Integrated sexual healthcare: the development and review of one model of service delivery

Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services

The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.

Complementary therapy provision in a London community clinic for people living with HIV/AIDS: a case study

AIM

To present a case study of complementary therapy (CT) provision within a community HIV multi-agency service in a Northwest London deprived area.

METHODS

Anonymised routine service data were provided for all clients (n = 1030) August 2010 to October 2012. Face-to-face meetings provided feedback from volunteers (9 CT-using clients and 9 staff).

RESULTS

CT-users were demographically similar to other clients. Support for coping with HIV was commonly cited as a service benefit. Over 26 months 1416 CT sessions were provided; 875 aromatherapy and 471 shiatsu. CT-users' most common concerns were pain (48%), stress (15%) and insomnia (13%), few had heard of or used CT before. Perceived mental and emotional benefits included relaxation,stress relief, relieving musculoskeletal aches and pains. Service challenges included time and funding, though staff felt CT may be cost-effective.

CONCLUSIONS

CT may provide important support and treatment options for HIV disease, but cost effectiveness requires further evaluation.

Impact of integrated family planning and HIV care services on contraceptive use and pregnancy outcomes: a retrospective cohort study

OBJECTIVE

To determine the impact of routine care (RC) and integrated family planning (IFP) and HIV care service on family planning (FP) uptake and pregnancy outcomes.

DESIGN

Retrospective cohort study conducted between October 10, 2005, and February 28, 2009.

SETTING

United States Agency for International Development-Academic Model Providing Access To Healthcare (USAID-AMPATH) in western Kenya.

SUBJECTS

Records of adult HIV-infected women.

INTERVENTION

Integration of FP into one of the care teams. PRIMARY OUTCOMES MEASURES: Incidence of FP methods and pregnancy.

RESULTS

Four thousand thirty-one women (1453 IFP; 2578 RC) were eligible. Among the IFP group, there was a 16.7% increase (P < 0.001) [95% confidence interval (CI): 13.2% to 20.2%] in incidence of condom use, 12.9% increase (P < 0.001) (95% CI: 9.4% to 16.4%) in incidence of FP use including condoms, 3.8% reduction (P < 0.001) (95% CI: 1.9% to 5.6%) in incidence of FP use excluding condoms, and 0.1% increase (P = 0.9) (95% CI: -1.9% to 2.1%) in incidence of pregnancies. The attributable risk of the incidence rate per 100 person-years of IFP and RC for new condom use was 16.4 (95% CI: 11.9 to 21.0), new FP use including condoms was 13.5 (95% CI: 8.7 to 18.3), new FP use excluding condoms was -3.0 (95% CI: -4.6 to -1.4) and new cases of pregnancies was 1.2 (95% CI: -0.6 to 3.0).

CONCLUSIONS

Integrating FP services into HIV care significantly increased the use of modern FP methods but no impact on pregnancy incidence. HIV programs need to consider integrating FP into their program structure.

Addressing sexual health needs: a comparison of a one-stop shop with separate genitourinary medicine and family planning services

BACKGROUND AND METHODOLOGY

Little evidence is available on the extent to which one-stop shops address users' sexual health needs and the extent to which they identify additional needs users may not have identified. As part of the One-Stop Shop Evaluation, a questionnaire was designed to compare the reasons for users' visits and the reported outcomes of visits at a one-stop shop with the experiences of users in separate genitourinary medicine (GUM) and contraceptive clinics.

RESULTS

The difference in the proportions of those attending the one-stop shop and those attending the control sites services for a sexually transmitted infection (STI)-related reason who were diagnosed with an STI was minimal, but those attending for an STI-related reason in the one-stop shop were more likely to receive an additional contraceptive outcome. Women attending for a contraceptive-related reason at the one-stop shop were more likely to have an STI screen than those attending the control sites for the same reason, but there was little difference in the proportions amongst this group receiving an STI diagnosis or receiving treatment. When focusing on women attending for a pregnancy-related reason, one-stop shop users were more likely to have received contraceptive advice or supplies.

