Sexual Health

Chlamydia

Genital chlamydial infection, caused by the bacterium Chlamydia trachomatis , is the most commonly diagnosed bacterial sexually transmitted infection (STI) in genito-urinary medicine (GUM) clinics in the United Kingdom . In 2004 over 104,000 cases were diagnosed, an increase of 8.6 per cent since 2003 and 223 per cent since 1995, with two-thirds of cases among young men and women in the 16-24 year age group.

Chlamydia is easy to treat once detected but a large proportion of the population, approximately 70 per cent of women and 50 per cent of men, display no symptoms, and are unaware of their infection and the need to seek treatment. In untreated women, infection can lead to serious conditions like pelvic inflammatory disease, which can progress to ectopic pregnancy and infertility. Complications among men with untreated infection include urethritis, epididymitis and Reiter's syndrome (chlamydia associated arthritis). Chlamydia has also been associated with an increased risk of HIV transmission and acquisition. The annual cost of chlamydia and its consequences are estimated to be more than £100 million.

The National Chlamydia Screening Programme (NCSP) in England began in April 2003 as part of the Department of Health's (DH) National Strategy for Sexual Health and HIV. A further commitment was made by the Government in the White Paper Choosing Health: Making healthier choices easier , published in 2004, which identified chlamydia as a new priority area. It stated that implementation of the NCSP would be accelerated with total coverage of England by March 2007, supported by an additional investment of £80 million

The NCSP offers screening to both sexually active asymptomatic young men and women less than 25 years of age in a variety of health and non-health care settings outside of GUM Clinics. The programme targets a population who otherwise would not have been tested and thus represent a potential 'hidden reservoir' of infection.

 

The programme aims to:

 

• Control chlamydia through early detection and treatment of asymptomatic infection
• Reduce onward transmission to sexual partners
• Prevent the consequences of untreated infection

 

The Health Protection Agency has been involved with the NCSP since its launch, providing scientific expertise and collecting and analysing all screening data, and in November 2005 took over the operational management of the programme; this includes co-ordinating implementation, monitoring and evaluating the programme.

In the second year approximately 62,000 young people were screened from 26 programme areas at over 870 sites and the prevalence of infection was found to be high, with 10.9 per cent testing positively among women and 11.9 per cent among men. Almost all positive index cases identified through the screening programme were confirmed to have been successfully treated.

The challenge now is to increase the proportion of young people tested, especially in light of the targets set out by the DH in the local delivery plan for chlamydia. The Agency will have a key role in monitoring the outcomes of the NCSP to ensure its effectiveness in reducing the incidence of chlamydia and its consequences among young people in England .

Another vital part of the campaign is to raise awareness of chlamydia and its consequences among the target group of under-25s. Working with the DH, the Agency is involved in producing patient information including a leaflet describing chlamydia and the screening process, and advising sexually active young people where they can have the test.

 

In the Regions

As part of the NCSP, the regional laboratory in Manchester is to carry out chlamydia screening for Greater Manchester's population of 2.3 million people. The contract was awarded by the Greater Manchester Strategic Health Authority in October 2005 and work is due to start in summer 2006.

Staff at Manchester have the specialist molecular diagnostic and IT expertise necessary to develop the first phase of the screening programme. The laboratory will be installing new equipment to provide this high through-put testing programme. A key component of the study is to collaborate with local NHS Trust laboratories to roll out the screening programme in the coming years so that locally-delivered services can be developed.

The Agency's work on Chlamydia extends beyond the NCSP. In the Cambridge laboratory, staff have developed and produced their own assays to test for the infection.

This work has brought many benefits to the laboratory including the need for repeat testing, and reduced costs to the Agency.

