‘A Framework for Sexual Health Improvement in England’ sets out the government’s ambitions for improving sexual health.

Designed to be used by local organisations when they are looking at how best to provide sexual health services in their area. This includes the need for:

• a fall in the number of unwanted pregnancies
•  greater efforts to prevent STIs and HIV
•  an increase in the number of people in high-risk groups being tested for HIV
• building an honest and open culture where everyone is able to make informed and responsible choices about relationships and sex
• making sure that all people have rapid and easy access to appropriate sexual health services
• offering counselling to all women who request an abortion so they can discuss the options and choices available with a trained counsellor

Responses to ‘Framework for Sexual Health Improvement’.

 The Sex Education Forum, based at leading children’s charity The National Children’s Bureau, welcomed the publication of the government’s strategy for improving sexual health and its focus on preventative measures, such as good quality sex and relationships education (SRE). However, more needs to be done to ensure all schools step up to the mark, in providing the information, support and advice that children want and need.

FPA welcomes the Government’s long-overdue publication of its Framework for Sexual Health Improvement in England document, which finally provides guidance to local government to help ensure that the nation’s sexual health improves.

Although we support the Government’s formal endorsement of the need to improve areas of sexual health like sexually transmitted infection (STI) and teenage pregnancy rates, we are acutely aware that there is absolutely no guarantee that local councils will actually act on this guidance.

We know from our Unprotected Nation report, released in January, that if the situation worsens, and local government chooses not to invest in sexual health services, the additional cost to the economy is likely to be over £135 billion over the next few years.

Brook

Responding to the publication of A Framework for Sexual Health Improvement in England Simon Blake OBE, Brook’s Chief Executive, said:

“We are pleased that the Framework for Sexual health has been published just in time for the move to local authorities and that there are clear aspirations for the improvement of young people’s sexual health, in particular that all young people have access to confidential services and support.

“We are also pleased to see the ambition that all children and young people should receive good quality Sex and Relationships Education (SRE) at school which we know is vital in preventing abuse and exploitation and promoting positive relationships. However, this ambition will never be realised whilst the Department for Education fails to ensure that every school is required to deliver a comprehensive programme of SRE.

“As we move towards 1st April we look forward to working local authorities to realise these ambitions and improve young people’s lives.”

FAMILY PLANNING 2020 names Director of the global partnership

The Family Planning 2020 (FP2020) Reference Group announced that long time global advocate for family planning and reproductive health Valerie DeFillipo has been named Director of the global partnership. FP2020 builds on the partnerships launched at the London Summit on Family Planning. It will sustain the momentum from London and ensure all partners are working together to achieve and support the goals and commitments announced at the Summit.

Results from a new study published in the March issue of Obstetrics and Gynaecology demonstrate that the use of depot medroxyprogesterone acetate (DMPA) does not appear to increase fracture risk. Whilst the use of DMPA reduces serum oestrogen levels and is associated with significant loss of bone mineral density (BMD), this study shows that it does not appear to have an effect on fracture risk.  In addition although DMPA users had higher fracture risk than non-users, the risk did not increase after starting DMPA but was similar to before it was initiated.

The retrospective cohort study by Lanza et al¹ of 312,395 women, who had had 11,822 fractures, was designed to assess the extent to which DMPA increases fracture risk. Using data from the General Practice Research Database, the study compared fracture incidence in DMPA users with women using non-DMPA hormonal contraceptives. It also investigated fracture incidence before and after initiation of contraceptive use. The study reported that before contraceptive use started, DMPA users had a higher fracture risk than non-users (incidence rate ratio [IRR] 1.28; 95% confidence interval [CI] 1.07-1.73). After use began, crude fracture incidence was 9.1/1000 person-years for DMPA users and 7.3 for non-users (crude IRR 1.23; 95% CI 1.16-1.30). Fracture risk in DMPA users did not increase after starting DMPA  (IRR after/before 1.08; 95% CI 0.92-1.26). Fracture incidence was 9.4/1000 person years in low exposure DMPA users, and 7.8/1000 in high-exposure DMPA users. DMPA users had a higher fracture risk than non-users at the start of contraceptive use, with no discernable induction period.

Commenting on the results Professor Anna Glasier, Honorary Professor of the University of Edinburgh and the London School of Hygiene and Tropical Medicine, said “This study confirms what others have shown, that women who use Depo-Provera^® appear to have a modest increase in fracture risk compared with women using other contraceptive methods. Importantly however, in this UK population the increased risk of fracture preceded the start of Depo-Provera^®. The difference in fracture risk was mainly in fractures associated with trauma rather than those typical of osteoporosis. Further research is indicated to explore behavioural differences among populations of women choosing to use different contraceptive methods.”

