An update on the National Chlamydia Screening Programme Wednesday 13 March, 2013 London

Deputy Chief Executive, Health Protection Agency Welcome Dr. Paul Cosford Director for Health Protection and Medical Director, Public Health England Deputy Chief Executive, Health Protection Agency

Kate Folkard NCSP Programme Manager kate.folkard@hpa.org.uk Overview of the National Chlamydia Screening Programme – challenges, successes and future direction Kate Folkard NCSP Programme Manager kate.folkard@hpa.org.uk

The National Chlamydia Screening Programme (NCSP) in England Aims to control chlamydia thus reducing transmission and sequelae Opportunistic screening of sexually active < 25 year olds Annually Change of sexual partner Clinical and non-clinical venues Routine offer at every consultation Standards for treatment and partner notification

The NCSP: achievements to date High volumes screened - deliver around 2 million tests and 150,000 diagnoses per year Expansion of sexual health services into community with range of providers Early adoption of new technologies Quality assurance programme Involvement of men Reaching those at higher risk and the socio-economically deprived

What are young people’s views? Don’t always see chlamydia as relevant to them Prefer a blanket approach to testing Want to be asked rather than have to ask for a test Don’t want to have to give a sexual history Need to be sure of confidentiality Want options – healthcare professional/ ’virtual’ testing Want results quickly Want support to be available to manage positive results Chlamydia Screening and Sexual Health Marketing – COI for DH. Define, 2008 Effectiveness of chlamydia screening will depend on several factors….to be discussed in more detail now…

Roles and responsibilities Cost effectiveness not discussed…

Trends in chlamydia screening: the impact of transition? Decline in screening activity: Drop in test volume and diagnoses over 2011/12 National diagnosis rate: 1,850 per 100,000 (Jul-Sep’12) Advice to local areas: Maintain sufficient investment in screening Integrate screening within primary care, SRH and GUM services (& reduce outreach) Ensure repeat screening annually/change of partner Achieve PN standards

Future direction of the programme Emphasis on integration and delivery models; embed within primary care, SRH and GUM services Deliver synergies with young adults’ sexual health interventions such as contraceptive advice, condom use and wider health promotion Chlamydia Testing Activity Dataset (CTAD) From coverage target to diagnostic indicator Public Health Outcome Framework Evaluation framework

Objectives of the day To bring together HPA, PHE, public health and commissioning colleagues with a remit for sexual health to: Present the latest evidence on chlamydia screening approaches and outcomes Provide an update on recent NCSP developments and future plans Ensure confidence in making the case for chlamydia screening at a local level Explore ways to ensure the NCSP can deliver effectively during the transition year and beyond

Agenda

Workshop Session: Delivering the NCSP during the transition 30 minute facilitated discussion around three questions: What are the priorities for the NCSP over the next two years? What do you want to deliver locally? What support do you need from NCSP nationally to deliver? Who is going to help you deliver at a local level / what are your new emerging local network?

The chlamydia screening evidence base – overview Kate Soldan kate.soldan@hpa.org.uk

Chlamydia trachomatis Common sexually transmitted infection Majority of infections are asymptomatic Highest rates of infection among young people Easy to detect using NAAT tests Easy to treat with antibiotics Chlamydia infected culture (Wellcome Images)

Rationale for chlamydia screening Chlamydia infection is a known risk factor for a number of serious health problems: Pelvic inflammatory disease Ectopic pregnancy Tubal factor infertility Neonatal pneumonia and neonatal conjunctivitis Epididymitis in men Treating chlamydia infections prevents the development of sequelae RCT showed 83% reduction in PID among treated compared to untreated chlamydia infection (p>0.05)[1] [1] Oakeshott et al. BMJ 2010;340:c1642

Rationale for chlamydia screening Asymptomatic screening to detect chlamydia trachomatis should: Reduce the prevalence and incidence of infection Reduce the risk of developing health problems

What do we want to know? Impact of widespread screening for asymptomatic chlamydia infections on Prevalence and incidence of chlamydia The incidence of complications Young adults’ sexual health and wellbeing The predicted impact The impact in practice Effectiveness of chlamydia screening will depend on several factors….to be discussed in more detail now…

Optimal models of service delivery What do we want to know? Optimal models of service delivery Partner notification Testing frequency Testing the right people Sustainable service configuration Cost effectiveness Cost effectiveness not discussed…

