Reducing sexually transmitted infections

Resource impact summary report

The guideline covers interventions to prevent sexually transmitted infections (STIs). It aims to reduce the transmission of chlamydia and other STIs, including HIV, and includes ways to help increase the uptake of vaccines and of STI testing in communities with greater sexual health needs. The guideline replaces the former guideline PH3 published in February 2007.

The number of STIs diagnosed at sexual health services (SHSs) and community-based settings in England was 317,901 in 2020. This is estimated to be around 565 people per 100,000 population. This is a decrease of 32% (from 467,096 or 830 per 100,000 population) diagnosed in 2019, but this coincided with a 25% decrease in sexual heath screens over the same period caused by the disruption in service provision during the COVID pandemic (PHE: Sexually Transmitted Infections and screening for chlamydia in England 2020). Prior to 2020, there was an increasing trend in STIs such as gonorrhoea and syphilis and there is already evidence of an increase in these STIs in 2021.

Most of the recommendations in the updated guideline reinforce best practice and do not need any additional resources to implement. However, some of the guideline areas and recommendations may represent a change to current local practice.  Where a change is required to current practice, this may require additional resources to implement, which may be significant at a local level. Benefits derived from the change in practice may help mitigate any additional costs.

Data on current practice for recommendations discussed in this summary report are not currently available due to variations in practice or challenges in obtaining such data.

There are different settings where interventions to reduce STIs take place. There is also variation within the services offered in each setting. Settings where services take place include sexual health clinics, some drug and alcohol services and some GP practices. Mental health services do not routinely provide STI-specific interventions, however HIV-care services do. Interventions are also delivered across a range of third sector services such as homeless charities and mental health charities; therefore the size of the resource impact should be determined at a local level.

Depending on current local practice, recommendations/areas which may require additional resources and result in additional costs include:

Delivering and evaluating interventions to reduce STI transmission (recommendation 1.1.11)

• Expert opinion suggests that for non-NHS community services (such as third sector drug, alcohol and sex worker services) there may be some additional costs to setting up this service offer in certain areas, although many areas will already have these services in place. There is variation across the country with areas of higher need likely to have services in place already.
• There will be a training cost for non-specialist staff in the NHS and third sector to provide relevant STI-specific interventions. Providing interventions such as regular testing for groups at higher risk of STIs may increase the number of cases found and treated. However, this may also lead to more cases prevented and associated benefits.

Improving uptake and increasing the frequency of STI testing (recommendations 1.2.1 and 1.2.2 )

Experts have identified that service reconfiguration in response to the COVID-19 pandemic has accelerated the delivery of remote STI self-sampling services. These services include remote follow-up after test results. The table below shows the change in how services are delivered.

Table 1 Recent change in how STI services are delivered

Source: Public Health England: Sexually transmitted infections data tables – Table 3 (September 2021).

All common STIs can be detected using self-sampling kits, although not all kits include blood tests, which limits which STIs they can detect.  Processing costs for remote self-sampling (samples sent to laboratory for processing) are the same whether these are sent from home or from the clinic. The cost of self sampling  compared with an attendance at clinic are shown in table 2. Self sampling and remote self sampling are cheaper than testing in a clinic, although cost effectiveness depends on the return rate of testing kits. There are also a number of other factors which may make in-person care cost effective, for example more rapid treatment and initiation of partner notification.

Table 2 Comparison of STI testing costs

Note: With self-testing there will also be a telephone call to discuss the appropriate test to be sent. The higher cost in the range includes screening for HIV, Hepatitis B and C.

PrEP for people at high risk of HIV (recommendation 1.5.13)

• NHS England will routinely reimburse the drug costs associated with Pre Exposure Prophylaxis (PrEP) for the prevention of HIV in line with guidance on the preventative use of PrEP from BHIVA/BASHH [NHSE Clinical Commissioning Policy PrEP 2020]. Clinical expert opinion suggests this recommendation may lead to an increase in demand for PrEP as it becomes more widely available. The increased availability of PrEP may lead to more attendances at sexual health services, as well as more STI testing, diagnosis and treatment.
• Clinics may need additional funding or expansion of services to meet increased demand as a result of implementing the recommendation, however there are significant benefits and savings from preventing HIV and from the earlier detection of STIs.

Implementing the guideline may lead to the following resource benefits:

• Improved access to care. The additional cost of providing interventions such as STI testing, preventative treatments and Hepatitis C clinics in non-healthcare settings across a range of services (see recommendation 1.1.11) are likely to be offset by savings through earlier diagnosis and treatment. These savings could happen within a relatively short time horizon.
• Free up clinician time and capacity at clinics where services can be provided remotely. This could also reduce geographic variations in accessing services where services for in-person care are limited. The cost-benefit is subject to the return rate of self-sampling kits. Self-sampling has short-term savings, because as demand increases these savings will be offset by increased demand for health service follow up after positive results.
• Savings from reduced risk of transmitting HIV. The lifetime costs of treating HIV range from £73,000 to £404,000 per person in the UK [Aidsmap 2021 How much does HIV treatment cost the NHS].
• The increased use of PrEP has contributed to the reduction in the incidence of HIV UK Health Security Agency HIV annual data tables [2021]. PrEP has also become cheaper since treatment options have become generic, therefore the use of PrEP for people at high risk of HIV in line with recommendation 1.5.13 is shown to be cost effective in preventing transmission and future healthcare costs. This is supported by the evidence for the guidance.
• Improved consistency of best practice across the country.
• Better health outcomes and care experience.

Services for reducing STIs are commissioned by local authorities (public health services [PHE Commissioning STI services]). Providers are NHS community health services such as GPs, sexual health clinics and local outpatient services and third sector organisations (such as charities supporting homelessness, sex workers and HIV prevention associations).