What is the role of sexual health services in the delivery of primary prevention of sexually transmitted infections? A narrative review
Danielle Jayes A , Rachel Merrick B , Caisey Pulford B , Erna Buitendam B , Hamish Mohammed B C and John Saunders
B C *
A Office for Health Improvement and Disparities, Department for Health and Social Care, London, UK.
B Blood Safety, Hepatitis, STIs and HIV Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK.
C Institute for Global Health, University College London, London, UK.
Sexual Health - https://doi.org/10.1071/SH22047
Submitted: 10 March 2022 Accepted: 7 July 2022 Published online: 4 August 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing
Abstract
Sexually transmitted infections (STIs) affect hundreds of millions of people globally. The resulting impact on quality of life and the economy for health systems is huge. Specialist sexual health services (SHS) play a key role in the provision of primary prevention interventions targeted against STIs. We conducted a narrative review to explore the role of SHSs in delivering primary prevention interventions for STIs. Established interventions include education and awareness building, condom promotion, and the provision of vaccines. Nascent interventions such as the use of antibiotics as pre- and post-exposure prophylaxis are not currently recommended, but have already been adopted by some key population groups. The shift to delivering SHS through digital health technologies may help to reduce barriers to access for some individuals, but creates challenges for the delivery of primary prevention and may inadvertently increase health inequities. Intervention development will need to consider carefully these shifting models of service delivery so that existing primary prevention options are not side-lined and that new interventions reach those who can benefit most.
Keywords: condoms, health promotion, health services, hepatitis, HPV, prevention, STIs, vaccines.
Introduction
Sexually transmitted infections (STIs) are a major public health concern. In 2020, the World Health Organization estimated that more than 374 million new infections occurred with either Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum or Trichomonas vaginalis.1 Many hundreds of millions more individuals are living with genital herpes simplex virus, human papillomavirus (HPV) and chronic hepatitis B infection.1 STIs are also often associated with shame, social stigma and intolerance, all of which can dramatically impact an individual’s wellbeing and quality of life.2
Undiagnosed or untreated STIs can lead to life-changing complications, including pelvic inflammatory disease; tubal factor infertility; ectopic pregnancy; cervical cancer; perinatal, congenital or disseminated infections; cardiovascular and neurological complications; and increased susceptibility to HIV.3 The resulting impacts on morbidity, mortality and costs on the healthcare system are enormous.4–6 Prevention and treatment of STIs can be significantly less costly than treating the sequelae of infections. For example, in the UK, initial treatment of syphilis is estimated to be less than 300 times the management costs for permanent disability caused by neurosyphilis (£77 vs £25 776).7
Efforts to prevent the acquisition of infections form a key part of activities undertaken by sexual and public health professionals.8 Broadly, these activities operate at each of the three levels of prevention in public health: primary, secondary and tertiary (Table 1). Primary prevention methods aim to prevent the acquisition of an infection and include activities such as the use of safer sex practices to reduce exposure (e.g. condoms), education on sexual and reproductive health and relationships (e.g. school-based education and public campaigns), the use of chemoprophylaxis (e.g. pre- and post-exposure prophylaxis for HIV, chlamydia and syphilis) and vaccination (e.g. for HPV, hepatitis A and B viruses). Secondary prevention aims to treat the infection to prevent health harms and transmission. Examples include STI testing, treatment, and partner notification and management. Tertiary prevention for STIs aims to reduce any long-term effects of chronic infections; for example, management of genital herpes and HIV.9
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Although a combination prevention approach should be taken, drawing on interventions across primary, secondary and tertiary prevention options, this narrative review focusses on evidence to support the delivery of primary prevention interventions for STIs, including education, condoms, vaccination and chemoprophylaxis, delivered within specialist sexual health services (SHS), and considers implications for delivery of these within future and emerging models of SHS delivery. A narrative review approach has been taken to allow inclusion of evidence across different populations, interventions, and outcomes relevant to SHS. Although the exact structure of these services will vary between countries and health systems, literature was chosen when the intervention related to primary prevention and it was delivered within a setting where the primary focus is the delivery of sexual health care and have healthcare professionals trained in sexual health. Although primary prevention for STIs can, and should, be delivered in a variety of settings, there are several features that make SHS particularly well suited. Healthcare professionals within these settings specialise in sexual health, a key part of which is having structured, culturally competent discussions about sex, risk and prevention that may be more challenging in other settings or for other healthcare professionals.10 This is important as concerns about being able to take sexual histories and being asked sensitive questions can act as a barrier to the delivery of good care. In many areas, there have been large changes in how these services are delivered over the last decade; for example, with the availability of technologies to allow for remote self-sampling. More recently, the coronavirus disease 2019 (COVID-19) pandemic has led to rapid and sustained changes in service delivery with a shift to more remote and digital delivery models; this includes a range of modalities including via telephone, video, or online.11 In the UK, there has been increased provision of remote consultations and management, and an increase in the number of individuals accessing online self-sampling testing.12,13 This change in delivery is reflective of a trend that was already occurring and has implications for the delivery of primary prevention in SHS. We consider potential consequences of these changes in how services are delivered and accessed on the delivery of primary prevention.
