Reducing sexually transmitted infections

Form a network of services, including online services, providing sexual healthcare for an area. Ensure that:

• everyone is signposted to, and can access, the care they need

• local pathways are in place to link people, including underserved communities, to the best possible care

• details of the network are kept up to date and all staff understand what each service offers.

Determine the most appropriate settings for services and interventions in consultation with groups with greater sexual health or access needs (see also recommendations in section 1.2). Include online and non-clinical settings.

Reduce barriers to services for groups with greater sexual health or access needs by:

• emphasising confidentiality, empathy and a non-judgemental approach

• offering access to a professional translator or interpreter instead of waiting for the person to ask, to ensure they are fully able to communicate and to understand the discussion

• making sure staff understand that services are free and available to everyone regardless of where they live (or are from), and they do not refuse access to someone who is entitled to the service

• supporting people to attend appointments and engage with treatment

• providing outreach activities.
  
  Take into account guidance on making services more welcoming and inclusive, such as the Department of Health and Social Care's 'You're welcome' quality criteria or UK Health Security Agency's (previously Public Health England) Inclusion health: applying all our health.

Target interventions at groups with greater sexual health or access needs. Identify local needs and priorities using data from the Joint Strategic Needs Assessment (JSNA) and other data sources.

Engage with groups with greater sexual health or access needs to understand how best to meet their sexual health and wellbeing needs. Take into account factors such as existing barriers to access (for example, for people with learning difficulties, or because of their gender or sexuality), language and other socioeconomic factors, including deprivation.

Co-produce (plan, design, implement and evaluate) services and interventions in consultation with the groups that they are for, in line with NICE's guideline on community engagement.

Ensure that interventions are culturally competent. This includes being delivered in a suitable language for people whose main language is not English. It might also involve recognising that people may be engaged in activities that are stigmatised by their communities (therefore, discretion may be particularly important for them).

Ensure that interventions include some or all of the following components:

• information and education about:

  • STIs

  • the impact of alcohol and drugs on sexual decision making

• information about:

  • sexual health services available, including that they are free, confidential and open access

  • the rates of STIs to explain why some groups are at higher risk

  • the impact of stigma

• sex-positive approaches to providing advice on the consistent and correct use of barrier methods, including providing external condoms in different sizes and textures, and internal condoms (see NICE's guideline on sexually transmitted infections: condom distribution schemes)

• risk assessment and risk-reduction activities, for example developing personalised risk-reduction plans, identifying triggers and setting goals

• Information–Motivation–Behavioural skills (IMB) model approaches and motivational interviewing techniques to guide conversations about risk reduction or safer-sex practices and address informational, motivational and skills-based barriers to change

• activities to increase sexual self-efficacy (for example, talking about sexual consent, negotiating the use of barrier methods and negotiating sexual preferences) and broader self-efficacy (for example, self-esteem)

• activities exploring the links between emotion and sexual behaviour, and coping skills (for example, using cognitive behavioural approaches)

• a plan for follow up (for example, repeated contact to review progress or make new plans).

Take into account the recommendations in the NICE guidance on behaviour change (see the NICE topic page on behaviour change) when co-producing interventions to reduce STIs.

Tailor interventions to the needs of the groups identified. Take into account safety concerns (such as sexual violence or coercion), stigma and discrimination. See also the NICE guideline on domestic violence and abuse: multi-agency working.

Deliver interventions to reduce STIs across a range of services, including within broader support interventions and community services (for example, in drug and alcohol services, abortion care services, HIV care and mental health services).

Think about whether one-to-one or group delivery is the most appropriate for the community the intervention is aimed at, and the content and aims of the intervention. Take into account people's preferences and any resource impact.

Ensure that people have the opportunity to have interventions that are delivered by peers or other trusted people they can relate to, who share a cultural or group background with the target group.

When delivering interventions:

• Avoid making assumptions about people or judging them. This could include using inclusive language (until the person expresses a preference) and recognising a range of relationships and sexual behaviours.

• Be sex and identity positive (for example, by using gender-affirming language and being respectful of their sex life). Focus on self-worth and empowering people to have autonomy over their bodies and their sexual decision making.

Commissioners and providers should regularly evaluate interventions, including the methods used to co-produce them, to determine their effectiveness and acceptability and identify gaps to make service improvements across the pathway. For example, this could be done through a health equity audit.

