to examine interventions such as guidance. There is the facility on the
the teaching of PSE as a school subject and group interventions NICE website to suggest topics for
within African communities. consideration for our future guidance
at:
www.nice.org.uk/page.aspx?o=topics
uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
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Stakeholder Section Comments Response
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Terrence Higgins 4.4 Populations Agreed. The scope will be amended
Trust (THT) In addition to referring to Department of Health guidance for to include ‘Working Together’ when it
clinicians on the provision of sexual health advice and treatment to is available.
young people, it is also essential that NICE guidance reflects
current protocols regarding the safeguarding of children stemming
from the Department for Education and Skills. For example, current
consultation on the guidelines, “Working together to safeguard
Children” will have implications for professionals working with young
people and advising them on sexual health and contraception.
Terrence Higgins 4.5 Comparators Although potentially difficult to do, we
Trust (THT) The scope currently indicates that interventions will be compared want the economic models to
“against each other and against routine care” where the data are compare interventions that are special
available. Obviously, benchmarking will be an important part of the or different with normal care. We will
assessment, but further clarity around how “routine care” might be see how feasible this is as we
defined would be welcomed. proceed.
Terrence Higgins 4.6 Outcome Measures Agreed, however to a large extent the
Trust (THT) If possible, when examining the outcome measures related to outcome measures which are used
partner notification programmes, it will be useful to assess the will reflect those in the literature.
number of contacts who later present for care themselves and of
these people, those who had undiagnosed infections for which they
were appropriately treated. A more specific reference to a reduction
in the prevalence of HIV would also be helpful within the outcomes
Terrence Higgins 4.7 Target Audience Agreed. The scope has been
Trust (THT) It is welcome that the target audience for this guidance is amended to reflect the range of client
acknowledged as being broader than NHS staff and providers. groups the voluntary sector works
However, the section referring to staff within the voluntary sector with.
only specifically refers to those developing or delivering sexual
health services for young people. Professionals within the voluntary
sector work with a range of client groups, including all of the
vulnerable groups listed as target populations for these assessed
interventions. A more explicit reference to this range of client
groups would ensure that all practitioners use this guidance where
relevant to their work.
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Terrence Higgins 4.10 Evidence for Consideration Noted.
Trust (THT) THT strongly welcomes the high level of stakeholder involvement in
the formulation of this guidance, and the opportunity for
stakeholders to feed in other evidence, including “grey literature”
during the development process. Given the difficulties sometimes
associated with gathering hard data on public health and health
promotion interventions, an examination of a variety of types of
evidence, beyond that normally found in scientific journals, will be
essential.
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Stakeholder Section Comments Response
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Love for Life General STI reduction will only be achieved with a holistic approach that Noted. We will look at the full range of
includes at least promoting equally actively through policy, strategy evidence before making
and grass root patient contact the delay of first sex, the reduction of recommendations, including evidence
casual sex and increased condom usage. relating to abstinence and delay of
first sex.
The risk is that health documents are almost entirely focused only
on services provision with little emphasis on how through the public
health medium and in the one to one consultation delaying first sex
and the reduction of partners can be promoted.
Unless we adequately address this deficiency future National
Survey of Sexual Attitudes and Lifestyles reports will only show
further lowering of age of first coitus and increased average number
of partners. Inevitably more service provision will be necessary as
sexual behaviours move increasingly to earlier coitus and more
partners.
How often in a family planning or STI consultation does the This is an empirical question. If the
practitioner suggest that the patient should seriously consider not literature provides evidence, then
having a concurrent partner or even that they might want to NICE will make the appropriate
consider not changing sexual partners or not becoming sexually recommendation.
active at all or later in a subsequent relationship?
This same behavioural approach is often used within health
promotional messages in a consultation around alcohol or drugs.
Women’s Health Guidance The title seems to emphasise screening for Chlamydia, rather than The words used in the title were those
Title suggesting a wide range of face to face or 1 to 1 interventions and used by the DH in its referral.
including a range of sexually transmitted infections.
We find the short title very appropriate.
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Stakeholder Section Comments Response
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Women’s Health Background Although we recognise that this draft is dealing only with We agree that tackling teenage
interventions and not a wider programme, it is our experience that pregnancy and STIs including HIV is
young people often do not reach the stage of having a 1:1 wider than a health service issue.
intervention until after being exposed to sexually transmitted Your point is important and will be
infections or potential pregnancy. discussed when recommendations
are being developed.
This is perhaps particularly true of interventions in health settings,
which are a major focus of this guidance. We hope that NICE will in We recognise the range of
future look at a wider programme to include social, educational, interventions that could be
financial, housing, cultural, press & media, advertising, new considered. There is the facility on the
technology and the broad range of issues that can impact on young NICE website to suggest topics for
people’s health and well-being. We recognise that this is wider than consideration for our future guidance
a health service issue, and that targets such as ‘to reduce the rate at:
of under eighteen conceptions by 50% by 2010’ may be www.nice.org.uk/page.aspx?o=topics
unachievable by health and education services alone. uggest We would expect that at some
point in the future NICE will be asked
to look at these issues.
Women’s Health Inequalities in In addition to those groups mentioned, young people with The scope includes the whole
sexual health disabilities, such as learning difficulties, may be particularly population.
unaware of risks and less able to protect themselves against risk.
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Women’s Health Interventions The interventions mentioned do not specifically include telephone Agreed. Telephone helplines, email
helplines, e-mail or text services. As a health information service, and Internet services have been
we receive enquiries and requests for sexual health information added to the scope as one-to-one
from young people aged 11 years upwards. Many young people interventions to be considered.
find it easier to raise sexual health issues anonymously and may
prefer these types of interventions.
We realise that gathering the evidence for these types of
interventions is likely to be a challenge. One-to-one peer-led interventions are
We also wonder whether peer interventions, such as by peer included in the scope.
mentors in schools or youth groups will be considered.
It would be good to consider interventions that deliver information in Agreed.
a range of formats, including those appropriate for people with
disabilities (verbal, written, visual, tape, different languages).
Women’s Health Populations We would also like to see some reference to young people with The scope includes the whole
disabilities, including learning difficulties. We also feel that boys, in population. Boys will be one of the
particular, may be harder to reach, as they may be less likely to groups to whom particular reference
access health services and feel less personally affected by sexual will be given.
health issues.
Women’s Health Target As well as those mentioned, we feel the guidance may also be NICE guidance is produced primarily
audience appropriate for faith and cultural groups (some these may be for the NHS, although our guidance
voluntary sector groups, others may not). Faith leaders and youth will be relevant to others, including
workers within faith communities can have a strong influence, in faith and cultural groups.
many different ways, on the young people they meet.
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Stakeholder Section Comments Response
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Leicestershire AIDS General 1) There is a need to ensure that interventions designed to Noted.
Support Services meet targets to reduce the rate of under 18 conceptions do
(LASS) not in practise run counter to the aim of reducing STI’s.
2) We have concerns about the use of depo-proverea and
promotion of early abortions.
i) People may have more unprotected sex assuming that
they will not get pregnant hence higher risks of STI’s
ii) Health concerns: bone problems, lack of
awareness/concern about STI’s, increased risk taking.
3) We are concerned that the focus on teenage conceptions
targets young girls – boys should be taught about
consequences with equal emphasis
4) The National Strategy for HIV and Sexual Health does not
seem to have the involvement Govt Depts other than the
DoH. As a result there are conflicting Social Policies ( e.g.
some people not receiving free treatment for HIV)
5) Prejudice and stigma re HIV must be addressed as a high
priority.
