Six years of outreach testing –is it working? Dr Carol Emerson Belfast Trust

Aim BASHH outreach standards Review of Belfast outreach Snapshot of Rainbow client questionnaire

BASHH outreach standards Just written and out to consultation Format as of clinical standards 9 standards: access, clinical assessment, diagnostics, clinical management, information governance, appropriately trained staff, links to other services and patient/public involvement

Each standard Quality statement Quality measure Quality standard Responsibility of commissioner Responsibility of service provider Responsibility of healthcare worker in the outreach setting People with needs relating to STIs Supporting information

Standard 2-clinical assessment Quality statement People with needs relating to STIs should have a medical and sexual history taken which includes questions about sexual behaviour and other risk factors. Those with symptoms should be offered a genital examination. If examination is clinically indicated but not possible in outreach settings, or if tests that are clinically indicated are not available, seamless referral pathways should be in place for swift transfer into appropriate services. The minimum investigations, even if asymptomatic, are tests for chlamydia, gonorrhoea, syphilis and HIV and should include samples from extra-genital sites.

Standard 2 Quality measure Sexual history – The percentage of people who have a relevant sexual history taken, by the STI service provider or self by completing relevant service documentation. HIV testing – The percentage of people with needs relating to STIs who are offered an HIV test at first attendance (excluding those already diagnosed HIV positive). – The percentage of people with needs relating to STIs who have a record of having an HIV test at first attendance (excluding those already diagnosed HIV positive). – If the outreach service is targeting high risk MSM, the frequency of repeat HIV testing should be monitored.

Standard 2 –what this means for.. Commissioners – have premises that are fit for purpose. – provide evidence of confidentiality, safeguarding and vulnerable adults policies and the training of staff to support these. – have clear links Level 3 GUM services for onward referral Service providers – recording of a medical and sexual history with interpreting services if required. – discussing the window period and limitations of HIV testing – performing a genital examination if facilities allow – collecting specimens offering self-collected pharyngeal, urine, vaginal or rectal sampling with adequate instructions. – safe storage and timely transport of specimens to and from the outreach location. – safe disposal of clinical waste and sharps. An agreement must be in place for who is responsible for the disposal of sharps and waste. – implementing confidentiality, safeguarding and vulnerable adults policies and the training of staff to support these.

Belfast Outreach Jan 2009-dec 2015

Background Hepatitis A outbreak In response, funding to test in venues highlighted by enhanced surveillance Jan 2009 first sauna clinic Monthly events rotating to 2 saunas and LGBT centre, annual pride testing

Method 2 doctors, a nurse and the Rainbow sexual health worker attend each clinic. Dates prearranged with rainbow and advertised by them Walk-in basis Clients are informed at entrance that the clinic is running and have free entry if they decide to attend (usually £7-12 fee). Sauna managers have been very supportive of the clinics. Rainbow volunteers allocate numbers and bring the people to the assessment area

Method Demographic data,sexual history and risk assessment is collected. Offered in Jan 2009 – Serological testing HIV, Syphilis, Hepatitis B + C – Urine CT – Vaccine Hep A+B July 2010 self collected rec CT Jan 2011 GC PCR Th/urine /rec, CT Th Pride events blood/vaccine only Sexual risk, STI protection, availability of post exposure prophylaxis for HIV, and methods of obtaining results and follow up are discussed. Cost per patient £110.

Results Over 6yrs, 79 sessions – 31 sessions sauna A – 23 ‘hardcore’ sauna B – 19 LGBT – 5 pride 1305 assessments, 626 individuals 226 pts have attended more than once, 66 attended 4 or more times Ages 16-83, mean 31.3yrs, median 28yrs – Sauna A 16-83yrs, mean 38.5yrs, median 37yrs – Sauna B 17-80yrs, mean 40.8yrs, median 41 – LGBT 17-71, mean 31.2yrs, median 28yrs – Pride 17-60, mean 31yrs, median 27.5yrs

Results 424 (68%) had never attended GUM before 391 (62%) had never had HIV test 494 Vaccines administered

Partner status and LSI

Last sexual intercourse –reported anal (n=904) 25% (44%) 22% (39%) 31% (49%) 23%

HIV Testing over time % 13% 34% 20% 26% 31% 23% 33% 16% 35% 13% 45% 14%

Vaccines given over time

Total infections detected

Rainbow snapshot of clients attending In 2015

Data from last Quarter 186 male, 2 trans women Identified as – gay man 156, – bisexual 27, – MSM 3, – heterosexual 2, – unsure 2 Martial status: single 122, married 7, civil partner 6, divorced 6, in relationship 35

How did you find out about outreach? – Been before 136 – Poster in sauna 25 – Facebook 50 – Grindr 15 – Gaydar/squirt 14 – Friend 25 – Website 62 – LGBT centre 13 – Word of mouth 3

If used outreach before, what made you return? Free entry to sauna 10 LGBT specific service 36 Timing 52 Accessibility 79 Drop-in 81 Staff 33 Time for reg check 5

If outreach not available would you have went to GUM? – Yes 144 – No 57 Would you recommend service to a friend? – Yes 98 – No 3

Summary We continue to face challenges in relation to sexual ill health. Outreach sexual health services usually target populations disproportionately at risk of poor sexual health and not accessing mainstream services, inc MSM, BME, CSW The outreach standards have been developed – supporting commissioners and – Supporting providers in achieving high quality outreach services – also specify what the public can expect of the outreach services they access. The nine standards bring together existing guidance. They cover all aspects of the management of STIs in outreach settings including access, the diagnosis and treatment of individuals, links to specialist Level 3 GUM providers and the contribution that outreach services can make to broader public health outcomes

Summary The sauna outreach clinic is reaching high risk men who often would not have been tested. There was a high rate of infection diagnosed. The clinic has increased access and raised the profile of the health services offered by the local genitourinary medicine clinic. Over time less vaccines were required Over time the percentage of never testers HIV dropped 34% -13% High risk men HIV testing more freq, 45% 0-6mths

Summary The men attending the clinic found it to be beneficial and welcoming, and almost all would recommend it to others. It is cost effective and efficient. The clinic has helped to develop partnerships with non-statutory groups.