The evidence base on outcomes of chlamydia screening

Reducing transmission and prevalence Sarah Woodhall sarah.woodhall@hpa.org.uk

How should chlamydia screening affect prevalence and incidence? Asymptomatic screening to detect chlamydia trachomatis (plus subsequent partner notification) should: Reduce prevalence of infection by removing cases from the pool of infections Identify infections earlier in the course of infection Reduce incidence of infection by preventing onward transmission to sexual partners

Natural course of chlamydia infection End of infection without screening Infection Natural clearance Develop symptoms/complications, treated

Screening reduces the duration of infection End of infection without screening End of infection with screening Infection Natural clearance Develop symptoms/complications, treated Screening test

Chlamydia screening can prevent transmission End of infection without screening Infection Natural clearance Develop symptoms/complications, treated Chlamydia passed on to sexual partner

Chlamydia screening can prevent transmission End of infection without screening End of infection with screening Infection Natural clearance Develop symptoms/complications, treated Screening test Chlamydia not passed on to sexual partner

Mathematical modelling Randomised controlled trials What do we know about the impact of chlamydia screening on prevalence and transmission in practice? Mathematical modelling Randomised controlled trials Analysis of routinely collected data Prevalence surveys

Mathematical modelling Randomised controlled trials What do we know about the impact of chlamydia screening on prevalence and transmission in practice? Mathematical modelling Randomised controlled trials Analysis of routinely collected data Prevalence surveys

Chlamydia prevalence among 16-24 year olds: Modelling the effectiveness of screening Testing coverage: 9% Chlamydia prevalence (%) Testing coverage: 26% Testing coverage: 43% Years after introduction of the screening programme Key assumptions: Baseline prevalence 6.5%; PN 20%; few cases treated in absence of screening programme NAO, 2009. Based on: Turner et al. STI 2006

Mathematical modelling Randomised controlled trials What do we know about the impact of chlamydia screening on prevalence and transmission in practice? Mathematical modelling Randomised controlled trials Analysis of routinely collected data Prevalence surveys

Randomised controlled trial of chlamydia screening, Netherlands RCT among >300,000 16-29 year old men and women Annual postal invitation to chlamydia screening for 3 years Lower than expected uptake (10% -16%) No significant fall in prevalence was observed some evidence for a fall in South Limburg Van den Broek et al. BMJ 2012

Ongoing randomised controlled trials of chlamydia screening Australia The Australian Chlamydia Control Effectiveness Pilot (www.accept.org.au) Randomised controlled trial of chlamydia screening in primary care. Finland Cluster randomised controlled trial as part of an HPV vaccine trial

Mathematical modelling Randomised controlled trials What do we know about the impact of chlamydia screening on prevalence and transmission in practice? Mathematical modelling Randomised controlled trials Analysis of routinely collected data Prevalence surveys

Chlamydia diagnosis rate (per 100,000 pys), 15-24 year old females GUM diagnoses represent uncomplicated CT; NNNG (Non-NCSP, non-GUM) diagnoses available from April 2008 onwards. GUM data as at Feb 2013; NCSP/NNNG data as at November 2012

Number of tests and proportion testing positive by gender (NCSP tests)

Number of tests and proportion testing positive by gender (NCSP tests)

Mathematical modelling Randomised controlled trials What do we know about the impact of chlamydia screening on prevalence and transmission in practice? Mathematical modelling Randomised controlled trials Analysis of routinely collected data Prevalence surveys

Population based prevalence surveys United States National Health and Nutrition Examination Survey Includes urine test for chlamydia UK National Surveys of Sexual Attitudes and Lifestyles Chlamydia prevalence in 2000 and ~2010 Comparability between survey years limited Pilot postal survey among young women conducted in 2 PCTs in 2011[1] Low response rate, therefore open to substantial bias Unlikely to be a feasible or appropriate method of monitoring prevalence over time [1]Woodhall et al, Under review

Summary In the absence of changes in any other risk factors, chlamydia screening should reduce the prevalence and incidence of chlamydia Mathematical modelling and routine data are consistent with a fall in chlamydia prevalence in recent years No empirical evidence to demonstrate a fall in prevalence Changes in chlamydia in the context of testing and trends in other STI will become more informative in the future

Kate Soldan kate.soldan@hpa.org.uk Preventing sequelae Kate Soldan kate.soldan@hpa.org.uk