Education, awareness and health promotion
Health promotion encompasses interventions aimed at changing individual behaviours and reducing risk.14 Accessible and high-quality information that empowers people to manage their own sexual health needs is essential to prevent acquisition and transmission of STIs.
Although some health promotion activities are universal in scope, others need to be tailored for key populations and marginalised groups disproportionately affected by STIs. Examples of these key population groups may include gay, bisexual, and other men who have sex with men (MSM), trans and gender-diverse people, and sex workers. Understanding the differences in knowledge and awareness of STIs in these population groups, as well as behaviours, attitudes and other factors that influence their risk of acquiring STIs, are essential for developing effective health promotion interventions.
Among MSM, poorer knowledge of STIs has been shown to be associated with higher risk behaviours. Although some MSM are well informed, there remains widespread lack of knowledge around prevention, modes of STI transmission and treatment options, especially among HIV-negative men or those with unknown HIV status compared with HIV-positive men.15–20 Specialist SHS play an important role in providing health promotion and advice and are widely perceived as acceptable and preferable as a source of information compared to other settings among MSM and young people.21,22 Barriers exist to accessing specialist SHS, including concerns over confidentiality and being identified within their communities among men of Black and Asian ethnicities in the UK, although variation exists with people from a Black Caribbean background more likely than those in other ethnic groups to access UK sexual health clinics.23,24
Community involvement in the design, delivery and evaluation of sexual health promotion and interventions is also recognised as an important factor among both MSM and Black Caribbean groups.25,26 To help stimulate behaviour change, health promotion activities and interventions should therefore be co-developed with key populations to ensure they are culturally relevant, tailored to groups that are at higher risk of acquiring STIs, and reflect different groups’ preferences for their content, format and delivery.
A shift towards remote and digital methods of SHS delivery highlights the need for education, awareness, and promotion activities to be accessible and delivered synergistically. The use of digital interventions have significant potential to provide a cost-effective way to deliver sexual health promotion given the reach and popularity of the internet and mobile phones,27 and could be delivered from SHS given they are broadly viewed as a trusted source of information.21,28,29 Young people consider Reproductive and Sexual Health Education through school as their the main source of information about sexual health, but cite doctors, nurses and clinics as a highly trusted and preferred setting for information about condoms and contraception,28,29 suggesting there is a role for SHS in the delivery of prevention. More targeted in-person or digital brief interventions that address key risk behaviours (e.g. drug and alcohol use) have also been widely used in SHS but, although feasible, have shown mixed results.30–33
Among MSM, the delivery of sexual health information and promotion through social media and dating apps is viewed as acceptable and feasible, but concerns around discrimination and judgement over social media were expressed and to be effective, messaging should be engaging, positive in tone and delivered by trusted healthcare organisations.22
A recent systematic review of digital interventions (i.e. social media, websites, text messages) for sexual health promotion among young people found evidence that these interventions are effective in increasing knowledge around the prevention of STIs and HIV; however, this increase in knowledge does not guarantee improved health outcomes.34,35
Although the provision of factsheets and clear, accurate written information about STIs and their prevention is recommended within STI management guidelines, the evidence to support the effectiveness of these factsheets to prevent reinfection is lacking.36,37
Although the use of digital interventions delivered by SHS is feasible, significant barriers exist to this approach. These include shared computer space (privacy concerns) or filtering software on phones or other devices.27 Moreover, the scale of digital exclusion needs to be considered to ensure the equitable delivery of digital or online health promotion messages.
Condoms
Consistent and correct use of condoms can significantly reduce the risk of acquiring STIs, including HIV.38–41 An international systematic review looking at the effectiveness of global condom promotion programs, including interventions relating to social marketing, promotion of condom brands and HIV/STI prevention programs that specifically promoted condom use, confirms that condoms remain a crucial intervention for the prevention of STI transmission.42 Interventions that teach and encourage correct and consistent condom use, along with communication and negotiation skills, are particularly effective in reducing STI transmission.43 The use of female (internal) and male (external) condoms (when women are given the option to make a choice of one or both at each sexual act) is more effective than use of male condoms only in preventing chlamydia and gonorrhoea, and is potentially more effective in preventing trichomoniasis and other STIs.44 Therefore, access to condoms of all types is an essential component of SHS delivery.