Offer a range of STI testing options based on local need, including remote self-sampling, in-person attendance at specialist clinics or in community pharmacies, primary care, and outreach services.

Offer people without symptoms remote self-sampling as an alternative option to clinic attendance. Self-sampling should test for the same infections as those tested for at the clinic.

Ensure that local service websites give up-to-date information on which testing options are available in their area.

Ensure that self-sampling kits meet the NHS Accessible Information Standard and are inclusive (for example, addressing the needs of trans and gender-diverse people, and making instructions and guidance available in different languages or different formats such as diagrams, photos, or videos targeted at people with learning difficulties).

Widen access to self-sampling kits. For example, by having a system for people to order a kit online or by phone, or providing self-sampling kits through 'pop-up' or outreach services.

Monitor the provision and return rates of kits to identify any groups that have low rates of accessing or returning them. Take action to try to address the reasons for the low rates.

Tailor interventions and information to the target users of the service. Where possible, ensure that interventions are available for other groups who may be excluded by this targeting. (See also recommendation 1.1.10.)

Recognise people's individual needs. Be aware that membership of a particular group does not imply that a person is necessarily at higher risk of an STI. Address this with cultural sensitivity and competency within the context of sex-positive approaches.

Consider personalising automated recall messages using low-level tailoring, for example adding the name of the person and clinician to the message. However, be aware of any potential risks of personalising messages, such as where there may be safety concerns.

Raise awareness of pre-exposure prophylaxis (PrEP) among local groups with greater sexual health or access needs:

• Use methods designed to target specific populations (for example, social media and relevant local organisations or groups).

• Follow the advice in NICE's guideline on community engagement.

• Pay particular attention to groups in which PrEP is less well-known or uptake is lower, such as trans people, cisgender women, young people (aged 16 to 24), people with a Black African or Caribbean family background and people from a lower socioeconomic status background.

Give relevant local community groups support and information resources to help them raise awareness of PrEP and increase trust in services.

Ensure that people in groups with greater sexual health or access needs understand that PrEP is for HIV prevention only and that it does not protect against other STIs, therefore barrier methods are also important. See NICE's guideline on sexually transmitted infections: condom distribution schemes.

Co-produce materials that target specific information gaps and causes of stigma within the target population.

Use peer support to normalise PrEP use, reduce all forms of stigma (originating from the person themselves, professionals and the wider society) and increase trust in services.

Tell trans people undergoing medical transition that there are no clinically significant interactions expected between PrEP and the common hormones used in this process, and that using PrEP is not expected to affect their transition.

Ensure that services offering PrEP are welcoming and accessible (see recommendation 1.1.5) for all the different population groups who are eligible, for example by co-designing services with the key population groups. Ensure that tailoring services to specific communities does not exclude or alienate other eligible groups.

Raise awareness among healthcare professionals (particularly those in primary care, community settings and gender identity clinics) about which groups of people are eligible for PrEP. This could be done through continuing education or through commissioning (for example, through local networks [see recommendation 1.1.3]).

Provide protected time for healthcare professionals who have day-to-day contact with people eligible for PrEP to have training on relevant issues.

Services that do not provide PrEP should connect people who are interested in PrEP and eligible for it to a service that can prescribe it.

Ensure there are clear referral pathways between services that do not provide PrEP and those that do.

Make provision for people who want to be referred to services outside their local area or community.

Offer PrEP to people at higher risk of HIV, using the criteria in the BHIVA/BASHH guidelines.

Support people who are taking PrEP, for example in decisions around the use of barrier methods and attending follow-up appointments. Continue to offer them all other relevant sexual health services, such as information, behavioural support and condom provision.

Support people who are taking PrEP to get regular HIV testing and STI screening (every 3 months).

Give people taking PrEP tailored information and education on effectiveness, adherence, side effects and monitoring risks (see NICE's guideline on shared decision making).

Follow up people taking PrEP in line with the good practice points and monitoring recommendations in the BHIVA/BASHH guidelines.

Monitor the kidney function of people taking PrEP, and any other adverse health events.

Help people taking PrEP to maximise adherence to treatment. Follow the general principles in NICE's guideline on medicines adherence and address factors specific to the use of PrEP, including those listed in the BHIVA/BASHH guidelines.