Chlamydia is an important cause of reproductive health problems in women Ectopic Pregnancy 7.6% Pelvic Inflammatory Disease 1% / 10% / 30% Chlamydia infection 10.8% Tubal Factor Infertility Source: Adams et al. STI 2007; 83;267-275

~10% to 20% risk of developing PID after a chlamydia infection[1,2] Chlamydia is an important cause of reproductive health problems in women ~10% to 20% risk of developing PID after a chlamydia infection[1,2] ~45% of tubal factor infertility is caused by chlamydia[3] 7/74 (9.5%) 18-29 year old women with untreated chlamydia developed PID within one year[*POPI] Synthesis of results from 8 studies estimates 16% - 20% risk of PID[*Price] [1] Oakeshott et al. BMJ 2010;340:c1642; [2] Price et al. Am J Epi. In press; [3] Price STD 2012;39(8)

Can chlamydia screening prevent PID? Chlamydia infection PID not prevented PID prevented

Can chlamydia screening prevent PID? Synthesis of published studies has estimated that ~41% to 61% of chlamydia-related ‘PID’ can be prevented by annual screening[2] Three randomised controlled trials have evaluated the effect of a single round of chlamydia screening on PID 1 year later [2] Price et al. Am J Epi. In press

Can chlamydia screening prevent ‘PID’? [4] Scholes NEJM:1996;334:1362-6; [5] Ostergaard CID:2000;31:951–7; [6] Oakeshott BMJ:2010;340:c1642

Rate of PID diagnoses in General Practice by definition (Females 16 to 44 years old) Source: French et al. STD 2011: 38(3):158-62

Rate of PID diagnoses* in General Practice by age group (Females 16 to 44 years old) Rates [of definite/probable PID] declined in all areas and among all age groups with greatest decline in women aged 16 to 19 years.” Levels of chlamydia screening amongst young women were relatively low during the study period. Re-analysis of data to the end of 2011, i.e. including years of higher chlamydia screening amongst under 25 year olds, is now in progress and should show whether screening at levels reached in 2009-11 is associated – in ecological analyses - with declines in PID. *Definite/probable PID diagnoses Source: French et al. STD 2011: 38(3):158-62

Summary Asymptomatic screening to detect chlamydia trachomatis can prevent the subsequent development of sequelae The proportion of PID and ectopic pregnancy episodes that can be prevented by screening depends on levels of screening natural history of infection

NCSP web survey 2012 – Attitudes to chlamydia screening and subsequent impact on behaviour Chlamydia Operations Group 13 Mar 2013 Tom Hartney, Paula Baraitser, Anthony Nardone Sexual Health Promotions Team thomas.hartney@hpa.org.uk

Web survey background Little data on attitudes of young people to chlamydia screening Qualitative study reported generally positive attitudes1 Little information on impact of screening on subsequent behaviour. Self-reported changes in sexual behaviour following a positive result for STIs: Increase of condom use post-treatment for STIs2,3. Decrease in sexual partners2 1 Hogan et al 2010; 2 Sznitman et al 2009; 3 Fortenberry et al 2002

Aims Aim: to inform the development of the NCSP through a survey of young people, both tested and non-tested. What are young people’s attitudes towards chlamydia and chlamydia testing? What impact does being tested have on future behaviour?

Methods Questionnaire took around 20 minutes, covered Web-based cross-sectional anonymous survey Used panel of young people accessed via market research company (small incentive, <£1) Eligibility criteria: Aged between 16-24 Resident in England Representative by age, sex and region Questionnaire took around 20 minutes, covered Testing history Sexual behaviour Demographics Attitudes and impact of testing on behaviour

Results 1,521 responses over 2 weeks in June 2012 Demographically weighted sample: 51% male, 81% white 46% ever tested (29% in last year) 57% of these tested more than once 13% had had a previous positive result 11% had >1 partner in last year (39% among tested) 29% had unprotected sex in last 3 months (61% among tested) 70% of those not tested didn’t consider themselves at risk

Assessing attitudes Questions use framework of Theory of Planned Behaviour Likert scale 1-5 (strongly disagree to strongly agree) “Please read the following statements and decide to what extent you agree or disagree with each of them...” “I should get tested for chlamydia every year if I am sexually active” “Getting tested for chlamydia is a normal part of young people’s lives” “My friends get tested for chlamydia” “Chlamydia is a problem that does not concern me” “I would be too embarrassed to ask for a chlamydia test” “Only people who sleep around get chlamydia” Cost effectiveness not discussed…

