Fiona Mapp

A systematic review of contemporary models of shared HIV care and HIV in primary care in high-income settings.

Summary HIV shared care is uncommon in the UK although shared care could be a beneficial model of care. We review the literature on HIV shared care to determine current practice and clinical, economic and patient satisfaction outcomes. We searched MEDLINE, EMBASE, NICE Evidence, Cochrane collaboration, Google and websites of the British HIV Association, Aidsmap, Public Health England, World Health Organization and Terrence Higgins Trust using relevant search terms in August 2014. Studies published after 2000, from healthcare settings comparable to the UK that described links between primary care and specialised HIV services were included and compared using principles of the Critical Appraisal Skills Programme and Authority, Accuracy, Coverage, Objectivity, Date, Significance frameworks. Three of the nine included models reported clinical or patient satisfaction outcomes but data collection and analyses were inadequate. None reported economic outcomes although some provided financial costings. Facilitators of shared care included robust clinical protocols, training and timely communication. Few published examples of HIV shared care exist and quality of evidence is poor. There is no consistent association with improved clinical outcomes, cost effectiveness or acceptability. Models are context specific, driven by local need, although some generalisable features could inform novel service delivery. Further evaluative research is needed to determine optimal components of shared HIV care.

Sexual health clinic attendance and non-attendance in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Objectives In Britain, sexual health clinics (SHCs) are the most common location for STI diagnosis but many people with STI risk behaviours do not attend. We estimate prevalence of SHC attendance and how this varies by sociodemographic and behavioural factors (including unsafe sex) and describe hypothetical service preferences for those reporting unsafe sex. Methods Complex survey analyses of data from Britain’s third National Survey of Sexual Attitudes and Lifestyles, a probability survey of 15 162 people aged 16–74 years, undertaken 2010–2012. Results Overall, recent attendance (past year) was highest among those aged 16–24 years (16.6% men, 22.4% women), decreasing with age (<1.5% among those 45–74 years). Approximately 15% of sexually-active 16–74 year olds (n=1002 men; n=1253 women) reported ‘unsafe sex’ (condomless first sex with a new partner and/or ≥2 partners and no condom use, past year); >75% of these had not attended a SHC (past year). However, of non-attenders aged 16–44 years, 18.7% of men and 39.0% of women reported chlamydia testing (past year) with testing highest in women aged <25 years. Of those aged 16–44 years reporting unsafe sex, the majority who reported previous SHC attendance would seek STI care there, whereas the majority who had not would use general practice. Conclusion While most reporting unsafe sex had not attended a SHC, many, particularly younger women, had tested for chlamydia suggesting engagement with sexual health services more broadly. Effective, diverse service provision is needed to engage those at-risk and ensure that they can attend services appropriate to their needs.

How social representations of sexually transmitted infections influence experiences of genito-urinary symptoms and care-seeking in Britain: mixed methods study protocol

BackgroundSocial understandings of sexually transmitted infections and associated symptoms and care-seeking behaviour continue to lag behind advancements in biomedical diagnostics and treatment, perpetuating the burden of disease. There is a lack of research linking perceptions, experiences and care-seeking for sexual health issues, especially research conducted outside of medical settings. We aim to explore lay perceptions of STIs and how these influence experiences of genito-urinary symptoms and associated care-seeking behaviour, in women and men in Britain.Methods and designThis study adopts a participant-selection variant of the explanatory sequential mixed methods design to incorporate quantitative and qualitative strands. We use data from Britain’s third National Survey of Sexual Attitudes and Lifestyles (n = 15,162) to analyse national patterns of symptom experience and care-seeking, and to identify a purposive qualitative sample. Semi-structured interviews (n = 27) following up with survey participants include a novel flash card activity providing qualitative data about infection perceptions, symptom experiences and decisions about healthcare. Quantitative and qualitative data are analysed separately using complex survey analyses and principles of Interpretative Phenomenological Analysis respectively. Data are then integrated in a subsequent phase of analysis using matrices to compare, contrast and identify silences from each method.DiscussionThis is an ongoing mixed methods study collecting, analysing and synthesising linked data from a national survey and follow-up semi-structured interviews. It adds explanatory potential to existing national survey data and is likely to inform future surveys about sexual health. Given the current uncertainty around service provision in Britain, this study provides timely data about symptom experiences and care-seeking behaviour which may inform future commissioning of sexual healthcare.