6) ‘Initiatives’ would be more effective if they were long-term
(e.g. 10 years plus strategies for genuine social change) and
also different Govt Depts ‘bought in’ to them and acted in
accord (e.g. Education linking up with Health re meaningful
education for young people; using methods which
demonstrably engage them (e.g. Theatre in Education) re
STI’s and HIV. Short-term ‘leaflets and campaigns’ will not
create long-term change in a highly sexualised culture
SOME INITIAL GENERAL
THOUGHTS/COMMENTS/OBSERVATIONS:
The aim of “reducing rate of under 18 conceptions” could be at odds
and a contradiction with the other aim of “reducing Sexually
Transmitted Infections” as conceptions could be reduced by a
concerted campaign to, for example, prescribe the oral
contraceptive pill; or injectable contraception like Depo-Provera; or
56
using emergency hormonal contraception or IUD; or even by
promoting early abortions (even in young girls who have already
had one or more before – as I have recently heard from one locality
Stakeholder Section Comments Response
number Please insert each new comment in a new row. Please respond to each comment
Department of Health Trends May also be Explained by a whole range of other factors not Noted.
mentioned here
Department of Health 4.2.9 [There are no QALYs for sexual health, except HIV where death is Noted. We will take this into
the endpoint. And specific to chlamydia, no one has quantified the consideration when designing the
quality of life costs of infection, treated infection, multiple infections, economic evaluation.
or undiagnosed/untreated infection(s). this will be a very difficult
standard for cost-effectiveness research on STIs. Economic
modelling using transmission dynamic models has been the next
best tool we have to assess the impact of interventions for STIs.
Note recent paper by Turner KME, et al. (2005) and forthcoming
paper by our team here.]
Department of Health Appendix 1 [again, are we talking preventing incidence cases or reducing We will consider both of these.
prevalence in the population or both
Department of Health Appendix 2 :[but these data only cover populations that seek services at GUM Noted.
clinics. If the intervention is not aimed to this population, this may
not be the best data source to use to assess the intervention’s
success.]
Department of Health General There is also an age limit for the NCSP and we would prefer that we We will address all of the areas within
all play to the same level and look at under 25's for everything. the scope as far as the evidence
Our final concern is that it is too focussed on STI's & HIV and the allows and will not focus more on
contraceptive / abortion side is missed. some areas than others.
One further issue that CAG need point out, is that the NCSP is not We will consider evidence from
due for full implementation until 2007, so chlamydia screening in all outside of the NCSP.
venues and by all providers, either within or outside the NCSP
should be included; also that since this covers only 1 to 1 We will consider one-to-one Internet
interventions, many self-initiated elements of the NCSP such as interventions, but not mass media
responding to pee in the pot interventions linked to internet or interventions.
poster campaigns are not covered.
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Stakeholder Section Comments Response
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Department of Health 4.1 Areas that We would be grateful if you could consider including the private We will not be considering mass
will be sector as well as statutory & voluntary, for instance through social interventions such as social
covered marketing. This would include pharmacies and condom marketing, however the scope does
manufacturers. include the private sector.
Department of Health 4.2 Under the contraceptive service element you may wish to consider: Agreed. The scope has been
Interventions Accessibility and acceptability amended to reflect this.
Where and when interventions are made, for example post abortion
(which needs to include the option of a complete range of
contraception not just advice)
Department of Health 4.4 Would you please consider what PCTs should commission, which The brief from the DH for this project
Populations in turn would then permit the role of group based interventions to be was very broad. Time and resource
considered. For instance, the addition of an outreach worker to a constraints meant that the work had to
sexual health service can make a significant difference in raising it’s be made manageable by some
profile, and therefore the uptake of that service. It is recognised means. NICE decided in this instance
though that it is beyond the NICE scope to comment in any depth that focusing on one–to-one
on the most effective content for any group interventions beyond interventions made this work
some basic possible functions. As far as DH is aware, the original manageable. We would expect that at
brief did not limit this to one to one interventions, so expanding it some point in the future NICE will be
would be helpful. asked to look further at sexual health
issues.
Department of Health 4.6 Outcome Could you please consider mentioning the uptake of services, for We will consider the widest range of
measures instance, which demonstrates some excellent and accessible outcome measures possible, though
services that are working in areas with (currently) less than the measures used will, to a large
satisfactory outcomes. extent, depend on the literature.
Department of Health 4.7 Target Could school nurses be included here? School nurses are included in section
Audience 4.7
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Stakeholder Section Comments Response
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Department of Health 4.8 Research Would you please consider amending the “one to one” question, to The brief from the DH for this project
questions read: ‘What interventions should be commissioned to contribute to was very broad. Time and resource
the reduction of STIs and unintended teenage conceptions?’ constraints meant that the work had to
be made manageable by some
means. NICE decided in this instance
that focusing on one-to-one
interventions made this work
manageable.
Department of Health 4.10 Evidence We would be grateful if you could consider referring to the Agreed. The scope has been
for Department of Health’s Policy Research Programme’s allocation of amended to include consideration of
consideration £1 million annually to the Medical Research Council , for research the MRC research on sexual health
on sexual health and HIV, to support implementation of the National and HIV.
Strategy for Sexual Health and HIV and to develop the longer term
evidence base. This programme of research is managed on DH’s
behalf by the MRC, and advised the Sexual Health and HIV
Research Strategy Committee (SHHRSC).
DH is keen to ensure that research output from this programme
feeds into the development of NICE guidance in this area.
The MRC will be collating comments from Members of the
SHHRSC on the draft scope, and submitting these separately to
NICE.
National Pharmacy General The National Pharmacy Association welcomes NICE’s intention to Thank you.
Association Ltd produce public health intervention guidance on preventing sexually
transmitted infections and reducing under 18 conceptions. We
believe the proposed scope is generally well defined.
National Pharmacy Section 4.1 We are pleased that NICE will focus not only on the effectiveness Agreed.
Association Ltd and cost effectiveness of interventions, but also investigate their
impact on health inequalities. The Department of Health (DH) has
acknowledged pharmacists as “probably the biggest untapped
resource for health improvement.” (A Vision for Pharmacy in the
New NHS, DH, July 2003).
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National Pharmacy Section 4.2 This section lists opportunities to provide advice about prevention of Noted.
Association Ltd under-18 conception and sexually transmitted infection (STI). The
point of supply of contraceptive medication/devices provides a
platform for providing advice and might usefully be added to your
list. In the case of Emergency Hormonal Contraception (EHC), it is
a licence requirement that a pharmacist consultation is undertaken
with the client at the point of over-the-counter supply. Choosing
Health Through Pharmacy: A programme for pharmaceutical public
health 2005-2015, DH 2005, p75) refers to a “strong evidence base”
for expanding pharmacists’ EHC supply service into “services for
the under 16s and into sexual health advice generally”. Thank you.
The new, national community pharmacy contract framework –
operational since April 2005 – provides a framework for advice,
signposting and health promotion in all community pharmacies.
Details are available at www.psnc.org.uk .
National Pharmacy Section 4.7 Appendix A’s list of primary healthcare professionals working in the Noted. The scope has been amended.
Association Ltd NHS includes GPs and practice nurses, as well as pharmacists.
Pharmacists are listed later as “private sector interested parties”,
which we take to be a reference to community pharmacists. In fact,
community pharmacists are acknowledged by DH both as
healthcare professionals (formally in DH guidance on the 24 hour
access to healthcare professionals target) and as an “integral part
of the NHS family” (A Vision for Pharmacy in the New NHS, DH,
2003, p7). Community pharmacists should be re-categorised
accordingly.
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Stakeholder Section Comments Response
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National Pharmacy Section 4.8 We believe that your list of research questions is comprehensive. Noted.