Attitudes towards chlamydia and testing

Attitudes by testing status

Combined attitudes scores Each statement either positively or negatively associated with testing “I should get tested for chlamydia every year if I am sexually active” “Getting tested for chlamydia is a normal part of young people’s lives” “My friends get tested for chlamydia” “Chlamydia is a problem that does not concern me” “I would be too embarrassed to ask for a chlamydia test” “Only people who sleep around get chlamydia” Level of agreement used to score each response from -2 to +2 Combined to form overall attitude score for each respondent

Proportion tested by combined attitude score

Behavioural questions “Would you say that having been tested for chlamydia has made you more or less likely to...” (1 = “Much less likely” to 5 = “Much more likely”) Know how to avoid getting chlamydia Discuss contraception with a new partner Use condoms every time I have sex Ask a new partner to have a test for chlamydia? Have fewer sexual partners Discuss my sexual health with a nurse or doctor Test for chlamydia again in future Ask my GP or practice nurse for a chlamydia test Recommend a chlamydia test to a friend

Impact of testing of future behaviour (n=695)

Impact by test result

Impact by time since last test

Conclusions Positive attitudes towards chlamydia and chlamydia testing are strongly associated with being tested More than half (55%) of those never tested agree that they should be tested every year Majority of young people report that testing has a positive impact on their behaviour More impact on health-care seeking than sexual behaviour positive result: more impact on condom use and discussing sexual health with professionals recent testing (<3 months): more impact on partner numbers Repeat of survey in summer 2013: track changes over time explore impact of testing in more detail

Thank you thomas.hartney@hpa.org.uk

Framework: The Theory of Planned Behaviour

Lunch

Chlamydia Testing Activity Dataset (CTAD) Update and future plans Dr Nicky Connor Consultant Epidemiologist, CTAD Nicky.connor@hpa.org.uk

Where does chlamydia data come from?

How do national NCSP and CTAD chlamydia diagnosis rates compare? Effectiveness of chlamydia screening will depend on several factors….to be discussed in more detail now…

How do regional NCSP and CTAD chlamydia diagnosis rates compare? Cost effectiveness not discussed…

How many laboratories submit CTAD data? Number of laboratories submitted data by 06.03.2013 England, by quarter: *estimate Number of missing laboratory submissions per quarter by region

How easily can we assign tests by area of residence? Proportion of valid postcode of residence available for non-GUM samples for each region by quarter

How can we improve local data?

What NCSP data will be available?

What reports will you be able to create on the web portal?

What routine quarterly reports will there be?

Making CTAD a success New data system at a time of change Improve data quality - testing services and laboratories Postcode of residence Testing service type Success Easier to collect data Better data Inform commissioning

Thank you! Laboratories Testing services Sexual health commissioners HPA sexual health leads HPA Regional information managers Chlamydia screening officers Sexual health facilitators GUMCAD surveillance team CTAD surveillance team NCSP team All other contributors

The evidence base on implementation issues

Internet testing for Chlamydia trachomatis in England, 2006 to 2010* Sarah Woodhall sarah.woodhall@hpa.org.uk *Woodhall et al. BMC Public Health 2012;12:1095

Background The NCSP offers free chlamydia tests to under 25 year old men and women in England Testing services are delivered locally Chlamydia tests are available from testing venues, for example: General practice Sexual and reproductive health services Non-clinical venues including the internet

The internet testing pathway Please call us to get your chlamydia test result. Laboratory

Aims To describe online access to chlamydia testing within the NCSP To evaluate websites offering testing in terms of signposting and health promotion advice

Methods (1) Data source NCSP chlamydia testing data, 2006 to 2010 15-24 year old men and women 71/95 programme areas with available data Compared reported characteristics for test from three settings (2010): Internet tests General Practice (GP) clinics Sexual and reproductive health services (SRH)

Identified websites offering chlamydia tests: Methods (2) Identified websites offering chlamydia tests: Free chlamydia tests through the NCSP Tests offered on a commercial basis Evaluated websites: Signposting to clinical services Health promotion information

What proportion of NCSP tests are carried out through the internet ? *Includes 71 programme areas (covering 111 PCTs) with specific codes for tests accessed through the internet.

Contribution of internet tests Percentage of programme areas What proportion of NCSP tests were carried out through the internet in each programme area? (2010) Contribution of internet tests Percentage of programme areas Under 2% 30% 2% to <10% 40% 10% to 38% *Includes 71 programme areas (covering 111 PCTs) with specific codes for tests accessed through the internet.