 

LGV - An Emerging Infection

Two years ago, lymphogranuloma venereum (LGV) was rarely seen by clinical services in the UK , although it was common in Africa, Asia and South America . Since then, there has been an outbreak of this sexually transmitted infection in the UK among men who have sex with men (MSM), and the number of cases reached 274 at the end of December 2005. Most cases have been seen in London , with a smaller outbreak in Brighton . About 80 per cent of sufferers are also infected with HIV.

LGV is caused by a specific type of Chlamydia trachomatis and all cases recently diagnosed in Europe have been of the L2 strain. LGV differs from the more common types of C. trachomatis in that infection is more invasive and can cause inflammation, lymph node infection, fever, muscular pain and general ill-health.

Infection can result in severe tissue damage to the genitals and rectum but the disease can be successfully treated with antibiotics and complications are rare in Western countries.

LGV is regarded as a serious emerging threat to sexual health. The Agency chairs the national LGV incident team to co-ordinate the public health response to the outbreak. Central to this has been the establishment by the Agency of laboratory diagnostic and reference facilities, and the enhanced surveillance system that has gathered information to inform intervention strategies.

 

Syphilis

Having declined sharply during the 1980s and early 1990s, syphilis, which is caused by the bacterium Treponema pallidum, has re-emerged in a series of outbreaks in the UK since 1997. Since the Agency established enhanced surveillance of syphilis in 1999, 5,452 cases have been seen up to the end of 2005. The majority of cases are found in men who have sex with men about half of whom were also infected with HIV. The high number of syphilis cases co-infected with HIV suggests that the epidemiology of syphilis has been influenced by developments in the HIV epidemic, including the availability of effective anti-retroviral therapies, increased HIV prevalence, and increased unsafe sex among MSM.

Although diagnoses continue to be centered within high-risk groups, an increased incidence among heterosexuals has been seen. Cases of congenital syphilis have been reported and this represents an emerging public health problem.

The Agency has been faced with a sharp rise in cases during the past few years, and has developed enhanced surveillance initiatives to track the spread of disease and identify the groups most at risk. It is also working with partner groups to promote knowledge about syphilis to inform decision making and choice in sexual relationships.

 

Rise in HIV Figures

The number of people living with HIV in the UK continues to rise. In a report released to coincide with World Aids Day in November 2005, the Agency and other health bodies reported that the figure now stands at about 58,300. This includes those already diagnosed and an estimated 19,700 who are unaware of their infection. In 2005, an estimated total of 7,750 new cases of HIV were diagnosed.

Data collated by the Agency identifies changing patterns within the spread of HIV. Detailed analysis shows the increase in numbers is mainly due to a continued rise in diagnoses in men who have sex with men, the group which remains most at risk of acquiring HIV in the UK , as well as high diagnoses among heterosexual men and women. Most of the new diagnoses among heterosexuals are acquired outside the UK , the majority of these in Africa .

The number of injecting drug users infected with HIV has also risen to its highest level since 1992. The Agency has issued advice to individuals as well as healthcare professionals, urging anyone who thinks they are at risk of contracting HIV to seek a test through their GP or a sexual health clinic.

 

GUM Waiting Times

Poor access to sexual health services can contribute to increases in sexually transmitted infections. Increased demand for help from GUM clinics leads to longer waiting times for patients, and the resultant delay in diagnosis and treatment increases the risk of onward transmission to sexual partners.

Early treatment is key to controlling the spread of sexually transmitted infections, and the public health white paper recommended GUM patients are seen within 48 hours of contacting the service. The Agency carries out quarterly audits of clinic waiting times in collaboration with the British Association for Sexual Health and HIV (BASHH) on behalf of the Department of Health. These show that less than half of patients are seen within 48 hours of first contacting a clinic, although there is considerable regional variation. Access is better in London , with almost seven out of 10 people being seen within that time, compared with less than 40 per cent of patients living in the West Midlands, Yorkshire and Humberside, and the North East.

In the future, with the development of electronic systems, waiting times will be monitored continuously. The Agency will also help prepare a more detailed annual report to assist professionals in this vital sphere of sexual health.