Association Ltd In particular, we are pleased that “setting/site of delivery” is
included, because accessibility of sexual health interventions is a
crucial ingredient in interventions’ effectiveness. Tackling Health
Inequalities: A programme for action (DH, 2003, p32) highlights the
importance of community settings, including community
pharmacies, in facilitating early detection and treatment in the public
health context. Choosing Health: Making healthy choices easier
(DH, 2004, p146) envisages testing and screening for STIs
increasingly being delivered in the community, citing community
pharmacies as a “building block” for this expansion.
Your researchers should, in our view, consider accessibility in terms Agreed.
of opening hours and promptness of service as well as
geographical vicinity.
MRC Section 3 - Although the reported numbers of new diagnoses of gonorrhoea Noted.
The need for and first episode genital herpes (FEGH) from GUM clinics
guidance decreased between 2003-4, this observation may have been
affected by deteriorating access to clinic services. Both gonorrhoea
in men and FEGH in both sexes often cause severe acute
symptoms. If patients were unable to access GUM care, they may
have sought treatment elsewhere. Cases diagnosed in other
locations are unlikely to have been reported and to appear in HPA
statistics.
MRC Section 4.1 - The scope of the intervention guidance concerns one-to-one sexual Agreed.
Areas that will health interventions.
be covered
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MRC Section 4.2 - In addition to the interventions outlined, the scope should also Interventions delivered to prevent re-
Interventions include the prevention of further acquisition of infection (and infection will be included.
unwanted conception) in those who have presented for care. The
so-called treatment / prevention synergy is important because
individuals who have presented with either symptomatic conditions
or who, although asymptomatic, perceive themselves at risk of
such, are sensitised to health education messages and future risk-
reduction.
Thus, services for treatment and care have a vital role in one-to-one
interventions to help prevent further sexual health problems in
individual patients.
Partner notification for STIs may take place in a variety of settings, We will consider evidence for PN from
and be performed by a variety of healthcare professionals. It will be any setting. If the literature highlights
helpful to compare outcomes from traditional GUM clinic-based PN differences between settings then
endeavours with those from PN conducted in primary care and these will be reported.
other community-based settings.
Within GUM clinics up to half of all presenting patients are The DH referral asks us to look at
asymptomatic and present for screening. In the draft scope, a chlamydia screening specifically, and
differentiation is made between Chlamydia screening in GUM and we will do this across both GU and
non-GUM settings. Where an individual presents for screening may non-GU settings, however general
not be necessarily indicate different levels of risk. Is it then screening issues are the remit of the
reasonable to exclude screening for chlamydia and other STIs in National Screening Committee.
GUM clinic attenders?
In many settings, including GUM, screening is performed for a Noted.
range of STIs rather than just for a single infection such as
chlamydia. This includes the routine offer of testing for HIV, which is
potentially the most serious STI.
62
Stakeholder Section Comments Response
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MRC Section 4.3 - The draft scope states that Standard sexual health screening in GU We will consider health promotion
Interventions departments will not be covered. The reason for this exclusion is interventions delivered at any point
which will not not clear, nor does it explain this refers to. Do the drafters mean to whether as part of general screening,
be included exclude standard STI testing of symptomatic patients? As explained or testing. We will not, however,
above, the inclusion of outcomes from GUM clinic interventions has consider screening (other than for
considerable importance in providing comparator data with hard chlamydia) or testing as clinical
outcome measures for prevention of reinfections and the efficacy of interventions as they are outside the
partner notification. It also excludes screening for HIV infection, remit of this guidance.
syphilis, and hepatitis B which are potentially serious STIs. The
national strategy contained targets for reducing the incidence of HIV
and for uptake of hepatitis B immunisation in men who have sex
with men. Hard outcome data for these endeavours exists.
MRC Section 4.5 - The document states that interventions will be compared …against Although potentially difficult to do, we
Comparators routine care. What is the definition of routine care in the context of want the economic models to
screening? It would be helpful to have this clarified. compare interventions that are special
or different with normal care. We will
see how feasible this is as we
proceed.
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MRC Section 4.6 – Some of the intermediate outcome measures are rather soft and NICE consider the broadest possible
Outcome place a high reliance upon self-reported data, that may correlate range of outcome measures, both
measures poorly with actual behaviour. In PN outcomes, it is important to hard and soft. However, the outcome
determine not only the number of contacts identified/notified, but measures we can report on will reflect
also the numbers of these contacts who present for care, who are those used in the literature reviewed.
found to have undiagnosed infections, and who receive appropriate
treatment. The primary outcome measures include: reduction in the
rates of STIs and unintended pregnancy rates. HIV incidence and HIV to be included.
prevalence are also important, as is HIV testing uptake.
It will be important to define within the scope which specific STIs
are being considered. In addition to uncomplicated bacterial STIs,
and first episodes of genital warts or genital herpes, complications
such as PID and epididymitis may need to be considered. HIV We agree that these are important,
should definitely be included. However, syphilis is also too serious a however, this scope will not be
health problem to be excluded. Diagnosis is of itself an outcome of considering treatment and care.
limited value to an individual unless it is followed by appropriate
treatment and care. The timeliness of treatment following
presentation and diagnosis is also highly relevant.
MRC General From experience of working in this area, it is very, very ambitious to We agree that this is very challenging,
ask for evidence on all one-to-one interventions that might reduce and we will be reliant on the outcome
STIs and unintended teenage pregnancies, as well as producing measures reported in the literature.
QALY gain estimates and some measure of inequality reduction,
the latter of which is entirely novel.
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Stakeholder Section Comments Response
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MRC General There is a worry about the reductionism of the NICE Reference Where the use of QALYS is not
Case for many interventions, but especially for public health practicable or possible, we will
interventions, and even more so for 'difficult' areas within public attempt to use other forms of
health, such as reducing teenage pregnancy. 'Normally', QALYs as economic evaluation. Your
a measure of benefit might be quite controversial because they do observation is helpful and will be
not cover all aspects of benefit; however, a case can at least be discussed with the health economists
made for computing results based on the NICE Ref Case (with at NICE.
QALYs as the main outcome/benefit measure) and building in
'broader concerns' around that. However, in the example of teenage
pregnancy reduction the main outcome itself (ie reduced
unintended pregnancies) cannot even be expressed in QALY terms;
it may be possible to express in QALY terms the various
complications or medical conditions averted by reducing such
pregnancies, but this will be only a very small part of the overall
picture of gains in well-being brought about.
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Stakeholder Section Comments Response
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MRC General Related to the concerns expressed in 2), there was a meeting at Noted.
NICE (in May?) which was about how to conduct economic
evaluations as part of the NICE HTA process now that public health
was being brought under the NICE remit. There was no particular
consensus on how to do this but a lot of concern was expressed
about 'shoehorning' evaluations of public health interventions into
the pre-existing NICE framework which the Reference Case is
largely representative of. This needs very careful consideration
here; a common alternative (proposed at the meeting referred to)
was simply to have all resource impacts (costs and cost savings)
expressed separately (and also netted out) on the cost side and to
have all impacts on well-being listed on the benefit side, and using
such a 'balance sheet' to aid a recommendation as to what to do.
Many would contend that such a 'balance sheet' approach would be
more reasonable than reducing everything to one number which
'gives an answer' This is a very worthwhile project, which will
highlight where there are current deficiencies in available evidence
and help inform future research calls for submissions to the MRC
SHHRSC. It is also to be hoped that it may ultimately lead to the
development of a Public Health Programme in Sexual Health Thank you.
