Ending HIV Transmission in Scotland by 2030 - elimination delivery plan 2023-2026: fairer Scotland duty assessment

Stage 2 – evidence

• What does the evidence suggest about existing inequalities of outcome, caused by socio-economic disadvantage, in this specific policy area? You might want to think about:
  • people on low incomes
  • people in deprived areas (and particular communities of place and interest)
  • people with no/low wealth or in debt
  • people in material deprivation
  • people from different social classes

Evidence shows that individuals living in socio-economic disadvantage are more likely to have less flexible working arrangements, making it more difficult to attend face to face appointments for sexual health. They may also have challenges with accessing childcare, for example due to lack of affordability of private childcare, in order to attend HIV services. Transport or other costs for visits to specialist clinics may be a concern or barrier to some for accessing services.

According to a National Aids Trust report, ‘the relationship between poverty and HIV is cyclical. Poor health caused by HIV increases demands on personal resources at the same time that ability to work and generate income becomes limited, creating an entry-point into poverty. Equally, poverty can cause significant deterioration of the health of someone living with HIV, with insufficient access to adequate nutrition, housing and healthcare and reduced capacity to pursue a healthy lifestyle.’^[3] By reducing HIV transmission, increasing support for those living with HIV, and by tackling the stigma around HIV, this policy will assist in breaking this cycle.

According to the Health and Wellbeing Census Scotland 2021-2022, those in secondary school years 4-6 living in the most deprived quintile were less likely to agree that it is easy to get information or ask for help on sexual health issues and were slightly less likely to agree that they had used a condom the most recent time they had sex.^[4] A report on Experiences of Relationships and Sex Education, and sexual risk taking found that children receiving Free School Meals did not tend to have the same quality of Sex and Relationships Education, were more likely to have sex before the legal age of consent, were having unprotected sex at a higher rate, and were generally more likely to engage in risky sexual behaviours.^[5]

For GBMSM (gay, bisexual and men who have sex with men), a study has shown that there is a correlation between individuals who have financial worries and their likelihood to test. Also, men having financial worries sometimes/all of the time (32.4%) are more likely to have a positive STI diagnosis in the last year compared to men with no financial worries (21.4%) in the last year.^[6] This study shows that individuals who have regular financial worries are more likely to have a positive STI test, than those without financial worries.

HIV transmission can occur through sharing of drug injection equipment.^[7] According to a report by the Scottish Affairs Committee on drug use in Scotland, those in poverty are ‘more likely to be exposed to additional risk factors… which increase the likelihood of a person being predisposed towards problematic substance use.’^[8]

Finally, in the public consultation on seeking views for challenging demand for prostitution in Scotland under the Equally Safe Strategy, it was highlighted by respondents that women involved selling sex struggled to access services due to factors such as stigma and irregular working hours.^[9]

Overall, the evidence shows that socio-economic disadvantage can have an impact on HIV acquisition risk, health services access, knowledge and support. This policy aims to reduce sexual health inequalities and improve equity of access to all those in Scotland.

• What does the evidence suggest about possible impacts of the policy/programme/decision, as planned, on those inequalities of outcome?

All decisions made regarding the content of this delivery plan have been evidence based. There has been extensive consultation with experts and third sector representatives, including those that have been part of the steering and writing groups for this plan, and therefore the policy is drawing on their experience and knowledge.

This policy will have a positive effect on equalities of outcome. The actions within the HIVTE Delivery Plan aim to improve access to HIV services across Scotland, making it easier for individuals living with socio-economic disadvantage to access services. For example, the ePrEP clinic pilot aims to support individuals to order HIV Pre-Exposure Prophylaxis (PrEP) for free online, without having to visit sexual health services. This will benefit individuals who work irregular shift patterns and are unable to take time off work to visit clinics. Furthermore, additional routes to testing contained in the Delivery Plan such as community testing and online postal self-sampling will augment current testing capacity and improve accessibility for various groups.

• Is there evidence that suggests alternative approaches to the policy/programme/decision? For example, evidence from the UK or international evidence?

The 2030 HIV Transmission Elimination Goal is aligned with global targets set by UNAIDS. Different countries internationally are taking different approaches to HIV transmission elimination based on epidemiology, health provision and local factors. This plan seeks to use the best available evidence to inform policy interventions that are most likely to achieve the goals in Scotland.

• What gaps are there in key evidence? Is it possible to collect new evidence quickly in other areas? For example, through consultation meetings, focus groups or surveys?

Data collection has been identified as a key issue within Scotland. The HIV Delivery Plan recognises the need for enhanced surveillance and includes an action for Public Health Scotland to develop a monitoring and evaluation plan to address surveillance gaps and track progress towards elimination.

• How could you involve communities of interest (including those with lived experience of poverty and disadvantage) in this process? The voices of people and communities are likely to be important for identifying potential improvements to the programme/policy/decision.

Third sector and community organisations, public health, academia, primary care, and services including drug and alcohol/sexual health/HIV were brought together in the development of the HIV Transmission Elimination Proposal to draw upon lived experience and expertise, laying the groundwork for this Delivery Plan. The approach was collaborative and included participants from outside Scotland to strengthen the evidence base and broaden the perspective in setting recommendations.