What proportion of tests were positive?

Who accessed chlamydia tests in each setting? *Proportions presented among those with available data. GP=General practice ; SRH= Sexual and Reproductive Health Services

Health promotion information and signposting NCSP websites (n=58) Commercial services (n=32) Condom use 85% 29% Contraception 33% 0% How to access other STI tests 47% 60% Signposting if symptomatic 79% 32% N=58 NCSP websites; 32 commercial websites

Summary Internet testing is an important component of chlamydia control Access to free chlamydia testing via the internet is widely available in England But fragmentation and duplication of services is a problem Internet testing reaches a population with a high risk of chlamydia (e.g. men, higher risk sexual behaviour) Websites should signpost to clinical care and health promotion information Routine audit tools now under development

Repeat testing after a positive test for chlamydia Sarah Woodhall sarah.woodhall@hpa.org.uk

Question Should the NCSP routinely recommend repeat testing following a positive chlamydia test result?

Overview Current NCSP policy related to repeat chlamydia testing Summary of available evidence relating to repeat chlamydia testing Risk of re-infection Current repeat testing patterns Different approaches to repeat testing The role of reinfection in relation to other interventions Acceptability and cost

Current pertinent NCSP policy Opportunistic screening in a variety of venues Screening annually and on change of partner Sexual health advice for all Treatment and partner notification standards No routine ‘test of cure’

Risk of re-infection following a positive chlamydia test Young people who test positive for chlamydia are at higher risk of subsequently testing positive for chlamydia[1-3] [1]Lamontagne. STI 2007; [2] PLoS.One. 2012;[3] Batteiger JID. 2010

Risk of re-infection following a positive chlamydia test High rates of re-infection have been consistently reported in several settings[4-8] Systematic reviews show: median of 14% of women re-infected at repeat test[7] median of 11% of men infected at repeat test[8] [4] Woodhall STI 2012; [5] Turner STI 2012; [6] Rietmeijer STD 2002; [7] Hosenfeld STD 2009; [8] Fung STI 2007

Impact on progression to sequelae, chlamydia incidence and prevalence Data from observational studies and mathematical models suggest that: Repeat chlamydia infections are associated with an increased risk of adverse sequelae[9,10] Re-infections within existing sexual partnerships are likely to be important in maintaining levels of chlamydia prevalence[11] There is limited evidence on the potential impact of increasing repeat testing on the incidence or prevalence of chlamydia or on the development of chlamydia-related sequelae Could assume to be at least as beneficial as diagnoses made through asymptomatic screening [9] Haggerty et al. JID 2010;201 Suppl 2:S134-S155; [10] Darville et al. JID 2010;201 Suppl 2:S114-S125; [11] Heijne et al. JID 2011;203:372-7

Current practice: Repeat testing rates in England Moderate rates of repeat testing already occur among young adults in England[12] - NCSP: 18 per 100 pys (see figure) - GUM clinics:26 per 100 pys Rates of repeat testing are 25% to 50% lower than might be expected if all young people were re-tested on change of sexual partner[12] The number of infections that would be diagnosed in addition to existing testing patterns has not been demonstrated in practice Cumulative proportion re-testing Number of weeks from baseline test Cumulative proportion re-testing after 6 weeks, NCSP tests 2010 [12] Woodhall et al. STI 2013;89(1):51-6

Current practice: Delivery models Scoping exercise, 19 services (CSP, GUM, SRH) Identified a range of existing recommendations and service delivery models No recommendation Repeat test recommended, but no active recall Repeat appointments Text messages, telephone or letter reminders Mailed testing kits Varying intervals Some categorisation by complexity of patient

International experience: Uptake rates by different approaches Reported uptake rates vary SMS reminders and mailed testing kits have been found to increase rates of repeat testing [13] Guy . STI 2013; [14] Downing STI 2013; [15] Dukers-Muijrers STI 2012; [16] Hoover CID 2012; [17] Gindi . Ntnl STD Prevention Conference. Philadelphia, PA, 2004; [18] Malotte STD 2004;31:637-42; [19] Paneth-Pollak . STD 2010;37:365-8; [20] Gudgel . National STD Prevention Conference 2006; [21] Kohn . Ntnl STD Prevention Conference 2010; [22] Xu . Obstet.Gynecol. 2011;118:231-9; [23] Sparks . STD 2004;31:113-6.