Understanding sexual healthcare seeking behaviour: why a broader research perspective is needed

BackgroundDespite effective and accessible treatments, many sexually transmitted infections (STIs) in high-income countries go untreated, causing poor sexual health for individuals and their partners. Research into STI care has tended to focus on biomedical aspects of infections using patient samples and prioritised attendance at healthcare services. This approach overlooks the broader social context of STIs and healthcare-seeking behaviours, which are important to better understand the issue of untreated infections.Main bodyThis paper is structured around three main arguments to improve understanding of help-seeking behaviour for STIs in order to help reduce the burden of untreated STIs for both individuals and public health. Firstly, biomedical perspectives must be combined with sociological approaches to align individual priorities with clinical insights. More research attention on understanding the subjective experiences of STI symptoms and links to healthcare-seeking behaviour is also needed. Secondly, a focus on non-attendance at healthcare services is required to address the patient-centric focus of STI research and to understand the reasons why individuals do not seek care. Finally, research using non-patient samples recruited from outside medical contexts is vital to accurately reflect the range of behaviours, beliefs and health issues within the population to ensure appropriate and effective service provision. We suggest piggy-backing other research on to existing studies as an effective way to recruit participants not defined by their patient status, and use a study recruiting a purposive non-patient sample from an existing dataset – Britain’s third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) as an illustrative example.ConclusionSTIs are common but treatable, however a range of social and cultural factors prevent access to healthcare services and contribute to the burden of untreated infection. Different conceptual and empirical approaches are needed to better understand care-seeking behaviour and reduce the gap between social and biomedical advancements in managing untreated infection.

P4.60 How does sexual health clinic attendance relate to risk behaviour? findings from britain’s third national survey of sexual attitudes and lifestyles (NATSAL-3)

Introduction In Britain, sexual health clinics (SHC) attendance has increased in recent decades. SHC remain the commonest place of STI diagnosis but many with STI risk behaviours do not attend. We explored attendance patterns and service preferences in those reporting ‘unsafe sex’ (condomless first sex with new partner and/or ≥2 partners with no condom use, past year). Methods Complex survey analyses of Natsal-3, a probability survey of 15 162 people aged 16–74 years (6293 men), undertaken 2010–2012 using computer-assisted personal- and self-interviewing (CAPI/CASI). Results Overall, recent SHC attendance (past year) was highest among those aged 16-24y (16.6% men, 22.4% women) and decreased with age (<1.5% among those aged 45-74y). Approximately 18% of those 16-44y (n=771 men; n=1080 women) reported unsafe sex; of these, >75% had not attended a SHC in the past year. Among those reporting unsafe sex, non-attenders were older, and less likely to report >2 partners and/or concurrent partners (past year). Most of these non-attenders did not report chlamydia (73% men, 41% women aged <25; 86% men, 73% women aged 25+) or HIV (97% men, 93% women) testing elsewhere (past year). The majority reporting unsafe sex who had previously attended a SHC would seek STI care there (72% men, 66% women), whereas most who had not would go to general practice (66% men, 77% women). Conclusion While SHC attendance was more likely among those reporting STI risk behaviour, many reporting unsafe sex had not attended and most of these did not report chlamydia or HIV tests, indicating they are not receiving sexual healthcare elsewhere. This is of more concern for those at higher STI risk for example the younger, MSM and those with concurrent partners, although higher proportions of younger people reported Chlamydia testing elsewhere. We used unsafe sex as one measure of exposure to risk, which does not take into account characteristics of partner(s) and the wider sexual network. Further improvements are necessary to reach those at-risk, including through effective, diverse service provision.

P067 Why don’t people with genito-urinary symptoms go to sexual health clinics? A mixed methods study about meanings of symptoms and care-seeking using the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Background/introduction There are both individual and public health benefits in people responding to genito-urinary symptoms effectively. Sexual health clinics are best equipped for managing symptoms but not everyone with symptoms chooses to attend. Aim(s)/objectives To examine the prevalence and meanings of genito-urinary symptoms and the impact on non-attendance at sexual health clinics among people in Britain. Methods An explanatory sequential mixed methods study design was used to estimate symptom and clinic non-attendance prevalences using data from 8,947 sexually-experienced women and men aged 16–44 years who participated in Britain’s third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). We conducted follow-up semi-structured interviews with Natsal-3 participants (n = 27) who reported current or recent symptoms and had never attended a clinic, in order to explore STI perceptions, symptom meanings and care-seeking behaviour. Results Prevalence of experiencing symptom(s) in the last month was 21.6% (95% CI 20.4–22.9%) among women and 5.6% (95% CI 4.9–6.6%) among men, of whom 86.3% (95% CI 84.2–88.1) reported not having attended a sexual health clinic in the past year. Bodily changes were not always viewed as symptoms and perceived potential causes were diverse, causing strong emotional responses. Individuals normalised, concealed and/or distanced their experiences from STIs. GPs were the preferred service provider although not all participants perceived a need for care. Discussion/conclusion Symptoms are more commonly reported by women although both women and men may benefit from interventions targeting symptom normalisation and concealment. Good links between services will facilitate efficient and appropriate care-seeking and service delivery.