Sexual health–a Health of the Nation failureBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7096.1743 (Published 14 June 1997) Cite this as: BMJ 1997;314:1743
- Michael W Adler, professora
- a Department of Sexually Transmitted Diseases, University College London Medical School, London WC1E 6AU
- Accepted 13 May 1997
The Health of the Nation initiative was launched five years ago in July 1992 with the publication of a white paper.1 The five key areas–coronary heart disease and stroke, cancers, mental illness, accidents, and HIV/AIDS and sexual health–were given priority and specific objectives, and targets were set. For HIV/AIDS and sexual health the objective was to reduce the incidence of HIV infection and of other sexually transmitted diseases, with specific targets related to gonorrhoea and conceptions among teenagers. These specific targets were to reduce the incidence of gonorrhoea among men and women aged 15-64 years by at least 20% by 1995 (from 61 new cases per 100 000 population in 1990 to no more than 49) and to reduce the rate of conceptions among girls aged under 16 by at least 50% by the year 2000 (from 9.5 per 1000 girls aged 13-15 in 1989 to no more than 4.8). A closer examination of the incidence of sexually transmitted diseases, HIV infection, and conception rates suggests that there is still a long way to go.
Although the target for gonorrhoea has been achieved ahead of time (fig 1), the incidence was declining so rapidly before the target had been defined, and continued to do so afterwards, that it was almost certain to continue declining without any new initiatives. The decline was therefore probably a poor indicator of effective health promotion and improved service delivery by departments of genitourinary medicine.
Caution is needed when claiming success for the Health of the Nation programme. New cases of gonorrhoea among homosexual men have not shown a rapid decline (fig 2).2 Cases of gonorrhoea seen in genitourinary medicine clinics in the Thames regions, reported as acquired through homosexual contact, declined in 1992 and 1993 but rose by 26% in 1994 and by a further 9% in 1995. Outside the Thames regions, levels have remained fairly stable. Some cases of gonorrhoea will be acquired through non-rectal and “safe sex”–namely, orogenital contact–and thus the number of cases of gonorrhoea alone, without site of infection, may mask adoption of safer sex practices. However, the numbers of cases of genital warts, chlamydial infections, and herpes also acquired through homosexual intercourse have not declined markedly between 1990 and 1994. The number of cases of genital warts increased in the Thames regions between 1990 and 1995 by almost 50%, from 572 to 853. Chlamydial and herpes infections have not shown a dramatic decline. Ascertainment bias will be a problem in judgments of the altering rates and incidence for sexually transmitted diseases, and possibly particularly so for chlamydial infections, which have received considerable attention in the lay and medical press, leading to an increase in chlamydia screening. These trends, however, do not support there having been major alterations in sexual behaviour during the Health of the Nation initiative.
In 1996 a study carried out in six genitourinary medicine clinics (two in London and four elsewhere) showed that homosexual men, despite knowing that they were HIV positive, continued to practise unsafe sex.3 The proportion of homosexual and bisexual men with HIV infection and sexually transmitted disease who were aware of their HIV infection before the clinic visit increased from 40% in 1990 to 55% in 1993 (fig 3). The authors acknowledged that the targets for gonorrhoea as set in Health of the Nation have been achieved but commented that high levels of sexual ill health continued. They said that new targets for HIV prevention, particularly ones focusing on homosexual and bisexual men, are required.
Gonorrhoea also presents a public health problem among young people, especially young women and people from ethnic minorities. Young women aged 16-19 have higher incidences of gonorrhoea, chlamydia, and genital warts than other age groups and men, particularly in the Thames regions.4 Low and colleagues have highlighted the problem in ethnic minorities in a report of gonorrhoea in adults resident in the London Borough of Lambeth, Southwark, and Lewisham attending 11 departments of genitourinary medicine between January 1994 and December 1995.5 They showed that the high rates of gonorrhoea in 15-19 year old women (138 per 100 000) and in men (292 per 100 000), nearly three and six times greater respectively than the Health of the Nation target of 49 per 100 000. Rates of gonorrhoea were 12 times higher in black ethnic groups than in white people, with particularly high rates in black women aged 15-19 (1710) and black men aged 20-24 (1685). Low et al calculated that these high rates of gonorrhoea in non-white people rivalled those seen in poor urban areas in the United States.” It has been indicated earlier that low national rates of gonorrhoea conceal what is occurring among homosexual men. Likewise, Low et al have shown how such generic rates mask an inner city epidemic that is associated with poverty and ethnic group. Similar increased rates of gonorrhoea have also been found in Leeds, where age specific incidence rates in black men and women were considerably higher than in white people.6
Thus, even though it is claimed that gonorrhoea targets have been achieved, these are too crude to show that considerable levels of new infections are occurring in homosexual men and ethnic minorities, particularly in the Thames regions. Also, gonorrhoea is not optimal for monitoring behaviour as its incidence is susceptible to vigorous case detection and contact tracing.