HPA 4.6 One of the primary outcomes described is a reduction in the rate of The outcomes will be defined by the
STIs but there should perhaps be some clarification of how this will studies reviewed, and the data and
be defined and what data will be used to assess this. Are routinely measures of change which are used
collected national surveillance data to be used or will data be in those studies will be considered.
collected specifically at the local level? Data on STIs are only
routinely collected at the national level from GUM clinics. For
Chlamydia in particular, the rate of diagnosis in GUM clinics is not a
good marker of infection incidence, since many individuals may be
diagnosed outside GUM clinics, and many will not be diagnosed at
all. Much of the large rise in Chlamydia diagnoses in recent years
will have resulted from more asymptomatic people being tested.
Chlamydia prevalence would be a better measure of control of this
infection.
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Stakeholder Section Comments Response
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LIFE General LIFE’s caring services exist to offer free pregnancy testing and non- Noted.
directional counselling to women who find themselves unexpectedly
pregnant, as well as those struggling with pregnancy loss or
suffering psychological trauma from previous abortion experiences.
We also offer practical and financial support to women facing crisis
pregnancies or struggling to raise young children. Through our
housing programme we provide supported accommodation to
women made homeless by pregnancy. This has enabled us to grow
, through experience, in knowledge of the reasons for what many
prematurely engage in sexual activity and the health effects of this
behaviour. As a charity we take pride in our Educational and caring
services which are geared towards reducing sexually transmitted
infections and under 18 conceptions. Our work in these sectors has
grown to meet demand in recent years for holistic and wholesome
sex and relationships education (SRE) This particular submission
will give LIFE’s proposals for how people involved in delivering one-
to-one sexual health interventions should advise or inform whose
who are accessing the service. Our recommendations are based
upon our own experiences from working in the relevant filed which Thank you.
we trust will be if benefit to NICE, the government and wider
society.
LIFE Contraceptive Advice on contraception should be veracious if it is to accord with Thank you. The guidance will be
advice good practice and be truly beneficial to young people. We agree developed on the basis of the best
with the statement in Appendix A 4.2 that information provided available evidence that most
should be “basic, accurate and unambiguous” (Ellis and Grey, effectively answers the questions,
2004). rather than relying on a predetermined
With reference to published material from government sponosr4ed view of what is available.
bodies and the contact of previous NHS campaigns Life believes
that young people have been misled and misinformed on several
specific issues.
1) When one offer information and advice on sexually transmitted Noted.
infections (STI’s), making generalisations in inaccurate and
irresponsible. An important fact to iterate is that STI’s can be
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Stakeholder Section Comments Response
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contracted in different ways. For example, HIV can only be passed
on via blood, semen and vaginal fluids, where as genital warts
(Human Virus) can be contracted via skin-on skin contact. This is a
crucially important point to make because young people are
frequently being given the false impression that using a condom
and practising ‘safer sex’ will protect them from the infections.
Currently the NHS website (www. playingsafely.co.uk) mentions the
above fact in small print, however, the prominent banner which
reads “Its your future. Use a condom” has the effect of seriously
misleading young people. WE suggest that in one-to one advice
that is given to young people it should be stressed that using a
condom will not offer protection against STI’s passed on via skin- Thank you for this point.
on-skin contact (e.g. Genital warts & Genital herpes). Of a patient is
not made consciously aware of this fact then they are putting their
own health and the health of others at serious risk.
2)Many young people are routinely misinformed about emergency
hormonal contraception (EHC).While there may have been a
change of opinion with regard to the beginning of human life in this
country, many people still hold fast to the principle that human life
begins at fertilisation (conception). Forms of EHC such as Levonelle
(morning after pill) are marketed as ‘emergency hormonal
contraception’ when in fact the drugs can have the effect if causing
a spontaneous early abortion through ejecting a fertilised ovum
from the mother’s womb. It should be incumbent upon those who
deliver one-to-one interventions that they describe how EHC
actually works and that an embryo, if conceived, will be discarded
as a result of taking the drug. We treat thousands of women every
year who suffer from psychological illness because of a previous
abortion. Many are affected once they face fertility problems
because they realise that their past conceptions would now be
welcome and are regrettably irretrievable. It is irresponsible to
withhold or under-emphasise exactly what taking emergency Noted.
hormonal contraception (EH) entails. We stress, information should
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Stakeholder Section Comments Response
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be basic, accurate and unambiguous
3) We are actively assisting young people in the free service that
we provide for the. Our comprehensive support programme of
pregnancy testing, counselling, supported accommodation, free
baby clothes and equipment is fee of charge for all to access. If
young people are made aware of practical alternatives to abortion
and the fact that they will receive, free of charge, physical, practical
and emotional support, they are less likely to feel pressured into
having an abortion as’ their only choice’. They will be given greater
time and opportunity to make a choice they can live with. If one is
aware of free and accessible alternatives to abortion the will not feel
coerced into making a rushed decision and thus putting their
psychological health at risk. This will be of benefit to young people
putting people as they will not feel coerced into a decision they are
uncomfortable with. This is also the case with regard to prenatal
screening: young people should be provided with information about
our ‘Zoe’s Place’ baby hospices, which provide 24 hour palliative
and respite care to babies with severe disabilities that are routinely
diagnosed via screening in utero. We would suggest that hose
delivering one-to-one intervention (particularly a pregnancy testing
service) make young men and women aware of the service that Noted.
LIFE provides as a priority to achieving optimum standards of
healthcare.
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National Chlamydia General I am concerned that there is the age range for unintended Our aim is to consider all elements of
Screening Programme conceptions but not for the STI’s. Lastly, with my Faculty Family the scope and we will not privilege
Planning hat on, I would like assurance that this document will not any particular section of it.
become just STI’s & HIV with the contraceptive bit minimal. It would
help in the document if STI’s were not always mentioned first.
Afterall, c for conceptions comes before S for STI or H for HIV
Genito Urinary Nurses General The document does not appear to consider confounding Confounding variables and links will
Association variables associated with risky sexual behaviour such as the be considered as they arise in the
use of alcohol and/or drugs literature reviewed.
The link between acquiring an STI and the increased risk of
acquiring HIV.
The link between unintended pregnancy and the increased risk
of acquiring an STI including Chlamydia.
The significant interventions that occur in G U Medicine (GUM) Interventions in GU will be included.
departments, in terms of advice about the use of condoms,
prevention of acquiring STIs, prevention of conception and the
public health issues related to partner notification, which are
initiated and undertaken by health care professionals in GUM
often when an individual attends the department/s for either a
standard STI screen or screening for HIV and/or hepatitis B.
During the consultation a sexual history (SH) is taken, one of
the rationales behind taking an in depth SH is to identify high
risk sexual behaviour, then to either offer an intervention or to
refer to another HCP to develop strategies to reduce the risk of
the acquisition of STIs and HIV.
Finally there were 1.5 million appointments made in GUM The interventions given at the time of
departments in England during 2004, a significant number of these screening or testing will be
attendances will have been for standard STI screens, which is to be considered. It is only the screen/test
encouraged, which include the screening for HIV, syphilis and if itself which will not.
appropriate Hepatitis B. We believe it will be extremely short
sighted to exclude the many interventions undertaken to decrease
the incidence of STIs during these consultations
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Sigma research Guidance title The title is imbalanced. If the assessment is about chlamydia make Noted. It is not our intention to
it about chlamydia. If it is about all STIs do not privilege chlamydia. privilege any particular aspect of this
A nodding reference to ‘other STIs’ only ensures they are not scope.
properly served. If this is ground-preparation to roll out chlamydia
screening do not forestall action on other STIs by suggesting that
this work has also been done.
Screening and other interventions do not reduce STI transmission
or conception. Interventions (should) reduce unmet needs or lacks
(eg. ignorance of infection, no access to treatment, weak or absent
interpersonal skills, ignorance of proper condom use, belief in STI
myths, being in an abusive relationship, etc.). No one intervention Agreed.
meets all needs so no one intervention could be expected to reduce
transmission in a population (even if given to everyone).