DISCUSSION AND CONCLUSIONS

It was not possible in our evaluation to determine the relative effectiveness of the one-stop shop in comparison to the traditional GUM and contraceptive clinics in improving sexual health status, however the one-stop shop was more likely to address additional sexual health needs that service users may not have previously identified.

Health systems' responses to 25 years of HIV in Europe: inequities persist and challenges remain

Europe is currently experiencing the fastest rate of growth of HIV of any region of the world. An analysis of policy and health system responses to the HIV epidemic in Europe and central Asia (hereafter referred to as Europe) over the last 25 years reveals considerable heterogeneity. In general, while noting hazards of broad generalisations and the differences that exist across countries in a particular grouping, effective policies to control HIV have been implemented more widely in western than in central and eastern Europe. However, the evidence suggests persistence of inequalities in access to preventive and treatment services, with those at highest risk, such as commercial sex workers, prisoners, intravenous drug users, and migrants often particularly disadvantaged, despite many targeted programmes. Responses in individual countries, especially in the early stages of the epidemic, were influenced by specific cultural and political factors. Strong leadership and active involvement by civil society organisations emerge as important factors for success but also a limiting factor to the response observed in eastern Europe, where civil society or NGO culture is weak as compared to western Europe. Scaling up of effective responses in many countries in eastern Europe will be challenging-where increased financial resources will have to be accompanied by broader changes to health system organization with greater involvement of the civil society in planning and delivery of client-focused services.

Success of a nurse led community based genitourinary medicine clinic for young people in Liverpool: review of the first year

OBJECTIVES

To assess the outcome and workload of a community based, nurse led comprehensive sexual health and contraceptive service for clients aged less than 25.

METHODS

Review of appointment diaries and clinic records of clients who attended the Brook genitourinary medicine (GUM) clinic. The workload, case mix, and achievement of national targets in the first year of the service were compared with those for the same age group of clients attending the nearby hospital based GUM clinic. A limited client satisfaction questionnaire was carried out 8 months after the clinic opened.

RESULTS

1061/1700 (62.4%) clients (185, 17.4% male) attended booked appointments. Chlamydia trachomatis was detected in 16.1% of women and 20.5% of men at Brook (p<0.05), where 22.6% of women and 50% of men had at least one sexually transmitted infection (p<0.001). HIV testing was offered to 98.5% of clients. 60.7% of all identified contacts attended a clinic for testing and/or treatment. Client responses to a questionnaire about the service were very favourable. Only 2.3% of Brook GUM clients needed referral to a physician.

CONCLUSIONS

Nurse led community based GUM services, such as the one provided at the Merseyside Brook Centre, appeal to young people and our success should encourage others to consider similar ventures.

One stop shop versus collaborative integration: what is the best way of delivering sexual health services?

OBJECTIVES

To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses.

METHODS

Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11).

RESULTS

The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory.

CONCLUSION

Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Use of a staff administered structured questionnaire to identify relevant life-style issues and social-health determinants in a sexual and reproductive health service

OBJECTIVE

To evaluate a staff-administered questionnaire to identify life-style issues and social-health determinants.

DESIGN

Structured questionnaire administered by a health professional after dealing with the primary reason for attendance.

SETTING

Community-based UK sexual and reproductive health service.

POPULATION

First 1329 selected clinic patients comprising 1018 women attending Family Planning and 161 women plus 150 men attending Genitourinary Medicine; 47% were aged under 25.

MAIN OUTCOME MEASURES

Identification of relevant health-risk taking, life-style issues, and unaddressed health concerns. Participants were offered appropriate support, information and referrals.

