Sexual Health and Blood Borne Virus Framework 2015-2020 Update

The Outcomes: Progress and Update

The Sexual Health and Blood Borne Virus Framework set out five high-level Outcomes that were relevant across the topic areas. These have guided activity over the last four years and although progress has been made the Outcomes remain relevant. The Outcomes are re-stated here, with a brief summary on progress over the last four years and an outline of on-going issues and priorities. More detail is provided within the following subject chapters.

Outcome 1: Fewer newly acquired blood borne virus and sexually transmitted infections; fewer unintended pregnancies^[1].

Good progress has been made in reducing new hepatitis C infections, but this progress is fragile and needs to be maintained by a continued commitment to prevention. We continue to face challenges in preventing new HIV infections and sexually transmitted infections (STIs). Over the first four years of the Framework the Scottish Government has invested in research undertaken by NHS Greater Glasgow and Clyde and NHS Lothian to inform HIV prevention strategies for men who have sex with men (MSM), and we need to translate that research and other emerging evidence into practice. Work has also been carried out to improve access to longer acting reversible contraception (LARC) and to sexual health services. At least in part because of these efforts the rate of abortions has fallen annually since the launch of the Framework and the number of live births has also fallen. However we need to continue our work to prevent STIs and to provide good quality contraceptive options to further reduce unintended pregnancies.

Outcome 2: A reduction in the health inequalities gap in sexual health and blood borne viruses.

The Framework stated the importance of health inequalities to the subjects of sexual health and blood borne viruses, and much work has been done locally and nationally to reduce such inequalities. However, the greatest impact of poor sexual health and blood borne viruses (BBVs) continues to be on those who are most vulnerable in our society. The broad financial context and welfare and benefits changes are major drivers and influencers of health inequalities.

In order to make progress we have to understand the population groups in which we wish to see change. More work needs to be done to define this robustly, to ensure we can target resources and monitor impact. In 2014 the Scottish Government surveyed a representative sample of 1,500 adults who had been in a sexual relationship in the past year.^[2] Amongst other findings this survey identified that those with a disability or illness were more likely to have experienced a sexual health and wellbeing issue with a potentially negative impact, as were respondents who were lesbian, gay or bisexual. Only 48% of people with a disability claimed to be happy in their sex life compared to 67% of those without a disability.

Outcome 3: People affected by blood borne viruses lead longer, healthier lives, with a good quality of life.

This outcome is about ensuring that people affected by blood borne viruses can access the best treatment and care and can lead a healthy life in all senses of the word. In Scotland we have a National Health Service free at the point of need and therefore anyone who needs care and/or support for HIV, hepatitis C or hepatitis B should be able to access it without financial barriers. We have increased the number of people accessing hepatitis C therapies over the life of the Framework and many more people have been cured of their infection. The smaller number of people infected with hepatitis B are well-supported and have opportunities to access the best care. The overwhelming majority of people diagnosed with HIV continue to have access to treatment.

The next five years will present greater challenges - principally concerning the cost of new hepatitis C therapies and the increasing costs of HIV treatment and care (particularly in the context of emerging evidence about the benefits of commencing treatment for HIV at an earlier stage). To ensure individuals can access treatment at a time that will lead to improved health outcomes we also need to do more to test for and diagnose all blood borne viruses as early as possible. We need to continue to work to promote testing in all services which engage with those at risk and not restrict testing to traditional NHS settings.

Critically, we also need to reflect that a healthy life is not purely about medical interventions - quality of life is also vital and this relates to much broader issues such as mental health, employment, relationships and wellbeing in the broadest sense. These are less tangible quality-of-life measures which are more subjective and difficult to define and measure. However, consideration will be given to whether or how these aspects can be captured within Framework indicators.

Outcome 4. Sexual relationships are free from coercion and harm.

All sexual relationships, whatever life stage, gender, gender identity or sexual orientation, should be free from coercion and harm. We continue to educate and raise awareness around positive sexual health, through Relationships, Sexual Health and Parenthood (RSHP) Education, and through Government, NHS and Third Sector awareness and information campaigns. Sexual health services in Scotland are adept at dealing with these issues and discussing sexual relationships with clients, but in other services there is more work that can be done. Good sexual health and wellbeing is about the promotion of healthy fulfilling relationships - not just preventing STIs or unintended pregnancy. This means that this outcome cannot be met purely by sexual health services and there is a leadership role for the promotion of good healthy relationships by other organisations and service providers. There are particular issues with young people, the influence of pornography and the perception of 'normal' healthy relationships amongst peers, but challenges also remain around coercion and harm in other relationships, notably within LGBT relationships and also in relation to online safety. Violence against women and girls damages health and wellbeing, and sexual health services have a role in early intervention. Practitioners in these services have daily contact with women and girls, and it is essential that they are able to identify those most at risk and are able to offer an appropriate, safe and consistent response. Sexual exploitation, including child sexual exploitation, is a particularly important issue that is relevant to this outcome and more work is needed to establish how best to measure our impact on this.

Outcome 5: A society where the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood borne viruses are positive, non-stigmatising and supportive.

Outcome 5 remains the most ambitious of the Framework outcomes. It is a statement about how we want Scotland to be. The success or failure of each of the other outcomes are predicated - to a greater or lesser extent - on the successful delivery of this outcome. We know there continue to be challenges around stigma and negative attitudes towards those affected by poor sexual health and blood borne viruses, and no strategy will resolve this in five years. What is needed is consistent, on-going efforts to raise awareness, to educate and to inform. Great efforts have been made over the last five years, through professional awareness-raising and public information and awareness campaigns such as the Always Hear campaign. This work must continue, but we also need to give further consideration to how we can measure the impact of this work, and how we can improve the attitudes of individuals and professionals towards those with poor sexual health or BBVs.

In the original Framework document we stated that there is a need to normalise attitudes towards the provision of HIV, viral hepatitis and sexual healthcare in Scotland, moving away from an exceptional approach and towards a more transparent and mainstream one. This continues to be the case, and continues to be a challenge as stigma and prejudice exist despite recent progress.