Mixed programmes of intervention may reduce rates in a
population. Perhaps the focus of the investigation should be on
mixed programmes rather than single interventions.
Perhaps the investigation should be of valid sexual health needs. Thank you for this point.
This is a political as well as empirical question.
It seems strange to lump together STI prevention and This is a helpful clarification.
conception prevention without mentioning unprotected
intercourse. Perhaps the focus should be on ‘Programmes to
reduce unprotected intercourse’ through the dual goals of
reducing intercourse and increasing condom use when
intercourse occurs
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Sigma research Background “The guidance will provide recommendations for good practice
that are based on the best available evidence of effectiveness,
including cost effectiveness.”
The assessment should not be limited to effectiveness. Planners Cost data will be considered where it
also need to know about the cost of different interventions, the is available.
feasibility of interventions in different settings, acceptability of
interventions to different target groups and bias in access to
interventions by different target groups (which is acknowledged in
the specification of under eighteen and vulnerable and at risk
groups).
“The guidance will support measures to achieve the government
targets for improving sexual health and reducing the rate of
under 18 conceptions.”
Could be more specific about who, exactly, this guidance is for. Please refer to section 4.7 in the
The assessment could usefully establish what are valid sexual scope for details of who the guidance
health needs for PCT funded interventions/programmes to is aimed at.
address? Interventions should then be required to demonstrate that Noted.
they address these specific needs.
“This guidance…will focus on those which are defined as one-to-
one or face-to-face interactive interventions.”
Face-to-face interventions can also occur in groups and so are not Thank you.
co-terminus with one-to-one interventions.
Sigma research The need for The number of infections is not evidence of the need for guidance. Thank you for this clarification.
guidance Evidence of need would be service planners and providers being
ignorant of (a) what valid sexual health needs are, (b) which of
those needs are commonly unmet in their local population and
which subgroups in the population have many needs unmet (ie. are
vulnerable to sexual ill-health), and (c) which interventions can best
meet those needs for the largest number of people with the greatest
degree of equity.
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Sigma research Inequalities in “The highest burden of sexual ill health is borne by gay men,
sexual health some black and minority ethnic groups, women and young
adults.”
The list seems to exclude only straight White men aged over 25 (ie.
Noted.
it excludes only about 30% of the population). It makes little sense
to say the highest burden of sexual ill health is born by 70% of the
population.
“Individuals and groups with the greatest need for sexual health
services are also those least likely to be able to access them...”
This underlines the need to know about the access bias in Agreed.
interventions rather than simply their effectiveness.
“In 2003, of newly diagnosed STIs among men in the UK, men
who have sex with men (MSM) accounted for 56% of HIV
infections”
This is deeply misleading in the context of prevention. MSM Thank you.
account for about 84% of all HIV infections acquired in the UK
(HPA, Focus on Prevention, p.44) and an even higher proportion of
infections acquired by men in the UK.
“Some of the UK’s black and minority ethnic populations are
disproportionately affected by poor sexual health.”
African and Caribbean people tend to have higher rates than the We will examine the wording.
White majority while Asian and Chinese people tend to have lower
rates. Concurrency of sexual partners (‘unfaithfulness’) and/or
having partners who are non-monogamous is probably important
here as well as access to services, and intra-network sexual mixing.
The scope could be more specific rather than say ‘some of the UK’s
BME populations’.
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Stakeholder Section Comments Response
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Sigma research Trends. You could also mention that condom use increased between 1990 Noted.
and 2000 but not sufficiently to off-set infection exposures due to
partner numbers.
You could say that the average length of time people have Noted.
undiagnosed infections has probably increased.
It is problematic (and heterosexist) to list sex between men per se Noted.
as a ‘risk behaviour’ when sex between men and women per se is
not also listed. To do so is over-determined and suggests that
reducing sex between men should be a population level goal to
reduce STIs. Sex between men is not a risk behaviour, certain
sexual acts between men are.
NSAAL suggests sex between women has become more common Noted.
also (to a greater extent than sex between men).
The increase in HIV diagnoses in recent years has been very much Noted.
due to increases in people with HIV moving to the UK, especially
from Africa.
Sigma research “professionals and others involved in the delivery of one to
4.1. one direct sexual health interventions“
It would be useful to be more specific about who you mean by this. Noted.
Rather than ask how these professionals can bring about (i) the Thank you for this point.
reduction of the incidence of STIs and (ii) the reduction of the rate
of teenage conceptions especially with vulnerable and high risk
groups, it would be better to ask how they can reduce the unmet
sexual health needs of their clients.
There seems to be a tension between the intervenors being Noted.
‘professionals’ and them coming from a wide-range of agencies and
possibly being unpaid.
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Sigma research 4.2 Generally I would not recognise these as ‘interventions’ as they do An interesting distinction.
Interventions not contain the minimum information (objectives and methods,
settings, aims and targets) to warrant being called such. Most of
them are methods, not interventions. None specify a setting, target
or aim.
‘Providing information’ through talking is a method. The aim is
usually an increase in knowledge.
‘Screening’ can mean simply asymptomatic testing of an individual;
more conventionally though it means doing this for a high proportion
of a specific population, so usually screening does not refer to an
individual intervention by a population level intervention. The aim is
usually an awareness of the presence of infection. [Screening is Thank you for this clarification.
rarely done alone – I think what you are referring to is ‘screening
and treatment’ whose aim is awareness of infection and access to
treatment drugs – the overall goal being reducing the length of time
people have undiagnosed infection].
‘Brief advice’ through talking is a method. The aim is usually that Noted.
the target knows what the advisor thinks they should do. (Often
indistinguishable in practice from ‘providing information’.)
‘Providing condoms’ is a method. The aim is usually having Noted.
condoms.
Counselling and cognitive behavioural therapy are not the same Agreed.
thing and one is not a subset of the other.
‘Counselling’ through talking is a method carried out by qualified Agreed.
counsellor. The aim is multifaceted, usually including clarity about a
situation, awareness of a range of options, belief in the possibility of
change, etc, as well as increases in knowledge and awareness.
‘Cognitive behavioural therapy’ is a method carried out by chartered Noted.
75
psychologists. The aim is usually an ability to insert a thought
between a desire and an action.
‘Skills development’ is an aim not an intervention. The methods Agreed.
Stakeholder Section Comments Response
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Sigma research General Targets: Under 18s
Objectives: Advise on prevention of contraception STIs including:
the range of preventative methods, including emergency hormonal
contraception and condoms.
Distribute condoms along with advice.
Settings: At pregnancy testing services, termination services and
antenatal services;
NHS and non-NHS; schools; mobile clinics (vans); streets.
Aims: Targets know the potential and limitations of the range of
preventative methods and have access to condoms
Objectives: When someone is diagnosed with an STI locate their
sexual partners and notify them that they may have been exposed
to an STI and refer them to testing and treatment services. Either:
provider notifies partners; or Index patient notifies partners; or
provider notifies partners if index patient has not done so within an
agreed period of time (known as contract or conditional referral).
Settings: NHS and non-NHS; schools; mobile clinics (vans); streets.
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Sigma research General Targets: 16–25 year old men and women
Objectives: Test for chlamydia opportunistically
Settings: Non-GUM; NHS and non-NHS; schools; mobile clinics
(vans); streets.
“The guidance will not cover an assessment of the efficacy of
individual contraceptive methods.”
The guidance will not include the sensitivity and specificity of
diagnostic tests but will include interventions in which those tests
are used (screening). Although the guidance will not include the
effectiveness of individual methods, it could include interventions in
which they are deployed – there will be differences in feasibility,
cost, access, acceptability, need, effectiveness and efficiency Noted.
between (eg.) a GP prescribing contraception to under 18s from a
family practice and one going into schools to do so, or (eg.) free
condoms distributed to under 18s through a sports centre or
through a mail-order service advertised in teen-magazines.