1. Lanza L. et al. Use of depot medroxyprogesterone acetate contraception and incidence of bone fracture. Obs and Gynae. 2013; 121(3):593–600.

JFPRHC is looking for a dynamic reader to take on the role of social media editor

The Journal already has a strong readership and offers online features such as a blog, podcasts, Facebook and Twitter.  This new post has been created to assist the editorial team in improving the journal’s interactivity and web presence via these and other social media, by promoting the journal’s content as well as helping its core readership to stay up to date with news and developments in the field.

You should be educated to degree level with knowledge of the journal’s subject area. Some experience of science communication and/or web content management systems such as Twitter, Facebook andWordPress would be preferred, but the main criteria for the successful applicant will be enthusiasm for the subject area, creativity, and an interest in using new technologies to disseminate scientific research.

The role would be ideally suited to a junior researcher or practising clinician. The full advert, and how to apply, is available at: http://jfprhc.bmj.com/site/misc/JFPRHC%20Social%20Media%20Editor%20advert%20Feb%202013.pdf

Sexual Health Commissioning

the Local Government Association and Public Health England have produced a document of FAQs. They address a number of transitional issues relating to the transfer of responsibility for commissioning sexual health services to local government.  In addition to these FAQs the Department of Health will shortly publish guidance on local government’s mandatory responsibilities for sexual health.

Reminder to register as stakeholder for NICE Patient group directions Good Practice Guidance

Management of PGDs will change from the 1st April when commissioning of services changes. All those involved in development or use of PGDs can contribute at the  consultation stage by registering as a stakeholder now. Individuals can contribute as service providers.

To register your organisation as a stakeholder send registration details (name of contact, name of organisation, email address) to pgd@nice.org.uk using the subject heading Patient group directions GPG stakeholder registration 2012/13

National Infertility Awareness Campaign Welcomes updated NICE Guideline on Treating Infertility

The National Infertility Awareness Campaign (NIAC) has welcomed the new clinical guideline on the assessment and treatment of couples with fertility problems, published by NICE yesterday but fears remain over its implementation.

People experiencing fertility problems will be able to seek NHS help sooner and get the medical treatment they might require earlier. The updated guideline also includes other specific groups of people for the first time; these include same sex couples, those who carry an infectious disease, such as Hepatitis B or HIV and those who are unable to have intercourse (for example, if they have a physical disability). It also includes updated recommendations for people who are preparing for cancer treatment who may wish to preserve their fertility. However, as NICE clinical guidelines are not mandatory, fears still remain over local implementation as patients may continue to face a ‘postcode lottery’ approach to funding. This coincides with the release of the

Latest UK fertility treatment data and figures: 2010-2011

Published this week by the HFEA – ‘Fertility Treatment in 2011: Trends and Figures’

Education about abortion in the UK is failing young people

A report published by Brook and Education For Choice (EFC) finds that education about abortion in the UK is failing young people.  Some schools are addressing the topic as part of comprehensive sex and relationships education (SRE), but there is evidence of widespread bad practice including medical misinformation being provided by teachers and visitors to schools.  The report pulls together findings from surveys with schools and young people, and an audit of teaching materials used. Young people describe negative experiences of the education they received, and report that some schools are using inappropriate teaching materials including graphic images and distressing, inaccurate video material.

Risk of Unwanted Pregnancies with Morning After Pill Conscience Clause

This article is published in the Journal of Medical Ethics today – “The Fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription”

Conscience clauses, which allow pharmacists to opt out of providing the “morning after pill” without a prescription, risk unwanted pregnancies and undermine the principle of universal healthcare in the NHS, say pharmacists in the Journal of Medical Ethics.  These clauses should either be banned or enhanced so that pharmacists and patients know exactly where they stand, rather than the current “fudge”, which serves nobody well, the authors conclude. Emergency contraception without a prescription became available from UK pharmacies in 2001 and the Republic of Ireland in 2011.  Built-in conscience clauses allow pharmacists to opt-out of provision on moral or religious grounds, providing they refer patients to other providers willing to prescribe the product.