Time between treatment and repeat testing The optimum interval for repeat testing has not been established This will depend on logistical and biological considerations Country Recommended re-testing interval USA Approximately 3 months Canada 6 months Australia 3 months New Zealand Scotland 3-12 months, or sooner if there is a change of partner

Repeat testing in the context of other interventions Re-infection is not inevitable; it reflects repeat exposure and is therefore preventable Interventions to reduce risk behaviours Partner notification But! High rates of re-infection have been observed even in studies with high levels of PN Lamontagne: 22.3 per 100 pys following a positive when all partners treated[1] Schillinger: 12% re-infected, 85% partners treated[24] Cameron et al: 13% - 22% re-infected in trial to increase PN[25] Batteiger: 65% of re-infections due to different partner, and 17% likely due to existing partner[3] [1]Lamontagne. STI 2007; ;[3] Batteiger JID. 2010; [24] Schillinger STD 2003;30:49-56; [25] Cameron. Hum.Reprod. 2009;24:888-95.

Acceptability & cost-effectiveness of repeat testing The acceptability of different approaches to encouraging re-testing has not been investigated No studies have reported the costs of different methods of repeat testing in England One study from the US found phone reminders to be more cost effective compared to motivational interviewing or a brief recommendation[26] [26] Gift et al. STD 2005;32:542-9

Summary: What do we know? Young people who test positive for chlamydia are at increased risk of subsequent infection High rates of repeat infection are consistently reported Repeat infections may be important causes of morbidity and maintaining chlamydia epidemics Rates of repeat testing in England are moderate, but could be higher Mailed screening kits, and telephone or text message reminders appear to increase repeat testing rates

Summary: What are the remaining questions? The number of infections that would be diagnosed and treated, over and above those identified via existing testing patterns Optimum interval for re-testing (3 months is consistent with evidence and international practice) Cost, acceptability and feasibility of different approaches to re-testing Impact of increasing repeat testing on the incidence/prevalence of infection, or the development of sequelae

Consultation and policy development Expert meeting held in December 2012 supported the introduction of a recommendation for routine retesting of young adults who test positive for chlamydia around 3 months after treatment Next steps External stakeholder consultation (March - April) Young person consultation Policy review and development of implementation materials

Coffee Break

Chlamydia, Contraception and Condoms (& HIV) 3Cs (& HIV) Programme Chlamydia, Contraception and Condoms (& HIV) A programme to support basic sexual health provision in general practice Paula Baraitser

Why 3Cs? Source: Adams et al. STI 2007; 83;267-275 All part of a basic sexual health offer – providing young adults with information and technologies to avoid sexually transmitted infection and unplanned pregnancy - It makes sense to offer them together Supports existing practice in primary care – this is nothing new but it is important and it is not consistently offered Takes minimal time – this is all about permission to discuss and signposting

Why HIV testing? HIV in the UK, 2011:1 Estimated 96,000 people living with HIV – 24% (22,600) are unaware of their infection Estimated prevalence of 1.5 per 1,000 population – higher among MSM and black Africans 47% of HIV cases diagnosed late (CD4<350) in 2011 Why focus on reducing late HIV diagnoses? Public health impact – treatment can prevent onward transmission2 - indicator within Public Health Outcome Framework Individual prognosis - early diagnosis can lead to near-normal life expectancy3 Cost - expanded HIV testing shown to be cost effective4-5 and increased costs of a late versus early diagnosis (x2-3 times) which persist longer term7,8 The proportion of late HIV diagnoses remained high (47%) in 2011 Public health impact Late HIV diagnoses indicator within Public Health Outcome Framework Approximately 25% of those with HIV unaware of infection, responsible for 50-75% of transmission Transmission risk reduced if aware of status and if on treatment Individual prognosis Late HIV diagnosis a major predictor of morbidity and short-term mortality. Early diagnosis can lead to near-normal life expectancy1 Cost The costs of a late HIV diagnosis are x3 those of an early HIV diagnosis (CD4 >500) Expanded HIV testing shown to be cost effective in studies 1. HPA HIV in the UK 2012 report; 2. Cohen et al NEJM 2011 3. Nakagawa et al AIDS 2012; 4. Paltiel et al N Engl J Med 2006; 5. Yazadanpanah et al Plos One 2011; 6. MMWR 2006; 7. Krentz et al HIV Med 2008; 8. Beck et al Plos One 2011 110