Other sexually transmitted diseases
Other sexually transmitted diseases confirm that no real reduction has been seen nationally and among heterosexual and homosexual people. Once again, ascertainment bias could affect these trends.
In England in 1995 the three commonest conditions seen in genitourinary medicine departments were anogenital warts (first presentation; 51 260 cases), chlamydial infection (39 289 cases), and genital herpes (first attack; 27 065 cases). These conditions show hardly any change since 1988; in fact, both genital warts and chlamydial infection have recently increased slightly.
If these other sexually transmitted diseases are used as proxy measures of sexual behaviour, it seems that the incidence of sexually transmitted diseases as a whole has not declined and has even increased slightly. The only caveat to this is that routine national data can be subject to ascertainment or treatment bias, or both. Other markers might be used to obtain good trend data on sexual behaviour. For example, antibody to herpes simplex virus type 2 is strongly related to sexual lifestyle and could be a suitable objective, serological marker of patterns of sexual behaviour in different populations.7 This underlines the fact that no data exist on trends in sexual behaviour and that we are continually using proxy outcome measures.
AIDS and HIV infection
The white paper did not set any specific target in reducing the incidence of HIV infection. The reason for this was the newness of the epidemic, as well as uncertainty about which would be the most robust indicators. Although the number of reported cases of HIV infection has continued to increase since then, it gives no real sense of incidence or more recent changes in seroprevalence of HIV. National data of reported diagnosed AIDS and HIV infection give some indication of the year by year trends by means of exposure (table 1). These data show a decline in the proportion year by year of those infected by sharing injecting equipment and through homosexual intercourse, with a marked rise in infection among heterosexuals. Such trends must be interpreted with caution as they cover only those individuals who have opted to be tested or are presenting for care, or both. Despite this, the sheer volume of the new reports of cases of AIDS and diagnosed HIV infection is worrying. Altogether, 1862 cases of AIDS were reported in 1996, the highest annual total to date and 18% more than in 1995, when 1578 cases were reported. Likewise, 1996 saw the highest annual total to date of newly reported HIV infection (2986). The number of infections acquired through sex between men rose by 11% from 1474 in 1995 to 1634 in 1996–a considerable rise compared with previous years.8
A better indication of trends can be obtained from the unlinked anonymous HIV prevalence monitoring programme carried out in genitourinary medicine clinics and agencies for injecting drug users, and among pregnant women (table 2).9 HIV seroprevalence in homosexual men attending “high prevalence” genitourinary medicine clinics in the Thames region seems to be declining slowly (22.4 in 1990; 11.4 in 1995), although in the rest of the London clinics HIV seroprevalence among homosexual men has changed little. A more detailed study to explain the possible reasons for this decline in London was undertaken in one clinic. Much of the fall could be “accounted for by the changing pattern of care for HIV1 infected homosexual and bisexual men …. They have received care in specialist clinics alongside routine genitourinary medicine clinics and so are less likely to be tested for syphilis.”9 HIV seroprevalence in “high prevalence” clinics increased moderately from 1990 to 1995 both in heterosexual men (0.95% and 1.14% respectively) and in women. Among heterosexuals in other London clinics a similar increase has been found. This increase among heterosexuals is supplemented with data from the programme for anonymous testing of pregnant women–specifically, the infant dried blood spots (Guthrie test). This indicates a prevalence in inner London of 0.26% in 1995 compared with 0.14% in 1990 but unchanging low levels in the rest of England, with a prevalence of 0.12% for outer London (0.04% in 1990).
Even though the anonymous seroprevalence data show a decline in prevalence of HIV infection among homosexual men, this is not borne out by national data, new reports of HIV infection, or data from the national survey of prevalent diagnosed infections and mortality, which all show continuing substantial incidence of new infections, with the highest number of new infections occurring through sex between men.10 Thus the national data show continuing transmission. More detailed studies among homosexual men show no decline in HIV infection and sexually transmitted diseases.5 This is confirmed especially among young men (aged less than 30 years), in whom the incidence between January 1992 and April 1994 was 8.9 per 100 person years, compared with 7.5 between January 1988 and December 1989.11 These data, as with gonorrhoea, are contrary to the crude national statistics, which suggest a decline.
Conception rates and unwanted pregnancies
The 1989 rate of conceptions among girls aged 13-15 (9.5 per 1000 girls) used by the Department of Health as its base represented the highest teenage conception rate in Europe. Teenage conceptions have slightly decreased since 1989, resulting in 1993 in the lowest level (8 per 1000) since 1982. Unfortunately, the latest figures (1994) show an increase again, to 8.2 (fig 4). These trends make it hard to see how the target of 4.8 will be achieved by the year 2000. However, with a fall in the age of first sexual intercourse, the rate among sexually active teenagers may be declining.