Young people experience the highest diagnosis rates of the most common STIs and studies have shown rising trends in diversity of sexual practices.45–49 Despite changes in behavioural patterns, the use and perception of condoms varies among young people with unintended conception viewed as a greater concern than contracting a STI.29 Young people also report major barriers to accessing SHS, including long waiting times, stigma and embarrassment, lack of clarity on which services are available, and an insufficient number of specialised SHS.29 Many of these access challenges for young people have been compounded by the coronavirus disease 2019 (COVID-19) pandemic and a move to online provision.13 Young people reported that their access to, and use of, free condom schemes was disrupted and that there was uncertainty and confusion about how to access condoms.50,51 These changing patterns of behaviour and barriers to access raise new challenges for health promotion and the provision of condoms through SHS, and there is an increasing need to improve digital sexual health literacy among young people.
Motivational interviewing has been found to be effective at increasing the frequency of condom use during anal or oral sex among MSM living with HIV in the 3 months following the motivational interviewing intervention.50,51 However, this intervention was delivered within an academic centre providing HIV outpatient care and there is a lack of evidence that motivational interviewing reduces the likelihood of unprotected anal intercourse with casual partners among young MSM. There is some evidence to suggest that lay health advisor-delivered interventions could be effective at reducing STI acquisition and improving condom use among young heterosexual African American men.52,53
Biomedical prevention
Vaccination
Safe and effective vaccines exist for several STIs and can be delivered to individuals attending SHS, although vaccine coverage varies between and within programs and populations. Within current delivery models, these require administration within the clinic, or by healthcare workers in outreach settings (Table 2); therefore, the shift to remote and digital delivery of SHS may present a challenge to ongoing vaccination efforts.
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Hepatitis A and B virus
There are 1.4 million new cases of hepatitis A virus (HAV) annually reported globally accounting for approximately 7000 deaths.69 In a number of countries, selective vaccination is recommended for individuals travelling to endemic countries and other key risk groups, including MSM (Table 2). Outbreaks of HAV in MSM do occur, most recently in England in 2017, partly attributable to variable implementation of vaccination in SHS.70
Hepatitis B virus (HBV) also causes an acute or chronic infection of the liver, and is transmitted through sex, blood-to-blood contact and perinatally. If persistent infection develops, it can lead to cirrhosis and liver cancer. There are approximately 250 million people living with chronic HBV infection and almost 900 000 people die from complications of infection annually.71 Vaccination is often available through a variety of healthcare settings, some of which may be more acceptable for some key populations compared to others. For example, infant vaccination programs have been introduced in most countries, but selective immunisation for certain key populations at risk through sexual exposure or blood; for example, MSM, sex workers, prisoners and people who inject drugs, is also recommended in guidelines (Table 2).72
Human papillomavirus
Human papillomavirus (HPV) is one of the most commonly transmitted STIs and worldwide, about 5% of all cancers are linked to the virus, mostly due to subtypes HPV16 and 18, including cervical, penile, anal and genital cancers and some cancers of the head and neck.73 Other subtypes of HPV, such as 6 and 11, cause external genital warts, which can place a significant impact on personal wellbeing, as well as an economic burden on health systems.74
Since the introduction of the HPV vaccine, there have been significant reductions in HPV infections, cervical intraepithelial neoplasia 2+ and anogenital warts diagnoses seen globally and, in England, the HPV immunisation program has almost eliminated cervical cancer in women born since 1 September 1995.75,76 In some countries where universal vaccination of school-aged children was not initially adopted, catch up vaccination of key population groups in SHS has been introduced. For example, in England, the HPV vaccination program has had a phased expansion based on modelling direct and indirect benefits to include MSM up to age 45 years attending SHS (since 2018) and boys via a gender-neutral, school-based adolescent immunisation program in school year 8 (i.e. aged 12 and 13 years (since 2019)).77,78 By the end of December 2019, 93% of specialist SHS in England reported HPV opportunistic vaccination activity for MSM.79
Barriers to HPV vaccination are varied and can range from lack of knowledge of HPV, HPV-related diseases, HPV or vaccine stigma and vaccine beliefs to delivery-specific concerns, such as long intervals between dose, and the inconvenience of multiple doses.80,81 Offering the vaccine when testing for STIs or within SHS, support from the healthcare provider and increasing public awareness of HPV and the health benefits of vaccination to MSM may overcome some of these barriers to facilitate vaccine uptake.80,81
Gonorrhoea and chlamydia
Although there are currently no licensed vaccines for most STIs, such as herpes simplex, chlamydia, gonorrhoea, and syphilis, or sexually transmissible enteric pathogens such as Shigella, several are in development.82–84 Efforts to develop vaccines against Neisseria gonorrhoeae have become increasingly critical given the rising threat of gonococcal antimicrobial resistance (AMR).85 Analyses of surveillance data collected in New Zealand showed that individuals who had received Meningitis B vaccine were at lower risk of subsequently acquiring gonorrhoea, and clinical trials are currently underway to evaluate the efficacy of the four-component meningococcal B vaccine (Bexsero) in preventing gonorrhoea in gay and bisexual men.86,87 An additional anticipated benefit to reducing diagnoses of gonorrhoea would be to slow the development of AMR; however, vaccine hesitancy could be an issue if the stigma associated with STIs extended to STI vaccines.