“Included in the guidance will be a consideration of the evidence Agreed.
of the effectiveness of the above interventions as perceived by
the people offered them.”
While individual members of the target group are well placed to say
whether or not the intervention was effective for them personally, Agreed.
they are not qualified to say whether the intervention worked for
others. It is also important to distinguish whether people found the
intervention acceptable from whether or not it brought about its
intended change. Evaluations often mistake acceptability for
effectiveness. The target group claiming the intervention ‘worked
well’ is not the same thing as it being effective.
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Sigma research 4.3 No rationale if offered in the scope for the inclusion or exclusion of That is not the intention.
Interventions particular groups of intervention. There is a danger of this piece of work
which will not being seen as an exercise in justifying the role out chlamydia screening.
be inlcuded Interventions which will not be included:
Sigma research 4.4 Populations This guidance will cover the whole population. Particular
reference will be given to those groups who are at the greatest
risk of STIs and teenage pregnancy and will include: MSM, some
black and minority ethnic groups, young people, particularly
those affected by poverty and social exclusion and have low
educational achievement, and those in and leaving care, plus
sex workers and refugee and asylum seekers.”
Noted.
What is the rationale for this catchment? The groups most affected
by (eg.) HIV and unintended pregnancy are very different. The
scope starts with and is organised around methods (face-to-face,
one-to-one), but here seems to realign itself to population groups.
Sigma research 4.5 “The interventions will be compared against each other and against
Comparators routine care where the data are available.“
But the interventions are not attempting to do the same things for the This point will be considered when we
same people. How can you compare (1) advice, chlamydia screening undertake the economic analysis.
and referral for under 25 year old heterosexuals in sports centres to
raise awareness of chlamydia and inform those with infection, with
(2) condom distribution for gay men at gay pubs and clubs to
increase access to condoms, with (3) individual mentorship and
training for people with learning difficulties at their homes to raise
sexual assertiveness skills?
THE ASSESSMENT WOULD BE MUCH MORE LIKELY TO This group will be included.
ACHIEVE A USEFUL OUTCOME IF IT FOCUSSED ON
INTERVENTIONS FOR UNDER 18 YEAR OLD HETEROSEXUALS.
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Sigma research 4.6Outcome “The aim of STI and teenage pregnancy prevention interventions
measures may be defined as any activities which proactively and positively
support the sexual and emotional health and well being of
individuals, groups, communities and the wider public through the
reduction of the incidence of sexually acquired infection and
unintended conceptions.”
The definition is over-determined and under-specified. The aims of Noted.
interventions cannot be defined as the activities of the interventions
as in the above sentence.
The aim of interventions is to reduce unmet needs; unmet needs
influence (but do not determine) behaviours; behaviours influence
(but do not determine) conceptions and infections; conceptions and
infections influence (but do not determine) health wealth and human
happiness. The ‘aim’ of STI/conception interventions could
therefore be set at an increase in health, wealth and human
happiness. But this would be a bit silly. As would setting the aim of
the intervention as a reduction in STI/conception rates. We can
conceptualise five levels of intervention/programme action:
STI and teenage pregnancy prevention interventions
Intervention objectives: Proactively and positively act, in order to,
Intervention aims: Reduce unmet prevention needs (eg. knowledge,
skills, access to resources, peer norms, etc), in order to,
Programme aims: Reduce population level conception and STI
transmission related behaviours (unprotected heterosexual vaginal
intercourse, taking antibiotics when infected with ST bacteria, taking
emergency hormonal contraception, etc), in order to
Programme goals: Reduce [specific population] rateconception and
STI transmissions, which,
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Government aims: Increase health [eg. less PID, sterility, AIDS],
wealth [eg. lower treatment costs, more productive workforce] and
human happiness [eg. less STI/conception related misery].
Stakeholder Section Comments Response
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Sigma research 4.8 Research How can one-to-one interventions contribute to the reduction
Questions of STI’s and unintended teenage conceptions?
By reducing unmet STI/conception related needs.
What are unmet STI/conception related needs?
This is the question the assessment could more fruitfully address.
The range of questions regarding the factors influencing Noted.
effectiveness of interventions at meeting their aims is very
appropriate but presupposes we know what valid STI/conception
needs are.
Sigma research 4.9.2 Economic evaluation method
Cost-effectiveness analysis with the Quality Adjusted Life Year
(QALY) as the health-related outcome measure will be adopted as
the primary measure for the economic evaluation of public health
interventions and programmes. This will ensure baseline
comparability within the UK healthcare sector and across the
Institute’s programmes.
The health gain from prevention interventions is determined We anticipate a number of difficulties
by the current and prospective level of an illness in a in the health economics (public
population – so it is not a solely function of the performance of health) strand.
an intervention (or programme of interventions). This is
fundamentally different from the assessment of the health gain
from clinical interventions. The value of any prevention or
clinical intervention is also related to the other interventions
currently being implemented and the relative national
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Stakeholder Section Comments Response
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Sigma research 4.10 Evidence I would be concerned that the diversity of questions being asked (if Noted.
for not narrowed) will leave little room for comparisons. The Medline-
consideration QALY approach is more suited to very narrow research questions
Sigma research 4.11 Outputs It would be useful to specify the objectives, aims, targets and most Noted.
importantly settings for each of these outputs/dissemination
interventions.
Genito-Urinary Nurses General The document does not appear to consider confounding variables The brief from the DH for this project
Association (GUNA) associated with risky sexual behaviour such as the use of alcohol was very broad. Time and resource
and/ or drugs constraints meant that the work had to
be made manageable. Where
confounding variables are mentioned
in the literature they will be
considered.
Genito-Urinary Nurses General The link between acquiring an STI and the increased risk of This risk has been acknowledged in
Association (GUNA) acquiring HIV the scope.
Genito-Urinary Nurses General The link between unintended pregnancy and the increased risk of This risk has been acknowledged in
Association (GUNA) acquiring an STI including Chlamydia. the scope.
Genito-Urinary Nurses General The significant interventions that occur in GU Medicine (GUM) The scope has been amended to
Association (GUNA) departments, in terms of advice about the use of condoms include one-to-one health promotion
prevention of acquiring STIs, prevention of conception and the interventions in GUM.
public health issues related to partner notification, which are
initiated and undertaken by health care professionals in GUM often
when an individual attends the department/ s for either a standard
STI screen or screening for HIV and/ or Hepatitis B.
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Stakeholder Section Comments Response
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Genito-Urinary Nurses General During a consultation a sexual history (SH) is taken, one of the Noted.
Association (GUNA) rationales behind taking an in depth SH is to identify high risk
sexual behaviour, then to either offer an intervention or to refer to
another HCP to develop strategies to reduce the risk of the
acquisition of STIs and HIV.
Genito-Urinary Nurses General Finally, there were 1.5 million appointments made in GUM This guidance will not cover testing
Association (GUNA) departments in England during 2004, a significant number of these and screening, other than for
attendances will have been for standard STI screens, which is to be chlamydia, however prevention
encouraged, which include the screening for HIV, syphilis and if interventions delivered at the time of
appropriate Hepatitis B. We believe it will be extremely short testing will be considered.
sighted to exclude the many interventions undertaken to decrease
the incidence of STIs during these consultations.
Royal College of General The Royal college of Physicians and the British Association for Thank you.
Physicians & The Sexual Health and HIV welcome the initiative to review the
British Association for evidence for effective interventions in the sphere of sexual health
Sexual Health & HIV and will provide appropriate input at each stage of the consultation
(Collectively) process.