Implementation NCSP develops the materials and training package NCSP (SHFs) train local trainers in each region Local trainers train individual GP practices (up to 1500 across England) Training adapted to each practice Ongoing support and feedback Resource pack and website NCSP coordinates, monitors and evaluates

Evaluation National NCSP monitoring – CTAD Practice specific data on: Chlamydia tests and positives Contraceptive prescribing for 15-24 year olds HIV testing in new practice registrants > 16 years old Condoms given out or use of C-card and local condom programmes

Summary 3Cs are already widely and expertly provided in general practice – we will encourage signposting to these services in most consultations young adults Sexual health service provision is variably supported in general practice – we will provide training and resources ongoing support and feedback This is an ambitious roll out - reaching 1500 practices – if successful it will have an important impact on sexual health among young adults

NCSP Quality Assurance Framework Erna Buitendam email: erna.buitendam@hpa.org.uk from 1st April 2013: erna.buitendam@phe.gov.uk m: 07760 - 991502

Elements of the NCSP QA framework Minimum standards for implementation of chlamydia screening plans Guidance on applying the standards for both commissioners and providers Position statements as required Surveys or audits on selected topics Incident monitoring and dissemination of anonymised ‘lessons learned’ reports The NCSP is committed to supporting the highest possible standards in the commissioning and provision of chlamydia screening. The NCSP QA framework sets out the NCSP Strategy for quality assurance. The framework consists of the following elements: minimum standards for implementation of chlamydia screening plans (aligned to those of British Association for Sexual Health and HIV); guidance on applying the standards for both commissioners and providers; position statements as required; surveys or audits on selected topics, and incident monitoring and dissemination of anonymised ‘lessons learned’ reports.

Standards Guidance Service Planning, e.g.: Data collection: NCSP integration into core services (March 2012), Outreach services (November 2011) Data collection: CTAD Management of results Other, e.g. Azithromycin Patient Group Direction Also Accompanying Document with more detail

Position statements Audits & Surveys Treatment of positive patients and retesting –February 2012 CQC registration impact on providers – May 2011 Dual testing for chlamydia and gonorrhoea - August 2010 Managing equivocal or ‘unconfirmed positive’ chlamydia results – August 2010 Equity of access (November 2012) Partner notification practice (March 2012) Patient and public engagement (January 2012) Treatment rates (July 2011 and July 2010) These statements clarified the NCSP’s approach to topics, not covered in the standards in that year, and that were frequently raised by providers and commissioners. This has also proven to be useful resource as this guidance facilitates a national consistent approach.

Incident monitoring and lessons learned When incident occurs: local reporting policy should be followed The NCSP Incident Policy aims to encourage reporting of incidents nationally so that: Any risks or lessons learnt, are shared with other programme areas in order to continue to improve performance and minimise risk across the country National guidance can be updated as appropriate We can provide support and respond to queries from other external parties as a result of the incident Please report to: NCSPteam@hpa.org.uk

QA framework priorities 2013-14 Review of QA framework to reflect learning from: The NCSP QA programme QA frameworks from related organisations Changing policy context from April 2013 Priorities for 2013/14: Expand the remit of future audits by measuring additional aspects of good practice in service commissioning and provision (as opposed to only measuring achievement of NCSP standards) Analyse existing data sets to inform service improvement Identify patterns of good practice to inform service improvement and share findings through SHF network and NCSP/PHE communications channels The QA framework requires regular review to reflect new learning from the NCSP QA programme, QA frameworks from related organisations, and predicted changes to the context for QA from April 2013. Review considered other organisations’ approach to QA and the implications of the changing environment in which the NCSP operates (increased plurality of providers and commissioners, impacts on audiences for audit & performance against standards needs to be maintained during transfer).

QA framework priorities 2013-14 Adapt audit methodologies to: Facilitate benchmarking, Include patient experience indicators Tailor methodologies to different audiences Apply to different screening settings/venues Provide online access to a menu of audit tools   Planned audits/audit tools 2013-14: Internet testing audit Test-result-treatment audit PN audit tool Access to menu of audit tools: for local use to assist providers and commissioners in undertaking self assessments when implementing standards or guidance This may be subject to change.

Workshop Session: Delivering the NCSP during the transition 30 minute facilitated discussion around three questions: What are the priorities for the NCSP over the next two years? What do you want to deliver locally? What support do you need from NCSP nationally to deliver? Who is going to help you deliver at a local level / what are your new emerging local network?

Closing Remarks

Thank you