Cuts to services set to saddle UK with a £136.7 billion NHS and welfare burden by 2020

A new report from the UK’s leading sexual health charities, Brook and FPA, has revealed for the first time the economic and social impact of NHS cuts to contraception and other sexual health services. Cuts are resulting in these services been reduced or restricted and this can already be seen across the UK today. The report looks at what happens if these restrictions to services continue unabated. The key findings of the report reveal:

-          A significant rise in the number of NHS abortions and STI rates by 2020

-          An additional cost burden on the NHS of £612.8 million as a consequence of increasing numbers of unintended pregnancies and STIs

-          An increase in wider public spending of up to £124.7 billion – equivalent to 10% of all welfare spending – by 2020

Anne Connolly, GP in Bradford, and Chair of the Primary Care Women’s Health Forum, said; “There is a clear danger that imminent changes to commissioning could significantly undermine the good work that professionals are doing. Maintaining progress requires investment and if we are brave enough to invest money at a time when there is pressure to disinvest there are massive cost savings as well as quality of life savings to be made, as this report clearly illustrates.”

In response to reports of restrictions to contraception across the UK Brook and FPA joined forces earlier this year to launch XES – We Can’t Go Backwards, a major awareness campaign. Brook and FPA are calling on people in the UK to join the campaign and rate and share their experiences of contraception services, good and bad, through the UK’s only interactive online sexual health map www.wecantgobackwards.org.uk

Education for Choice hightlights misleading pregnancy counselling

Education for Choice support young people’s right to informed choice on abortion. They report that Feminist Action Cambridge held a demo in Cambridge city centre to raise awareness of local ‘crisis pregnancy centres’ which they feel are ‘using emotionally manipulative techniques’ and misinformation ‘in order to increase the guilt women might feel at having an abortion.’ They sent mystery shoppers to three counselling centres in Cambridgeshire and found that, at each one, women were being given some kind of false information about abortion and/or subjected to ‘counselling’ which was biased and often based on personal anecdotes.

New NICE Clinical Guideline: Ectopic pregnancy and miscarriage

This clinical guideline offers evidence-based advice on the diagnosis and management of ectopic pregnancy and miscarriage in early pregnancy and is available from NICE at: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=14000

The Morning After: A Cross Party Inquiry into Unplanned Pregnancy

2020Health.Org report that “Over half of unplanned pregnancies happen because people are not using sufficient contraception, according to a survey by a Cross-Party Parliamentary Inquiry.

Th inquiry, supported by 2020health, into unwanted pregnancies, highlights three main findings:
1.That a large proportion of unwanted pregnancies are happening because people are not using sufficient contraception;
2. That there is inadequate Sex and Relationship Education in schools; and
3. That there is a lack of access to contraception for over 25s.

http://www.2020health.org/2020health/Press/latest-news/Unplanned-Pregnancy-Report.html

ICEC has relaunched its website with easily accessible information on all aspects of emergency contraception worldwide. The map of registration status of EC pills is particularly interesting as is the status and availability database

New IUS launched

Skyla, has gained FDA approval and is due to be launched in the USA next month – the first new device to come to market in 12 years.  Skyla contains 13.5 mg of Levonorgestrel and differs from Mirena in that it prevents pregnancy for 3 years rather than 5 and appears to be aimed at younger women who have not had children.

MEDFASH eBulletin

Read all the latest SRH news here

The following papers have been published at http://jfprhc.bmj.com/content/early/recent

The financial costs to patients of diagnosing and excluding ectopic pregnancy (Unger et al)

In their article, Unger and his colleagues in Edinburgh report on their assessment of an area of patient experience that is not often considered when assessing medical interventions. The financial impact on patients’ lives of the need to seek medical attention can be considerable and may become more significant as economic hardship increases. This paper describes a well-conducted questionnaire study on the costs that patients themselves incurred in attending their general practitioners and a hospital clinic with a suspected ectopic pregnancy. The authors argue that such costs need to be factored into decisions regarding the cost-effectiveness of medical procedures. from David Horwell, Advisory Editor

Despite the best intentions: a reflection on low client numbers for a pilot telemedicine sexual health service (Garrett & Kirkman)

This “Better Way of Working” article describes the outcome of a pilot of a telemedicine sexual health service for rural youth in Victoria, Australia. Despite expecting high client numbers, few used the service. This article explores the reasons for the disappointing usage, and concludes that clinicians’ expertise and passion for improving access to health care may not be enough to guarantee successful design and implementation of the most appropriate service. from Gillian Robinson,  Associate Editor

Uptake and continuation rates of the intrauterine system in a university student general practice population in the UK (Armitage et al)

This is a very simple real-life observational study of a cohort of young nulliparous women in a university-based general practice choosing and continuing with LARCs as their first line method of contraception. This paper compels the reader to offer this ‘fit and forget’ method of contraceptive to our younger population, of course along with all other forms of contraception, as a matter of routine. from Scott Wilkes, Associate Editor

Removal of a fractured Nexplanon^® (Elliman)

In a letter to the editor Alyson Elliman describes removal of a partially fractured, curved implant with no obvious cause and asks if other clinicians have observed anything similar.

