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Abstract
Objectives Men who have sex with men (MSM) bear a disproportionate burden of STIs. While routine STI surveillance data suggest MSM regularly access specialist genitourinary medicine (GUM) clinics for their sexual healthcare, the extent to which MSM attend non-specialist sexual health services (SHSs) is unclear.
Methods We used data from the GUM Clinic Activity Data Set (GUMCADv2), the national STI surveillance system, to compare the characteristics, service usage and STI outcomes of MSM accessing specialist and non-specialist (non-GUM) SHSs in England in 2014. Pearson's χ2, Student's t-test and logistic regression analysis were used.
Results Where sexual orientation was recorded (92%), 11% (4552/41 597) of non-GUM attendances were among MSM compared with 28% (280 466/999 331) of GUM attendances (p<0.001). Compared with those attending GUM services, MSM attending non-GUM services were younger (mean age: 30.2 years vs 37.7 years; p<0.001) and were more likely to be of mixed ethnicity (4.9% vs 3.5%; p<0.001), to have had a full sexual health screen (chlamydia, gonorrhoea, syphilis and HIV tests) (48.0% vs 37.0%; p<0.001) and to be diagnosed with chlamydia (7.4% vs 4.1%; p<0.001) and gonorrhoea (8.5% vs 6.5%: p<0.001). MSM attending non-GUM services had slightly lower HIV test uptake (87.0% vs 95.0%; p=0.157) and were less likely to be diagnosed with HIV (0.5% vs 0.8%; p=0.019), compared with those attending GUM clinics.
Conclusions Non-specialist SHSs play an important role in the care of MSM and should ensure services meet their needs.
- SEXUAL HEALTH
- SURVEILLANCE
- GAY MEN
- HIV TESTING
- SERVICE DELIVERY
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Introduction
Men who have sex with men (MSM) bear a disproportionate burden of STIs.1 In England, MSM are more likely to be diagnosed with gonorrhoea or syphilis than heterosexual men.1 Additionally, while an estimated 2.6% of men in the UK are MSM,2 they accounted for over half of all new HIV diagnoses in 2014.3
Contrary to other countries such as Australia, Germany and Canada, there are fewer barriers to MSM attending sexual health services (SHSs) in the UK: National Health Service care is free at the point of delivery and open access genitourinary medicine (GUM) clinics have a reputation for providing non-judgemental services.4
In England, STI surveillance data have traditionally only been reported by specialist clinics but, to obtain a comprehensive assessment of STI epidemiology and service provision, reporting was expanded to non-specialist (non-GUM) services in 2012.5 These non-specialist services include enhanced general practices (GPs), sexual and reproductive health (SRH) services, young people's (YP) services and other SHSs such as termination of pregnancy and prison services.6 Specialist services provide a comprehensive STI testing and treatment, including the treatment of complicated infections and specialised care for patients such as pregnant women and MSM. Non-specialist services perform STI testing and treatment of uncomplicated infections.6 In England, there is a long-standing evidence of utilisation of specialist services by MSM,1 but the extent to which MSM attend non-specialist services is unclear. Furthermore, little is known about the characteristics and health needs of MSM who access SHSs outside of traditional specialist settings; we investigated the degree to which MSM attend non-specialist setting for sexual healthcare and whether their needs differ from those attending specialist settings.
Methods
Data source
All data returns from non-GUM (324/633) and GUM (227/227) services in England submitted to the GUM Clinic Activity Data Set (GUMCADv2) in 2014 were considered in this analysis. Non-GUM returns included data from SRH services (179/324), YP services (19/324), enhanced GPs (110/324) and other SHSs (16/324). GUMCADv2 is a pseudoanonymised patient-level electronic data set which collects information on diagnoses made and services provided by non-GUM and GUM services in England.
The original GUMCAD system was implemented in 2008 to collect sexual health data from all GUM clinics across England and was expanded to cover other commissioned SHSs in 2012.5 ,6
Data analysis
Records of attendees with unknown age (0.2%), residence (8.7%) or ethnicity (0.1%) were excluded. The frequencies of demographic characteristics, service usage and STI diagnoses in MSM accessing non-GUM and GUM services in 2014 were determined. MSM were defined as men whose self-identified sexual orientation was gay or bisexual at least once throughout their clinic attendance history.
Prior to analysis, the clustering of the data set was taken into account for patients with multiple attendances and only independent observations were retained. Student's t-test, Pearson's χ2 and univariate logistic regression models were used to determine the association between demographic (age, ethnicity and region of residence) and clinical (diagnoses with STIs and receiving a full sexual health screen) characteristics of MSM and the service type attended (GUM and non-GUM). Only the statistically significant results from the univariate analysis were considered in the multivariable logistic regression model.
HIV test uptake was defined as the number of service attendances where a HIV test was accepted as a proportion from those who were offered a HIV test or a full sexual health screen (tests for chlamydia, gonorrhoea, syphilis and HIV). A separate analysis to investigate the association between HIV test uptake and service type attended was performed using the Pearson's χ2 test.
Unadjusted and adjusted ORs (ORs and aORs, respectively) with 95% CIs are reported and p values <0.05 were considered to be statistically significant. Analyses were performed using STATA V.13.1 (StataCorp LP, College Station, Texas, USA).
Results
Of all attendances by men where sexual orientation was recorded (92%), 11% (4552/41 597) of non-GUM attendances were made by MSM compared with 28% (280 466/999 331) of GUM attendances (p<0.001). The majority of attendances to non-GUM services were reported from SRH services (3987/4552; 87.5%) followed by other SHSs (315/4552; 7%), enhanced GPs (181/4552; 4%) and YP services (69/4552; 2%).