RESULTS

Two hundred and sixty-four (23%) of the Family Planning women and 83 (52%) of the Genitourinary Medicine women [plus 103 (69%) of the men] reported two or more sexual partners in the last year. A third of participants denied regular condom use. Six per cent of women and 5% of men questioned had previously been forced to have sex. Eleven per cent of men admitted to having paid for sex and 9% of women disclosed physical assault (one-quarter in the home). Eight per cent of women and 7% of men had unresolved issues relating to previous miscarriage, termination, or stillbirth.

CONCLUSIONS

It is possible to identify relevant life-style issues and social determinants of health during routine practice using a staff-administered questionnaire. The resulting information may not otherwise have been disclosed and may impact significantly on health and care delivery. The information collected provides opportunities for both individuals and service planners to address wider health needs.

A comparative study of clinical management strategies for vaginal discharge in family planning and genitourinary medicine settings

OBJECTIVE

To compare strategies for management of women with vaginal discharge in genitourinary medicine (GUM) and family planning (FP) settings.

METHODS

The setting was a centre housing both FP and GUM departments within a primary care trust in Scotland. The study participants were 200 women presenting with vaginal discharge. A randomised, controlled, crossover design was employed. Strategies typical of FP and GUM were performed on every participant in a randomised sequence. Day 1 diagnoses were made by the FP strategy (history and examination) and the GUM strategy (nearpatient microscopy added). Day 7 results were obtained from final analysis of all specimens. Days 1 and 7 results were compared with the reference standard provided by all the test results. The main outcome measures were incorrect diagnoses on Days 1 and 7.

RESULTS

On Day 1 the FP strategy resulted in significantly more incorrect diagnoses than the GUM strategy when compared with the reference standard (73 vs 32; p <0.001). On Day 7 the GUM strategy resulted in significantly more incorrect diagnoses than the FP strategy when compared with the reference standard (32 vs 17; p = 0.019).

CONCLUSIONS

Vaginal discharge can be managed effectively in community settings such as FP and primary care. The addition of near-patient microscopy produces a more accurate immediate diagnosis. The addition of a high vaginal swab for culture produces a more accurate final diagnosis. The costs of on-site microscopy must be considered.

Feminization of the HIV epidemic in the United States: major research findings and future research needs

This article describes several HIV prevention interventions that have demonstrated efficacy in reducing women's risk of HIV and identifies key research questions to be addressed in the area of HIV prevention for women. The article is organized in a question-and-answer format for clarity of presentation. This format is particularly useful in the latter half, which focuses on specific questions that have emerged from past and ongoing research among women. Some of these research questions include the following: (a) How can researchers develop effective strategies that can prevent women from relapsing to risky sexual practices? (b) What are effective HIV prevention approaches for Latina women? (c) How can interventions be tailored to the needs of women living with HIV? (d) How can we improve the efficacy and cost effectiveness of comprehensive HIV prevention strategies for reducing HIV and other blood-borne and sexually transmitted infections among women?

A 6-month pilot of a collaborative clinic between genitourinary medicine services and a young persons' sexual health clinic

OBJECTIVE

To investigate whether situating a genitourinary medicine (GUM) clinic within a Brook centre is successful in attracting a younger client group than that traditionally seen in GUM clinics within hospitals.

DESIGN

A descriptive study of a 6-month pilot clinic.

SETTING

Brook in Manchester. A community clinic providing sexual health advice to clients under the age of 25 years. With the collaboration of Withington Hospital GUM Department, Manchester.

PARTICIPANTS

All clients under the age of 25 years attending the pilot GUM clinic.

MAIN OUTCOME MEASURES

The age of the clients attending and the diagnosis made.

RESULTS

A total of 137 visits were made by 93 clients. Under-16s comprised 6% of all visits compared to 1.5% at Withington GUM clinic (adjusted for the under-25s) and 12% at Brook. Far more Chlamydia trachomatis was seen (34% of all clients) than in a traditional GUM clinic (18% of all clients). Contact tracing resulted in 82% of named contacts being traced.

CONCLUSION

The pilot clinic was successful in attracting a much younger client group than a traditional hospital-based service.