NICE Good Practice Guidance: Patient Group Directions is now under development.

This guidance is now in development and due to be published in April 2013

Stakeholder registration is now open.  To register your organisation as a stakeholder* send registration details (name of contact, name of organisation, email address) to pgd@nice.org.uk using the subject heading Patient group directions GPG stakeholder registration 2012/13

*for the purposes of this guidance stakeholders are:

• national patient and carer organisations that directly or indirectly represent the interests of people whose care is covered by the guidance
• national organisations that represent the healthcare professionals who provide the services described in the guidance
• companies that manufacture the medicines or devices used in the area covered by the guidance and whose interests may be significantly affected by the guidance
• providers and commissioners of health services in England, Wales and Northern Ireland
• statutory organisations including the Department of Health, the Welsh Assembly Government, NHS Quality Improvement Scotland, the Healthcare Commission and the National Patient Safety Agency
• research organisations that have done nationally recognised research in the area

See http://www.nice.org.uk/mpc/goodpracticeguidance/PatientGroupDirections.jsp for further information.

Philippine Government finally passes Reproductive Health Bill after 14 years.

This is a huge victory in the Philippines for access to maternal health services, family planning, and sex education. The reproductive health bill gives the national government the mandate to make reproductive health services accessible to poor families through information and education and the provision of free contraceptives.

Branded, generics or branded generics? Do you know the difference?

When a branded, or proprietary, drug comes ‘off patent’ it is common for other companies to apply for marketing authorisation and we are, increasingly, seeing this in sexual health. This can be for generic versions or for branded generics. Branded generics are simply generic equivalent drugs with a brand name given by the particular company. When a pharmacist dispenses a proprietary drug or branded generic they are obliged to dispense the named product, if a pure generic is prescribed they can give any product containing the generic compound/s but this is reimbursed at the current generic rate.

To give an example in contraception Microgynon 30 & Ovranette are proprietary brands and Levest & Rigevidon are branded generic equivalents.

MeReC bulletin summarises:

• Generic medicines are, overall, much less expensive to the NHS. Their appropriate use instead of branded medicines delivers considerable cost savings. In England about 5% of medicines are still prescribed by their brand name when generic equivalents are available.
• List prices for some ‘branded generics’ may be lower than the reimbursement price for equivalent generics. However, any cost savings achieved by their use may be unsustainable by the manufacturer and may not necessarily be cheaper, or in the best interests of the NHS overall.

This may be because many companies marketing branded generics negotiate a fixed price for a fixed period for their products with pharmacies or clinics which are lower than, even, generic alternatives – however generic drug prices are subject to fluctuation due to market forces and may fall over time meaning this would no longer be the case.

The MeReC bulletin also signposts the UK Medicines Information (UKMi) Q & A document “Which medicines are not suitable for generic prescribing in primary care?” This lists medicines that may be considered suitable to prescribe by specific manufacturer’s product (branded or generic). These include:

– multiple ingredient products
– ensuring adherence to long-term medications, where differences in appearance between manufacturer’s products might cause confusion and anxiety

In contraception, over the years, we have probably not noticed when this has happened and the first of the reasons above, as well as the fact that there were not many generic versions available, may explain this. The second may be more pertinent in the future.

There are a number of reasons why these issues are currently topical in sexual health:

• cost saving – not only perceived savings on generics vs brands but increased bulk/group purchasing to afford greater savings within Trusts
• more companies are making and marketing branded generics than in the past
• more medicines used in sexual health are due to come off patent now or in the next year including: sildenafil, many HIV drugs, desogestrel and mifepristone
• increased use of paperless IT systems with built-in drug data bases, as in general practice, where generic equivalents are often highlighted
• different ordering capabilities of independent pharmacies vs large national companies/chains

There are potentially more likely to be problems with contraceptive pills prescribed in general practice than in clinics as clinics generally see women at each visit and can explain any differences there may be in dispensed products. A woman taking an FP10 to a pharmacy (if it is prescribed generically) may be given a different product from previously without the prescriber being aware that this could occur. And this may happen even if she goes to the same pharmacy as last time. Clinicians will be aware of the issues that arise if women are given different pills and the anxiety this may cause followed by increased clinician time required for extra appointments to handle any problems. This is always assuming the woman doesn’t just stop her pills if she is unable to access help in a timely fashion. Food for thought.

ella-One® black triangle removed

The MHRA has removed the black triangle from ella-One®. The black triangle will be removed from all company materials over the next few months and EC providers may need to update some documentation.

