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On the Brink: The Hidden Crisis in Sexual Health

sexual health
sexual health

Johnathan McShane

Chair of Terrence Higgins Trust and former Cabinet Member for Health, Social Care and Devolution, London Borough of Hackney

Chair of Terrence Higgins Trust and former Cabinet Member for Health, Social Care and Devolution at London Borough of Hackney, Jonathan McShane, highlights how sexual health services are “at breaking point”.

 This time a year ago, sexual health services were dealing with a new emergency, one which went largely unseen by the wider health system thanks to the tireless work of a dedicated group of clinicians. Between May and November 2022, more than 3,700 people, predominantly gay and bisexual men, were diagnosed with the mpox virus.

Those who were affected in the early days of the mpox outbreak turned to the trusted healthcare professionals that always treat them with sensitivity and empathy – sexual health services. Despite mpox not technically being a sexually transmitted infection (STI), gay and bisexual men knew how they wanted the healthcare system to serve them. Sexual health clinicians stepped up without question. Central government did not. Costing tens of millions, the mpox response was paid for by cancelled PrEP appointments and the absence of long-acting reversible contraception.

The good news was that a vaccine effective against mpox already existed – and the UK Health Security Agency (UKHSA) was quick off the mark in procuring doses for those at the highest risk across the UK. Just as the outbreak was reaching its peak, a huge vaccination drive was rolled out again via sexual health clinics.

For many gay and bisexual men, the outbreak had dismaying echoes of the early days of the HIV epidemic and caused immense anxiety – many of those eligible were clamouring to get vaccinated. Demand was much higher than officials at UKHSA predicted, illustrated by the queues of men waiting for vaccines outside pop-up clinics last July. Almost 68,000 people were vaccinated with a first dose and nearly 27,000 people were vaccinated with a second dose by the end of March 2023.

The outbreak is officially declared over. The vaccination programme is, therefore, coming to an end and everything can go back to normal. Except ‘normal’ for sexual health services means trying to put back the pieces on a service that has been hammered by a decade of incremental cuts, a novel disease outbreak, and the effects of a global pandemic. Clinics are left managing skyrocketing demand with ever-dwindling resources – as the Local Government Association (LGA) recently put it, services in England are now at “breaking point”.

In England, the public health grant simply hasn’t kept pace with costs and public health has faced an overall cut of £1 billion since 2015/16. During the same period, demand for services has increased by a third. This is creating a perfect storm, with the LGA estimating that spending on testing, treatment, and contraception declined by 17% between 2015/16 and 2020/21. Given the public health grant was increased by a paltry 3.3% this financial year, and with inflation running at least three times higher, those declines are only set to deepen.

As a stark example of this, sexual health clinics in England actually lost money for providing emergency support during the mpox outbreak. Clinicians stepped up without question but because mpox displaced around a third of usual activity in clinics – namely STI testing, HIV prevention, and contraception – some of their services lost hundreds of thousands of pounds in funding. Commissioners were unable to justify allocating money to a new condition that wasn’t technically an STI. This is despite the fact that the 2022 mpox outbreak was largely propagating within specific sexual networks of gay and bisexual men.

Rather than putting more pressure onto already-stretched A&Es, sexual health services took on the challenge of supporting men who had been exposed to the virus, and they literally paid the price.

The result of this is that it is now harder than ever to get an appointment at a sexual health clinic, and rates of gonorrhoea and syphilis are increasing. Research published by HIV organisations last autumn found that people are facing long waits for the HIV prevention medication, PrEP – almost a quarter of people who took part in that research said that due to a lack of appointments, they were turned away from sexual health clinics when trying to access PrEP. An inquiry by the All-Party Parliamentary Group on sexual and reproductive health uncovered huge problems faced by women trying to access contraception.

This is a hidden crisis and it is entrenching health inequalities that have already been building for a decade. Rates of STIs have been increasing consistently for years. And certain groups are at higher risk of poor sexual health, especially young people, gay and bisexual men, people living with HIV, and people of Black Caribbean ethnicity.

Research by the Health Protection Research Unit (HPRU) in 2017 found that the disproportionate rates of STIs amongst people of Black Caribbean ethnicity were not explained through any clinical or behavioural factors, instead, they were linked with socioeconomic factors and structural inequality. In short, poor sexual health is a health equality issue, but one that is almost never discussed in terms of levelling up. Poor sexual health doesn’t exist in isolation. It is a symptom of wider social and health inequality.

As both a former local government Cabinet Member for Health and Social Care, and the current chair of the HIV and sexual health charity, Terrence Higgins Trust, I have enormous sympathy with the pressures local government commissioners and service providers are facing. It is becoming much harder to deliver services that meet the needs of people who are often facing multiple disadvantages, and commissioners are being forced to make increasingly impossible funding choices.

Improving funding for sexual health must certainly be part of the solution but we also need a nationwide strategic vision for sexual health in England. There is still no Sexual and Reproductive Health Strategy (since renamed an Action Plan), despite a commitment from the UK Government to develop one in 2019.

Mpox showed how brilliant our sexual health services are but also what a precarious state they’re in. Last year’s outbreak was a lucky escape, but only if we learn the lessons and prioritise tackling poor sexual health as the major public health concern it is.

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