In England there is considerable geographical variation, with the highest rate of teenage conceptions (15.9) among girls in Barnsley, Doncaster, and southeast London. In contrast, eastern Surrey has particularly low rates (3.9). Districts with high underprivileged area scores, inner city areas, and other urban areas are more likely to have high rates of teenage conception. Studies show that the highest level of teenage births occur to the most socioeconomically disadvantaged women. The Office for National Statistics has shown in a longitudinal study that teenage birth rates among manual social classes were three times higher than among non-manual classes.12 The reasons for unwanted teenage pregnancy are complex, with both socioeconomic factors and a failure in effective health education and contraceptive services for high risk girls playing a large part. It is thought that at least half of teenage pregnancies are unintended and 52% of conceptions end in abortion. Currently, Britain has the highest teenage birth rate in western Europe.
The Health of the Nation is an important public health initiative and has for the first time established an agenda and targets for improving the health of the general population. The current lack of success in relation to achieving “good” sexual health is unfortunate, but such failures can indicate how we need to improve our approaches and strategies.
Health education and promotion have to be the foundation for improving sexual health. The high level of sexually transmitted diseases among young people, some homosexual men, and ethnic minorities, and such high rates of teenage pregnancies, are indicators of both the failures and the way forward. Effective health education needs a two pronged approach, aimed in a general way at all young people and also at those identified as at particularly “high risk.”
Young people have a right to sound, unbiased information that allows them to make informed choices before they have sexual intercourse. We have the highest teenage rate of conception and termination in Europe, illustrating the failure of our education programmes. The 1993 Education Act has created anomalies around sex education and contraceptive advice in schools, which present barriers to the dissemination of information to all young people. Pupils have their own rights with regard to education about sex and personal relationships, and sex education must become part of the national curriculum. That the provision of sex education in schools will bring forward the onset of sexual experience is not borne out by the evidence.13
Attempts to withhold information on the basis of a particular agenda of family values and morality have resulted in large numbers of young people not protecting themselves against sexually transmitted diseases and unwanted pregnancy. Socioeconomically disadvantaged people have the highest morbidity in relation to sexual health. Why should teenage birth rates be three times greater among manual social class groups than among non-manual groups? As with cancer, depression, heart disease, and other diseases, this will only be understood and tackled once health is approached across government departments and the effect of poverty and social alienation on health are acknowledged.14 Focused and targeted education that recognises the needs of specific groups is also required. The Department of Health has recognised the problem of continuing high levels of sexually transmitted diseases and HIV infection in homosexual men, especially young ones, and has commissioned the Terence Higgins Trust to mount extensive campaigns. Local health promotion units in London also recognise the need for targeted health promotion for this group. Less recognised and easily solved is the issue of high levels of sexually transmitted diseases in certain ethnic minorities; we need to talk about what is happening without apportioning blame or stigmatising groups in society. The needs of ethnic minorities with regard to sex education and services for sexually transmitted diseases and HIV infection is of urgent concern and should be acknowledged, described, and tackled. Delivery of general health education to all young people must incorporate a recognition of the considerable influences of poverty and social deprivation on health.
Primary prevention through education and health promotion must be complemented by the provision of services for sexually transmitted diseases and contraception. These services have been largely transformed as a result of extra resources made available through ringfenced money for AIDS/HIV services; recognition by the Department of Health of the pivotal role played by the specialty in caring for patients with sexually transmitted diseases and HIV infection; and one to one health promotion and condom distribution. It is encouraging that clinics are used by a wide demographic spectrum of the population and that they attract those at high risk of infection.15 The service has been at the centre of providing clinical care and health promotion for those with HIV infection and AIDS and those uninfected but with concerns and requiring testing. The decision to disaggregate services for HIV infection and AIDS is likely to destabilise this model, which is based on open access and not area of residence–an important ingredient of offering rapid, open door services to clients.
The Health of the Nation has so far failed to deliver. The agenda for success is fourfold. Firstly, it requires clear, easily obtainable sex education and contraceptive advice for young people before they start to have sexual relationships, with the ability of schools to give this without fear or hindrance from the Department of Education. Secondly, continuing and increasing programmes are needed for particular groups such as young homosexual men and certain ethnic minorities. Thirdly, governmental interdepartmental approaches should recognise that “poor” sexual health can be driven by poverty and young people's sense of social alienation and worthlessness. Finally, the infrastructure of a good service for sexually transmitted diseases exists but needs to be protected, nurtured, expanded, and funded.
Conflict of interest: None.