A programme to support basic sexual health provision in general practice
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Supporting sexual health provision in general practice
• The 3Cs & HIV programme is designed to support general practices deliver:
– A basic sexual health offer (‘3Cs’) during any routine consultation with young adults (15 – 24 year olds):
• A chlamydia screen
• Signposting or provision of contraception advice
• Free condoms
– HIV testing in adults (≥ 16 years) in line with current clinical guidelines:
• Awareness of indicator conditions where HIV testing should be considered
• In high prevalence areas, routine offer of HIV test to all new practice registrants
• The 3Cs & HIV programme is specifically designed meet the needs of, and to fit alongside work already being undertaken by, GP teams.

An important role in sexual health promotion
• At least 60% of young adults visit their GP every year - and want the option of accessing sexual health services 1,2
• Most people become sexually active between 16-19 years old: 3,4,5
– Sexual activity can be opportunistic, unplanned and linked with alcohol and drugs
– STI rates and under 18 conceptions are indicators of ongoing health inequality
– 70% of young adults who have had a chlamydia test are more likely to test again in future, and 68% are more likely to recommend testing to friends
• The 3Cs & HIV programme will help young adults access sexual health advice and services to avoid negative health outcomes that may impact their future life chances
1.Salisbury et al. British Journal of General Practice. 2006; 56:99-103; 2. Hogan et al. BMC. Public Health 2010, 10:616; 3. DH. Improving Access to Sexual Health
Services for Young People.2007 ; 4. DfES. Teenage Pregnancy Next Steps. 2006; 5. HPA Web Survey of Young Adults (2012)

Why include HIV testing?
HIV in the UK, 2011: 1
• Estimated 96,000 people living with HIV – 24% (22,600) are unaware of their infection
• Estimated prevalence of 1.5 per 1,000 population – higher among MSM and black Africans
• 47% of HIV cases diagnosed late (CD4<350) in 2011
Why focus on reducing late HIV diagnoses?
• Public health impact – treatment can prevent onward transmission 2 - indicator within Public Health Outcome Framework
• Individual prognosis - early diagnosis can lead to near-normal life expectancy 3
• Cost - expanded HIV testing shown to be cost effective 4-5 and increased costs of a late versus early diagnosis (x2-3 times) which persist longer term 7,8
1. HPA HIV in the UK 2012 report; 2. Cohen et al NEJM 2011 3. Nakagawa et al AIDS 2012; 4. Paltiel et al N Engl J Med 2006; 5. Yazadanpanah et al Plos
One 2011; 6. MMWR 2006; 7. Krentz et al HIV Med 2008; 8. Beck e t al Plos One 2011

• 76% of people diagnosed with HIV had been seen in health services in previous year – of which, 76% in general practice 1
• Department of Health pilot projects investigated expanded
HIV testing in general medical services: 2
– Feasible
– Cost-effective
– Acceptable to patients
1.
Burns et al AIDS 2008
2.
HPA Time to Test for HIV Report 2011

Anticipated results
• The 3Cs & HIV programme adapts an intervention trialled by the HPA to increase chlamydia testing in general practice
• In this randomised controlled trial, surgeries that fully engaged with the intervention significantly improved screening rates and chlamydia detection 1
• These results provide a realistic measure of the take up and efficacy of the 3Cs
& HIV intervention if commissioned in General Practice
• The 3Cs & HIV programme is designed to strengthen sexual health work already funded and underway in your area, and support delivery of Public
Health Outcomes Framework indicators
1.McNulty C. In press

Outline of delivery
The 3Cs & HIV programme is designed to fit into current general practice activity, and support surgeries engage young adults in an evidence-based sexual health intervention
The NCSP will offer 1,500 surgeries across England the opportunity to participate in 2013/14:
• Local areas sign up to participate and identify a local 3Cs & HIV trainer
• NCSP ‘train the trainers’ and provide all 3Cs & HIV programme materials
• 3Cs trainers engage local practices in participating
• Local 3Cs & HIV practices deliver offer to young adults on ongoing basis
• 3Cs & HIV practice data collected and evaluated across 2013/14

Employing the Theory of Planned Behaviour
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Behaviour: sexual health offer for all young adults
External Barriers
Chlamydia screen offer forgotten, surgery premises’ barriers etc.
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Theory of Planned Behaviour: supporting general practice engage young adults in chlamydia screening
INTERVENTION SOLUTION
Personal
Attitudes
IDENTIFIED BARRIERS
“Low numbers of young adults visit my practice”
“Young adults don’t want to talk about sexual health”
Show surgery annual footfall for 15-24 yr olds
Discuss the evidence base showing young adults’ preference for sexual health services via their GP
Subjective
Norms
Perceived
Barriers
“My colleagues do not offer sexual health care to young adults”
“I lack knowledge about STIs,
HIV and pregnancy rates”
“I lack experience / confidence engaging young adults in sexual health matters”
•
•
•
Normalise the sexual health offer through:
Appointing a sexual health champion per surgery
Surgery posters promoting the initiative
Invite cards given to young adults at Reception
Practice staff offered training sessions and provided with information resources
Training videos show the offer being delivered