The Medical Foundation for HIV and Sexual Health is 25 yrs old (rebranded as MEDFASH). Established in 1987 by the BMA, as an independent foundation, with the aim of improving knowledge and understanding of HIV among health professionals it has grown and spread to encompass all aspects of sexual health.

As part of this celebration the foundation has a new website and has launched its Sexual Health & HIV Policy eBulletin.  MEDFASH Chief Executive, Ruth Lowbury, introduces the eBulletin: it is designed with local sexual health and HIV commissioners and providers in mind. It will give a concise and regular round-up of emerging policy developments, relevant evidence updates and available tools and resources across the field of sexual and reproductive health and HIV. It will also consider the impact the change agenda is having on this area of healthcare through a series of eFeature articles and interviews with those working at both national and local levels. This is particularly useful now at a time when service delivery is changing and many of us will be involved with new (and possibly challenging) ways of working and new communication channels.

Amonst other things the first issue includes: transfer of sexual heath services to local authorities; local transition arrangements; re-tendering of GUM services; Healthwatch England (the new consumer champion for health and care in England); HIV treatment for overseas visitors.

Australia Adopts Herd-Immunity Approach in Fight Against HPV

On July 12, 2012, Australia took a stand to become the first country to provide coverage of the Gardasil® vaccine to boys between the ages of 12 and 13, through a National Immunization Program-sponsored school-based initiative. In her press release, the minister of health, Tanya Plibersek, stated that the government-sponsored initiative was targeted to synergize with the current immunization program in girls to decrease the incidence of human papillomavirus (HPV) infection in the Australian population.

Girls don’t see HPV vaccine as green light for sex

A study by Bednarczyk et al in Atlanta and published in Pediatrics has concluded that HPV vaccination in the recommended ages was not associated with increased sexual activity–related outcome rates.

Nurses in Zimbabwe to prescribe HIV drug

Faced with the ambitious target of reaching 85 percent of people in need of HIV treatment by the end of 2012, the Zimbabwean government has announced that nurses will be trained to prescribe and manage antiretroviral (ARV) drug treatment. Experts welcomed the move but warned that nurses would have to be adequately prepared and supported to take on the additional duties. Previously, nurses were allowed only to administer the drugs after a doctor had prescribed them. Now, changes made in the job descriptions of nurses by the Nurses’ Council of Zimbabwe will see them prescribing the medication. Report from HIV/AIDS/Zimbabwe (HAZ)

UK Sexual Health Awards 2013

Nominations are invited in the following catergories:

• Sexual health professional of the year.
• JLS young person of the year.
• Adult sexual health service/project of the year.
• Pamela Sheridan young people’s sexual health service/project of the year.
• Rosemary Goodchild Award for excellence in sexual health journal.
• Sexual health media campaign/storyline of the year.
• Durex community pharmacy award.

More information and nomination forms from fpa/Brook

By coincidence, the publication of this season’s Journal occurred at the same time as the mushrooming revelations around Jimmy Savile’s abuse of many of his fans over many years. The press are currently talking about 50 or 60 people but he must have come into contact with thousands of vulnerable young, star-struck youngsters in his time. The abuse appears to have been well masked (or ignored) because of the money he was then able to donate to many good causes.

The Commentary and Lead Article in the Journal demonstrate one of the many serious outcomes for future health that childhood abuse can have using attitude to cervical screening in later life as an example. These also highlight the value of one particular organisation who are likely to be inundated with more calls for help and support.

NAPAC is the only UK national charity that supports adult survivors of all forms of childhood abuse. Founded in 1997, NAPAC runs Britain’s only free phone support line for adult survivors and is accredited by the Helplines Association. The support line is staffed entirely by volunteers some of whom are survivors themselves. The organisation was profiled in the Journal in 2011 by our consumer correspondent Susan Quilliam.  The organisation can be contacted at www.napac.org.uk, email at: support@napac.org.uk or the freephone Support Line on 0800 085 3330.

To learn more about the work of NAPAC follow this link to the podcast featuring Sarah Kelly, Training and Development Manager: http://podcasts.bmj.com/jfprhc/