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Stakeholder Section Comments Response
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Royal College of Section 1 Title Under the guidance title we suggest the addition of HIV after This has been added.
Physicians & The sexually transmitted infections, otherwise it is unclear whether HIV
British Association for is part of this guidance. The title would then read: ‘An assessment
Sexual Health & HIV of interventions (including screening) to reduce the transmission of
(Collectively) Chlamydia and other sexually transmitted infections (STIs, including
HIV), and to reduce the rate of under eighteen conceptions,
especially among vulnerable and at risk groups.’
The Short title would be: ‘Interventions to prevent sexually This has been added
transmitted infections including HIV and reduce under 18
conceptions’.
Justification: HIV is clearly a sexually transmitted infection and a
major threat to public health. Any assessment of the effectiveness
and cost-effectiveness of interventions must take into account the
direct impact on HIV incidence (through behaviour change) and the
indirect impact by reducing other sexually transmitted infections
which increase the transmissibility of HIV.
Royal College of Section 2 There is a lot of focus on young persons sexual health particularly The remit given to NICE by the DH
Physicians & The Background teenagers. It may not be within the scope of this guidance but specified that NICE look at under-18
British Association for reducing the rate of unwanted pregnancies across all age groups conceptions.
Sexual Health & HIV would be worthy of consideration.
(Collectively)
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Stakeholder Section Comments Response
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Royal College of Section 3 The There are some factual errors. On page 4 the document includes Noted. The scope will be amended to
Physicians & The need for the following statement: ‘there were more than 1.5 million clarify this.
British Association for guidance appointments made in genitourinary medicine (GUM) clinics and
Sexual Health & HIV 696,419 new STIs were diagnosed.’ It is essential that data from
(Collectively) the Health Protection Agency are used with care and are thoroughly
understood. The figure of 1.5 million refers to the number of
diagnoses (of all conditions, not only STIs) and other workload
measures including the number of screens carried out. Individuals
will be coded more than once in this system and therefore the
overall figure of 1.5 million does not reflect either individuals or
diagnoses. It would be advisable to rephrase this as follows: ‘Data
released on 30th June 2004 by the Health Protection Agency (HPA)
showed that, in 2004, 751,282 new diagnoses were seen in
genitourinary medicine clinics (GUM) in the United Kingdom, (UK),
an increase of 2% on 2003.’
*The bullet point on page 4 repeat the points in the table and could
be removed.
Royal College of STI Current STI surveillance data (this applies to information here and Noted.
Physicians & The Surveillance: in the outcome measures later in the document) are limited.
British Association for General Point Surveillance is based on returns from GUM Services, so if capacity
Sexual Health & HIV has been reached and patients attend other sexual health provides,
(Collectively) their information will not be collected. Surveillance of laboratory
data (reports of positive isolates) is also incomplete, and there is
currently no routine surveillance of STIs diagnosed in primary care
or other sexual health services outside of GUM.
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Stakeholder Section Comments Response
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Royal College of Suggest In view of the public health importance of HIV/ AIDS we think that Thank you.
Physicians & The additional this merits an additional subsection. The following may be useful
British Association for subsection on (from HPA)
Sexual Health & HIV HIV/ AIDS
(Collectively) ‘At the end of 2003 an estimated 53,000 adults aged over 15 were
living with HIV in the UK, 14,300 (27%) of whom were unaware of
their infection. Since the epidemic began in the early 1980s about
15,750 deaths I HIV infected individuals are known to have
occurred in the UK. Currently the number of people living with
diagnosed HIV is rising each year due to increased numbers of new
diagnoses and decreasing deaths due to antiretroviral therapies.
There were 6,606 new infections diagnosed in the UK during
2003, 58% (3801) of these were amongst heterosexuals, with
gay and bisexual men accounting for 26% (1735).
The increase in number of newly diagnosed infections is the
result of a combination of factors, but is largely contributed to by
the migration of people from areas of the world where there is a
high prevalence of HIV, such as sub-Saharan Africa.
The number of new infections diagnosed in gay and bisexual
men is expected to be the highest for over 10 years, with 1,735
diagnoses reported so far for 2003.
In addition, the number of heterosexual HIV diagnoses likely to
have been acquired in this country has increased from 139 in
1998 to 341 in 2003.’
Under consequences of poor sexual health there are many that
have been omitted, including complications in men, (e.g. sexually
acquired reactive arthritis and epididymitis), chronic pelvic pain in
women, stigma and the breakdown of relationships, intimate partner
violence, mortality from HIV, congenital syphilis and intrauterine
death, cardiovascular and neurological complications from
untreated syphilis. 85
Stakeholder Section Comments Response
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Royal College of Inequalities in This section is generally well written and highlights the issues. Noted.
Physicians & The sexual health However, within the scope, most of theses highlighted areas will not
British Association for be covered. There are targets for offer and uptake of HIV screening
Sexual Health & HIV and targets for Hepatitis B vaccine uptake in higher risk groups with
(Collectively) hard outcome measures as part of the National Strategy. HIV is the
most expensive STI in terms of public health impact.
The bullet point on men who have sex with men is incorrect (see
data above – MSM account for only 26% of newly diagnosed HIV in
2003). MSM account for 25% of gonorrhoea in men, and 54% of
syphilis in men.
Royal College of Trends Under this section it is essential to point out that data on STI trends Thank you. We are aware of these
Physicians & The are becoming increasingly difficult to interpret as service provision complexities.
British Association for is shifting more to primary care, yet there are no adequate
Sexual Health & HIV surveillance mechanisms to capture this. It would also be helpful to
(Collectively) point out that an increase in the numbers of STI diagnosed may be
a positive outcome – for example the numbers of cases of
Chlamydia will rise substantially in the coming years due to the
increased availability of screening and the increased sensitivity of
diagnostic tests.
At the end of the paragraph on sexual behaviour it may be useful to
add that the proportion of men reporting having paid a woman for
sex in the previous 5 years has increased from 2.0% in 1990 to
4.2% in 2000.
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Stakeholder Section Comments Response
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Royal College of Section 4 The Opportunities for one – to – one We are aware of these complexities
Physicians & The Guidance and an important part of the NICE
British Association for The intervention considered is the delivery of one to one direct public health guidance is the
Sexual Health & HIV access within a consultation or other interaction. It is crucial to look involvement of the Implementation
(Collectively) at the different sites where one to one interventions take place, and Team during development to address
how changes to service provision and delivery may be altering this. these issues.
For example, the tragedy of services being unable to cope with
demand is that there is potential for less emphasis on health
promotion, i.e. less time for precisely the interventions that the
consultation is addressing. People found to have an STI or HIV
may receive treatment but not have health promotion due to lack of
clinic resources. Many patients may not get a follow- up visit –
these are increasingly done on the telephone. To our knowledge
this change in service provision has not been evaluated in terms of
partner notification outcome or health promotion opportunities. At
the time of attending a service and certainly receiving a positive
sexually transmitted infection diagnosis ‘patients’ are more
receptive to health promotion messages. Some health care
workers within the same setting have better skills. Application in
different settings may also have an impact e.g. a nurse
performance in GPs may differ from the sexual health specialist
nurse. These should be considered as part of the synthesis of
research evidence.
Patients who have a sexual health screen, in GUM or elsewhere,
may also not re-attend for results. Pressure to cope with increased
demand has led some GUM clinics to operate a ‘ no news is good
news’ policy, where patients are old that they will be contacted only
if there is an abnormal result. Again this reduces the opportunity for
face – to – face intervention and post- test counselling.
We therefore think that it is essential to consider the impact of
changes in service on the ability to deliver one – to – one
interventions. There is little point in finding out that a ten minute
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counselling session or condom skill intervention is effective if the
clinics are structured only to offer a rapid diagnostic and treatment
services with no time for these additional functions.