Compared with GUM services, MSM attending non-GUM services were younger (mean age: 30.2 vs 37.7 years; p<0.001), were more likely to be of mixed ethnicity (4.9% vs 3.5%; p<0.001) and reside outside London (49.9% vs 45.6%; p<0.001). On multivariable analysis (table 1), compared with 15-year-olds to 19-year-olds, older MSM were increasingly less likely to attend non-GUM services. MSM of mixed ethnicity were significantly more likely to attend non-GUM services compared with their White counterparts (aOR 1.18; 95% CI 1.02 to 1.36; p=0.026).
The results of a multivariable analysis showing the association between demographic and clinical characteristics of MSM and their likelihood of attending non-specialist SHSs in England, 2014
HIV test uptake among MSM attending non-GUM clinics was lower compared with GUM attendees, but this was not significantly different (87.0% vs 95.0%; p=0.157). MSM attending non-GUM services were more likely to have had a full sexual health screen (48.0% vs 37.0%; p<0.001) at any visit compared with those attending GUM services.
MSM attending non-GUM services were more likely to be diagnosed with chlamydia (7.4% vs 4.1%; p<0.001), gonorrhoea (8.5% vs 6.5%; p<0.001) and first-episode genital herpes (0.8% vs 0.5%; p=0.009) compared with those attending GUM services. Syphilis (primary, secondary and early latent) (0.7% vs 1.3%; p=0.001), non-specific genital infection (0.6% vs 1.9%; p<0.001) and newly diagnosed HIV (0.5% vs 0.8%; p=0.019) were less likely to be diagnosed in MSM attending non-GUM services compared with MSM attending GUM services.
Discussion
A substantial number of MSM attend non-specialist SHSs for STI testing and care. MSM attending non-specialist services were at considerable risk of STIs and were less likely to have been tested for HIV. Therefore, there is a need to ensure that non-specialist services meet the sexual health needs of this group of patients. Our findings highlight the important role that non-specialist services play in the sexual health of MSM and the importance of ensuring a high uptake of HIV and STI screening in this setting.
There were a number of limitations which could have influenced the findings of this investigation. Contrary to specialist services (100% reporting coverage), reporting coverage from non-specialist services is suboptimal (52%). Recording of key variables such as sexual orientation is not consistent in non-specialist services (62% completeness), varying from 81% in SRH services, 45% in YP services to 14% in enhanced GPs, compared with specialist services (96%). Thus, our analysis is subject to selection bias and our findings may not be generalisable to all MSM attending non-specialist services. Another key limitation of the data set used is that patients cannot be tracked between different services. Service location was used for the HIV test uptake analysis; thus, we could not compare test uptake by residence in high (≥2 per 1000 15-year-olds to 59-year-olds) or low HIV prevalence areas.7
Consistent with our findings, non-specialist services were previously reported as not meeting the standards required for MSM sexual healthcare, preventing this at-risk population from benefiting from the wider range of settings which provide non-specialist services.8 Prior evidence also suggests access of non-specialist services such as GPs for sexual health check-ups or HIV testing was most common among younger men (under 30).9 Furthermore, a systematic review indicates a low HIV testing coverage due to low levels of provider test offer rather than patient acceptance, suggesting improved surveillance of HIV testing outside of specialist services is needed to assess whether these services are adhering to testing guidelines.7
Our findings highlighted the utility of implementing STI surveillance in non-specialist services, as this is pivotal to understanding the level of care provided to at-risk populations such as MSM. It is important, therefore, to recognise the role of these non-specialist services in sexual health provision and, as more data are submitted, review the trends in STI diagnoses and service utilisation.
In conclusion, this study demonstrates the high levels of utilisation of non-specialist services by MSM in England, within which there are comparably high proportions of STI diagnoses to those attending specialist services. It is essential that these services meet potentially complex care needs of this group of men. A younger cohort of MSM is more likely to attend these non-specialist services, perhaps due to greater acknowledgement of lesbian, gay, bisexual and transgender communities in general, such that younger people may find services more ‘gay friendly’ than older MSM would have done in the past. Limited options of SHSs outside major conurbations could explain why MSM who reside outside London were more likely to attend non-specialist services. Thus, this should be viewed as an opportunity to increase access and provide services that meet their needs. Furthermore, through targeted service provision such as increased HIV test uptake and strengthening care pathways and linkage to specialist services, non-specialist services can make a meaningful contribution to the improvement of sexual health in MSM.
Acknowledgments
We thank all clinics who submit GUMCADv2 data to Public Health England (PHE). We are grateful for the assistance of Ms Mandy Yung and Ms Lou Salome in developing this report and Mr Saleh Mohammed for his helpful suggestions and input.
Footnotes
Handling editor Jackie A Cassell
Contributors GH and HMo conceived the analysis and agreed the data analysis plan with HMe. HMe performed the analysis and prepared the first draft with the assistance of BS, JW and MF. All authors read and critically reviewed the manuscript and helped in developing the final version for publication.
Competing interests None declared.
Ethics approval GUMCADv2 is a routine public health surveillance activity, therefore no specific consent was required from the patients whose data were used in this analysis. PHE has permission to handle data obtained by GUMCADv2 under section 251 of the UK National Health Service Act of 2006 (previously section 60 of the Health and Social Care Act of 2001), which was renewed annually by the ethics and confidentiality committee of the National Information Governance Board until 2013. Since then, the power of approval of public health surveillance activity has been granted directly to PHE.
Provenance and peer review Not commissioned; externally peer reviewed.