Forgetting to make the offer during a routine consultation
Risk that practice momentum declines over time
Practice environment not conducive to making the offer
The use of computer pop ups & templates encouraged
GP practice receives three contacts, including at least one visit
GP practice receives regular newsletter and information on the practice’s results
Intervention can be tailored to suit each surgery’s set up

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• Analysed 76 intervention and 81 control surgeries. Of the 76 surgeries offered the intervention:
– 47 (63%) fully engaged (received three contacts with support worker)
– 16 (21%) partially engaged (received one or two contacts)
– 13 (17%) did not engage (refused all contacts)
• During the trial period:
–
2,907 vs. 2,379 screens in intervention and control surgeries, respectively
– 76% screening increase in intervention surgeries vs. controls (p<0.001)
– 40% increase in infections detected per surgery population (p=0.04)
• ‘Fully engaged’ intervention surgeries:
– Increased screening rates 2.33 times vs. controls (p<0.001)
– Increased chlamydia detection by 76% (p=0.005)
– Increased screening significantly for at least 9 months following the intervention
1.McNulty C. In press

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Start of intervention
Support ends
Increase in screening is sustained nine
months after support ended in intervention practices
Intervention period
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Impact sustained
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Control practices
Intervention practices
Non-selected NCSP practices in study area
Once trained, 3Cs &
HIV surgeries can use programme to strengthen their sexual health offer on long-term basis
Chlamydia screening rate per 100 15-24 year olds in study surgeries
January 2009 to January 2012, by month
1.McNulty C. In press

Qualitative Results
• Feedback from qualitative interviews:
– Intervention was detailed and thorough
– Easy access to the support available
– Chlamydia support team went to the surgery to implement the intervention
– Chlamydia support team stayed in contact over a year
– Reward and recognition
“I think probably coming and actually explaining what it was and giving us the support and phone support after and coming back to the practice and checking how we were doing was helpful”
Practice Nurse

Preliminary GP interviews
“I think doing all ‘three Cs’ would be reasonable”
“I think GU services and contraception go hand in hand”
“We should be giving sexual health advice alongside the chlamydia testing, otherwise we’re just testing not educating”
“It’s a good idea to make the link between chlamydia, condoms and contraception. It makes sense to look at prevention at the same time as cure”
“It’s a population that needs a bit of lateral thinking on how to engage them”
“Really, I think it’s vital that chlamydia testing is offered with these other things as well”

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• NCSP currently inviting expressions of interest from areas
• To participate, areas must identify someone currently working in sexual health to become their 3Cs & HIV trainer
• The 3Cs & HIV trainer will deliver the programme locally: engaging local practices, providing ongoing support and evaluating achievements
• The time required by 3Cs & HIV trainers will vary per area, depending on the number of practices engaged, but estimated at 0.5 WTE if 30 practices

The NCSP will provide the following to support local delivery of the 3Cs & HIV programme:
• ‘Train the 3Cs & HIV trainer’ course
• Two follow up contacts with each 3Cs & HIV trainer
• 3Cs & HIV resource pack for practices
• Free condoms
• Performance data, per practice
• Project coordination and monitoring

Support and resources for practices
The programme is designed by GPs to fit general practice – and can be tailored to each practice, building on their current skills and services.
Each practice receives:
• An interactive training session
• Ongoing supportive follow up from their area trainer
• 3Cs & HIV practice resources to promote the programme
• 3Cs & HIV website – further information and resources

• The NCSP will evaluate the impact of the 3Cs & HIV programme
• Using local systems to collect data by practice on:
– Chlamydia testing and diagnoses
– Contraceptive prescribing data for 15-24 year olds
– HIV testing
– Registration / use of C-card and local condom programmes
• Aim: data available ~6 months after the end of each quarter

• Jan – May 2013: expressions of interest & participant selection
• May – Jun 2013: NCSP training of 3Cs local area trainers
• End of May – Jul 2013: 3Cs & HIV trainers recruiting GP surgeries
• Jul 2013 onwards: 3Cs & HIV programme delivery roll out

• If you are interested in participating, please discuss with your NCSP sexual health facilitator:
– London
– South East & Central
– East of England
– West Midlands meroe.bleasdille@phe.gov.uk
ruth.e.hall@phe.gov.uk
wendy.elliott@phe.gov.uk
janet.deeming@phe.gov.uk
– North West patrick.lenehan@phe.gov.uk
– Yorkshire, Humber & North East sharron.ainslie@phe.gov.uk
– East Midlands
– South West deborah.shaw@phe.gov.uk
norah.obrien@phe.gov.uk
• We look forward to working with you.

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