Stakeholder Section Comments Response
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Royal College of Outreach It is unclear what kind of outreach services will be included within Outreach services will be considered.
Physicians & The Services this review. Outreach has been shown to be an important way of The specific kinds will depend upon
British Association for reaching some vulnerable populations either with health promotion, the literature available.
Sexual Health & HIV advice and condom distribution, or with screening, or with full
(Collectively) clinical services. Outreach services can be expensive and often
take many years to show an impact but clearly need to be
considered as they provide key opportunities for effective one – to –
one interventions.
Royal College of Section 4.3 The Scoping document states that standard sexual health screens One-to-one interventions delivered at
Physicians & The in GU departments and screening for HIV, syphilis and hepatitis B the time of screening will be
British Association for infection will not be included. We are very concerned about this. considered – the screening itself will
Sexual Health & HIV There are over 750,000 sexual health screens carried out in GU not.
(Collectively) Clinics each year and each of these provides the opportunity for
one – to – one intervention to reduce further risk. There is a large
body of international research on the impact of HIV and STI testing
and counselling and it would be odd to exclude this from the scope.
The definition of a standard sexual health screen is required. Many
so-called asymptomatic patients inevitably turn out to have some
unrecognised symptoms on questioning and so should be included.
It is problematic differentiating between testing and ‘screening’.
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Stakeholder Section Comments Response
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Royal College of Screening The scope should include the possible negative consequences of Noted.
Physicians & The outside the expanded screening outside of GUM, where single tests may be
British Association for GUM carried out. For example the Chlamydia screening programme
Sexual Health & HIV does not include routine screening for HIV and other STI as
(Collectively) recommended in GUM settings. HIV testing has been undertaken
in non-health care settings and effectiveness and value for money
so should be included. Single test approach, when it is known that
other STIS are multiple, should be part of evaluation.
The question of the effectiveness and efficacy of Chlamydia
screening is linked to that of HIV testing – in particular, the rate of
undiagnosed HIV. Reducing the rate of undiagnosed HIV is a
priority first set in the National Strategy for Sexual Health and HIV.
There is evidence that widening of Chlamydia testing outside the
GUM setting may tend to reduce the early diagnosis of HIV.
Chlamydia is known to be more common in individuals of some
black ethnic minority groups, which are also at increased risk of
HIV. Data from the NATSAL study showed that patients diagnosed
with Chlamydia in primary care were mush less likely to have had
an HIV test than those tested in the GUM setting. If an increasing
proportion of Chlamydia tests take place outside the GUM setting,
and are not accompanied by HIV testing, it is possible that a smaller
proportion of HIV infected individuals will be diagnosed through
early voluntary counselling and testing.
It is therefore essential that the evaluation of Chlamydia testing in
non-GUM settings should take into account the tendency of a
particular model of care to increase, or to decrease, the rate of
undiagnosed HIV and not to regard this as a separate issue.
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Stakeholder Section Comments Response
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Royal College of Pharmacy A ‘Chlamydia Pathfinder’ pilot ‘Screening’ programme has recently Noted.
Physicians & The testing for been announced in which Boots will be undertaking Chlamydia
British Association for chlamydia Screening. Although an evaluation tender has been published,
Sexual Health & HIV details of the project have not been widely released. It would be
(Collectively) useful to include any evaluation of the one – to – one interventions
associated with this scheme.
Royal College of Post- Exposure PEPSE involves the unlicensed use of HIV medication to protect Evaluation of PEP as a public health
Physicians & The HIV exposed, or potentially exposed, individuals against HIV after prevention intervention will
British Association for Prophylaxis sexual exposure. New guidelines have been produces, which are considered.
Sexual Health & HIV after sexual the subject of some controversy in the UK. Some GUM clinics are
exposure
(Collectively) spending a significant proportion of their budgets on this treatment
(PEPSE)
to prevent the transmission of HIV (an STI). Evidence for its
effectiveness is both incomplete and controversial. The Terence
Higgins Trust have undertaken a publicity campaign to promote the
use of PEPSE. The evidence base around its effectiveness in
preventing HIV infection is controversial. There maybe negative
public health gain in that unsafe sex, already widely practised, will
increase as infected individuals may adopt more risky behaviour.
Evaluation of the effectiveness and efficacy of PEPSE, with Evaluation of the clinical effectiveness
evidence based recommendation taking into account public health of PEPSE is outside the remit of the
outcomes as well as clinical data, is an urgent and important topic Centre for Public Health Excellence
for review within the scope for the review required by the and would need to be considered by
department of health. This is an expensive one to one intervention the clinical teams at NICE.
in terms of costs of drugs and time with patients. This is not funded
by commissioners and is adding to HIV funding deficits. This
should be included in the scope.
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Stakeholder Section Comments Response
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Royal College of Public and On Page 9 it is stated that consideration by people offered the Noted.
Physicians & The Patient intervention will be undertaken. Engaging those diagnosed with
British Association for Involvement sexually transmitted infections other than HIV has proved
Sexual Health & HIV problematic. Some patients actually refused to see health advisers
(Collectively) as they do not want to address their sexual behaviour and risks of
transmission or infection. The evidence base available is I think
lacking. Some soft data may be available e.g. patient satisfaction
within specific services. Patients who may speak up are those who
are badly effected by complications e.g. infertility. This will
inevitably be a very biased sample. Clearly this is an important
area to address but challenging.
Royal College of Section 4.5 Routine care needs to be defined Noted.
Physicians & The
British Association for
Sexual Health & HIV
(Collectively)
Royal College of Section 4.6 Primary Health outcome should include, where possible, re- Thank you. The outcomes reported
Physicians & The Outcome infection rates (maybe possible to do this by the proxy measure of will largely be determined by the
British Association for Measures the proportion of people with an STI who have had one before) and available literature.
Sexual Health & HIV repeat pregnancies and/ or terminations or pregnancy. Few studies
(Collectively) have been undertaken looking at re-infection rates certainly in the
UK. Previously diagnosed sexually transmitted infections is
routinely collected albeit in paper form at GUM Clinics. This may be
a useful indicator.
HIV infection in people who have had previous negative tests is
also a key indicator, since they will have had the opportunity for
intervention.
There are problems with using reduction in the rate of STIs as an
outcome measure. (See above). It is important that sexually
transmitted infections are identified and identifying more infections
may be a better PH outcome. The availability of different diagnostic
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tests in different settings also has an impact on this outcome
measure.
Appropriate and timely treatment is an important health outcome.
Changing sexual behaviour is difficult. How some of the
intermediate outcome measures will be obtained e.g. intention to
use condoms is challenging. Some are very ‘soft’. Access to rapid
diagnosis and treatment given the difficult of changing sexual
behaviour is a key component in reducing transmission of infection.
And this is an intervention on a one basis that must be included.
Regductions in numbers of partners is a difficult outcome to relate
to the interventions, since most interventions stress safer sex rather
than partner reduction is an unlikely outcome, whereas consistent
and effective use of condoms is more appropriate.
One outcome that may be important relates to the circumstances of
first sexual intercourse, not merely its timing. The objective of many
interventions is for young people to make informed choices about
when, with whom and in what setting they should have sex. Too
many young people feel pressured into earlier or inappropriate
sexual activity.
Royal College of Section 4.8 It is important that the quality and consistency of any interventions Noted.
Physicians & The Research is included. CBT may be effective in some small studies but
British Association for Questions ensuring consistent quality in the delivery in practice can be very
Sexual Health & HIV difficult.
(Collectively)
While this guidance is unlikely to be able to answer it, the question
of measuring the impact of new initiatives, such as the Chlamydia
screening programme, at the population level must be a priority for
the future.
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