Executive summary

There were 447,694 new diagnoses of sexually transmitted infections (STIs) in England in 2018, against a backdrop of deep funding cuts and demand outstripping availability for sexual health services. Though there have been successes in reducing diagnoses of HIV and genital warts, there have been increases across common STIs including chlamydia and herpes, while rates of syphilis and gonorrhoea are soaring. On top of this, new challenges are emerging with rarer STIs, including mycoplasma genitalium (Mgen), shigella and trichomonaisis, as well as the continued threat of antimicrobial resistance (AMR). The clear lack of vision in England for tackling these STIs and the threat they pose, as well as the unwillingness to prioritise this, does little to combat the rising concern.

This report aims to bring together the current knowledge on STIs in England - looking at the trends in STIs, and who they are affecting. Why we are seeing these trends, and why some groups are more affected than others is key to addressing them. In doing this, the report will focus on behaviours that may be associated with transmission, as well as structural issues such as inequalities, barriers to access, visibility and awareness. This will be considered within the political context of changes to commissioning structures and continuing brutal cuts to public health funding. In summarising what is known, the report will also identify the gaps in knowledge. This report aims to make recommendations for improving the state of the nation’s sexual health in relation to STIs.

The sector-wide calls for a national sexual health strategy have finally been answered, with the government in 2019 committing to deliver this. It is now essential that the strategy addresses the issues that are set out in this report and uses it as a starting point to address the poor state of the nation’s sexual health.

The burden of STIs is not evenly distributed with some communities disproportionately affected. Inequalities are two-fold: structural and data-based. Structural inequalities include the impact of poverty - with individuals living in poverty experiencing higher rates of STIs. However, there is also much we don’t know about the impact of structural inequalities on sexual health. There is little research looking at the impact of discrimination, including racism, homophobia and transphobia, on the trends seen in STIs.

The research on inequalities is largely lacking. This is evident within the data gaps identified. This report found little evidence or data looking at men who have sex with men (MSM) who don’t identify as gay or bisexual, as well as trans and non-binary, including gender diverse, people, and sex workers. There is also a lack of evidence on specific ethnic minority communities - with too much data  using the unhelpful ‘BAME’ and “other” groupings. An intersectional approach was missing from the evidence, which focuses often on one specific group, thus failing to look at the experience of multiple marginalised identities. Ultimately, the lack of data in these different areas erases the experience of anyone in these groups, and the voices of people affected by poor sexual health will not be heard without a better understanding in these areas. The limited information on inequalities does little to inform a holistic approach to STIs and needs resolving if we are to tackle STIs.

In order to overcome the increasing rates we are seeing in many STIs, and seek a solution to the under-funded and over-burdened sexual health services, the commitment to a national sexual health strategy is vital. However, there has been a complete lack of recent national vision on sexual health and STIs have not been seen as a priority. In autumn 2019, the UK Government finally committed to a sexual health and reproductive health strategy.

The current indicators in the Public Health Outcomes Framework (PHOF) that exist to monitor progress in STIs are not good enough, and despite the introduction of a new overall indicator, there is a risk that it will mask trends in specific STIs. We also urgently need strengthened evidence on the return on investment of STI prevention interventions to support the case for such interventions.

Behaviours associated with STI risk include condomless sex, increased number of sexual partners, and concurrent sexual partners. In addition, chemsex and the use of dating apps are changing behaviours and associated risk. However, surprisingly, there is limited up-to-date research on behaviours – even in MSM who have seen the biggest volume of research to date.

There is also a stark lack of research on what is driving behaviours. Advances in HIV have come a long way to improve the lives of people living with HIV and increase HIV prevention options. PrEP has undoubtedly contributed to the reduction in transmissions of HIV, and provides an opportunity to engage individuals at higher risk of STIs into sexual health services. The message of U=U has emphasised that people living with HIV with an undetectable viral load can’t pass it on. However, HIV and STIs are still viewed in silo. This must change to ensure that the sexual health of people living with HIV does not fall through the gaps.

Though we are seeing these changes in behaviours, the current STI prevention tools available are simply not keeping up. For prevention of STIs, we are overly reliant on the well flogged combination of condoms and regular testing. Access to condoms has been impacted by cuts to prevention services and a lack of public engagement in condom use has been compounded by their perception. For instance, with some people thinking of condoms as a way to prevent pregnancy as opposed to STIs as well. Testing is key in preventing onward transmissions of STIs and for the initiation of treatment to prevent any complications. Partner notification has been impacted by reductions in the sexual health workforce and changing behaviours, such as anonymous sex, making partner notification more challenging.

Clear success stories seen in the impact of the HPV vaccine and PrEP for HIV are examples of additional and acceptable prevention methods. Learning from these successes could enable new ground to be covered in the world of STIs.