The complex life cycle of chlamydia has made vaccine development challenging. A recent first-in-human clinical phase 1 trial showed a vaccine candidate and adjuvant were immunogenic, safe and well tolerated with further efficacy studies underway.88
Doxycycline prophylaxis for chlamydia and syphilis
Doxycycline as pre- and post-exposure prophylaxis for syphilis and chlamydia has been shown to reduce the risk of acquiring chlamydia and syphilis in a very small number of published studies.89,90 There are several ongoing international studies to further explore the efficacy and potential harms of doxycycline prophylaxis, particularly in relation to AMR.91,92 Significant uncertainties currently exist about the efficacy, safety, harms and most appropriate target populations for doxycycline prophylaxis. So, although the delivery of antibiotic prophylaxis could feasibly be delivered through SHS, it is not currently recommended in any guidelines internationally. Despite this, there is evidence that some MSM at higher risk of STIs (e.g. MSM on HIV-pre-exposure prophylaxis (PrEP)) are self-sourcing antibiotics to use as STI prophylaxis, and healthcare providers should be aware of the issues.93–98
The future of primary prevention in SHS
Although there are many strengths to the approach of delivering primary prevention in SHS, there are also several potential weaknesses and emerging challenges. SHS are limited in their physical and financial capacity to deliver care to those at risk of STIs. Key populations still experience significant barriers to accessing services and continue to be disproportionately affected by STIs.
The COVID-19 pandemic has accelerated the move to online provision of SHS. This has implications for the delivery of primary prevention in SHS and provides opportunities to enhance the role of digital interventions by providing more targeted, user-friendly, and interactive prevention messaging that is tailored to key populations and groups disproportionately affected by STIs.
Although this may facilitate access for some groups, it may also present a significant barrier to access for others, and it is increasingly important to ensure that key populations remain able to access prevention services, that existing barriers are not exacerbated, and that digital exclusion does not increase inequalities.
Online delivery may provide savings due to factors such as reduced staffing costs, but there is limited existing evidence to support the cost-effectiveness of online service models. Those who are already disproportionately affected by STIs are also those who may struggle most to use digital health care, thereby cementing and worsening health inequalities.99 This highlights the need to ensure that multiple access points are available in addition to the delivery of online services and that both face-to-face and digital prevention is delivered in line with the preferences and needs of key populations. Ongoing evaluation is essential to improve our understanding of the impact that digital interventions could have on sexual health outcomes.
In terms of the delivery of the primary prevention interventions outlined above, there are obvious challenges in delivering many of these through virtual consultations. Online models of PrEP delivery may offer an example of how biomedical STI prevention could be delivered in the future, but vaccination currently requires face-to-face delivery. However, self-administered intradermal and intramuscular influenza vaccination has been shown to be acceptable and feasible among healthcare workers so could be explored for other vaccines and for lay users, although logistical issues particularly around cold-chain management could be an issue.100 Self-administration of heparin and long-acting contraception are other examples that could be drawn upon.
Conclusion
SHS are ideally placed to provide a variety of primary prevention interventions to a range of key population groups. Evidence to support their delivery in these settings predominantly comes from observational data to show it is feasible and acceptable, but quantifying the economic and disease impacts remains challenging. Evidence we have drawn upon in this review are often non-comparative studies, making it challenging to drawn definitive conclusions about the effectiveness of interventions. Interventions to improve uptake and delivery of primary prevention should be co-produced with input from the population groups for whom these interventions are targeted. Although the shift to delivering online services may help to create opportunities for some service users, digital exclusion could contribute to worsening health outcomes for others; therefore, robust evaluation should underpin any intervention development and delivery to improve our understanding of what works for whom, why and in what context. This is important to allow services in other settings to adopt and adapt interventions to best suit their own context.
Data availability
Data sharing is not applicable as no new data were generated or analysed during this study.
Conflicts of interest
The authors declare no conflicts of interest.
Declaration of funding
This research did not receive any specific funding.
Acknowledgements
The authors would like to thank Katy Sinka and Kate Folkard at the UK Health Security Agency; Adam Winter, Sydney Joyce and Andrea Duncan at the UK Department of Health and Social Care for their assistance with this study.
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