What is clear from the research is that the political context has had a major impact on sexual health in England. Both the Health and Social Care Act (2013) and public health funding resulted in seismic shifts in the delivery of sexual health services. The changes in commissioning structures have left systems fragmented, complex procurement processes in place and barriers to long term planning. Within the current response there is a move towards co-commissioning in an attempt to rectify this. What this will look like is currently unclear.

Public health funding cuts have been brutal, resulting in sexual health budgets being cut by a quarter. A recent Government promise of a 1% budget increase in public health is nowhere near the radical uplift needed to support strained sexual health services. These cuts gamble with the sexual health of the nation, risking widening inequalities as well as failing to provide accessible and holistic services. Cuts have also impacted the workforce, for example by preventing staff training and development.

While demand rises on sexual health services, they have been left strained and unsupported by these budget cuts. There is a need for improved investment and the proposed co-commissioning needs to urgently improve integrated working across services.

The changing commissioning structures and funding cuts have been highlighted as contextual issues impacting the sexual health of the nation. Where this is strikingly apparent is in access to sexual health services. Public health funding cuts have compromised service user access by facilitating service closures and staff cuts, both of which have contributed to longer waiting times and difficulty accessing appointments, as well as impacting on key preventative services such as outreach with communities.

Online access to self-sampling test kits enable people who are able to use this platform to carry out STI tests in the comfort of their own home, however these do not work for everyone. Local pharmacies have become another player in some parts of the country, through the provision of tier 1 and tier 2 sexual health services. Although innovative and, potentially, outstanding service provision has been supported by these outlets as well as online services, it is critical to  recognise that both of these are not substitutes to sexual health clinics, and access to face-to-face services needs to be supported.

The benefit of community organisations can be seen in the response to HIV. For STIs and HIV, such organisations have been able to reach groups that may not usually engage with services, providing testing and advice, carrying out research, and enabling the co-production of services.

Compulsory relationships and sex education (RSE) is a welcome step to ensuring young people’s awareness of STIs and safer sex practices, and schools must be fully funded to ensure that it is delivered at a high quality across the country.

However, key groups such as older people and migrants may have already missed out on this education. Myths and misconceptions among older people can contribute to STI transmissions. Considering that older people are also often absent from health promotion messaging these risks are exacerbated. Health promotion messaging should also be inclusive of people who have low levels of either health literacy or English literacy.

The response to HIV has been successful in helping to improve the lives of people living with HIV. The voices of people living with HIV have been clear, pushing for change, and are seen in the research, co-production of services, and in combating HIV stigma. In contrast, sexual health champions are few and far between. The invisible voices of people affected by poor sexual health leaves the fight against STIs without clear community advocates.

Safer sex practices, including the use of condoms, dental dams, and lube, are often missing in mass media and porn, with missed opportunities to encourage these behaviours on a wider scale. Mass media could be a way to help to encourage norms that are related to safer sex behaviours and tackle misinformation. Increasing visibility, therefore, has a key role to play in tackling the trends seen in STIs. The lack of voices, champions and visibility of sexual health in mass media runs the risk of perpetuating stigmatising attitudes.

STIs occur within a wider context. Even one STI may be related to further co-infections with other STIs. Beyond this, HIV, STIs and sexual health should no longer be considered in silo. As shown by the complications untreated STIs can cause, reproductive and sexual health are also clearly intertwined. This can also relate more broadly to wider health, for example mental health, and this relationship should not be overlooked. The wider social determinants impacting sexual health, and in particular relating to STIs, are clear. Inequalities, and the economic and political context all have an effect on STIs.

Clearly, a holistic approach is vital for ensuring future planning and strategies regarding STIs and sexual health.

This report is vital if we’re to ever tackle unacceptably high rates of STIs as it provides a stocktake of the current situation of STIs in England, as well as highlighting the stark gaps in the current evidence available. It is evident that although progress is being made in some areas, such as HPV and genital warts, there is still a long way to go if the current increasing trends in STIs are to be, at the very least, managed, and, ultimately, reversed.

Access, awareness, choice, and visibility of sexual health are all key components to keeping up with the changes in STIs, however, there are clear barriers and glaring gaps among each of these. A large part of being successful in this progress is producing richer data and evidence in order to understand the full picture. Without this, only surface level solutions will be proposed, when it is evident that real change must target the roots of the problem. The Government has a critical role to play in supporting this change through recognising the damaging impact of funding cuts and silo working. The upcoming national sexual health and reproductive health strategy will be key and has the potential to address many of the recommendations in this report.

Despite the clear challenges we face, we now have the opportunity to come together and realise the potential improvements that can be made and finally address the trends seen in STIs. We will be working to implement the recommendations of this report as part of both Terrence Higgins Trust and BASHH’s work on sexual health. We hope you will join us.

Read introduction to State of the Nation

Read full list of recommendations