Key findings

• Overall, the number of new sexually transmitted infections (STIs) diagnosed among residents of Staffordshire in 2019 was 4,485. The rate was 510 per 100,000 residents, lower than the rate of 816 per 100,000 in England, and lower than the average of 545 per 100,000 among its nearest neighbours.¹
• Staffordshire ranked 130th highest out of 149 upper tier local authorities (UTLAs) and unitary authorities (UAs) for new STI diagnoses excluding chlamydia among young people aged 15-24 years in 2019, with a rate of 529 per 100,000 residents, better than the rate of 900 per 100,000 for England.
• The chlamydia detection rate per 100,000 young people aged 15-24 years in Staffordshire was 1,660 in 2019, worse than the rate of 2,043 for England.
• The rank for gonorrhoea diagnoses (a marker of high levels of risky sexual activity) in Staffordshire was 104th highest (out of 149 UTLAs/UAs) in 2019. The rate per 100,000 was 58.8, better than the rate of 124 in England.
• Among sexual health service (SHS) patients from Staffordshire who were eligible to be tested for HIV, the percentage tested in 2019 was 56.1%, worse than the 64.8% in England.
• The number of new HIV diagnoses among people aged 15 years and above in Staffordshire was 22 in 2019. The prevalence of diagnosed HIV per 1,000 people aged 15-59 years in 2019 was 0.9, better than the rate of 2.4 in England. The rank for HIV prevalence in Staffordshire was 124th highest (out of 149 UTLAs/UAs).
• In Staffordshire, in 2017 - 19, the percentage of HIV diagnoses made at a late stage of infection (CD4 count ≤350 cells/mm³ within 3 months of diagnosis) was 42.9%, similar to 43.1% in England.
• The total rate of long-acting reversible contraception (LARC) (excluding injections) prescribed in primary care, specialist and non-specialist sexual health services per 1,000 women aged 15-44 years living in Staffordshire was 15.0 in 2019, lower than the rate of 50.8 per 1,000 women in England. The rate prescribed in primary care was 1.6 in Staffordshire, lower than the rate of 30.0 in England. The rate prescribed in the other settings was 13.4 in Staffordshire, lower than the rate of 20.8 in England.
• The total abortion rate per 1,000 women aged 15-44 years in 2019 was 18.1 in Staffordshire, similar to the England rate of 18.7 per 1,000. Of those women under 25 years who had an abortion in 2019, the proportion who had had a previous abortion was 30.4%, similar to 27.7% in England.
• In 2018, the conception rate for under-18s in Staffordshire was 16.8 per 1,000 girls aged 15-17 years, similar to the rate of 16.7 in England.
• In 2018/19, the percentage of births to mothers under 18 years was 0.7%, similar to 0.6% in England overall.

Figure 1. Chart showing key sexual and reproductive health indicators in Staffordshire compared to the rest of England

The local result for each indicator is shown as a circle, against the range of results for England shown as a grey bar. The line at the centre of the chart shows the England average, the diamond shows the average for the West Midlands PHE Centre.

Compared to England:

• Better
• Similar
• Worse
• or
• Lower
• Similar
• Higher
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• Not compared

Key for spine bars

Introduction

Aim

This report describes sexual and reproductive health in a local area in an integrated way, including sexually transmitted infections (STIs), HIV, under-18 conceptions, abortion and Long Acting Reversible Contraception rates for women aged 15-44.

This is produced alongside other PHE local HIV, sexual and reproductive health intelligence tools to help inform local Joint Strategic Needs Assessments (JSNAs) so that commissioners can effectively target service provision.

Information used in this report

Unless otherwise indicated this report is compiled from publicly available data on the online Sexual and Reproductive Health Profiles. Please access this tool for further data analysis and more information about the data included in this report which is described in the 'definitions' tab for each indicator.

Please note that City of London and Isles of Scilly and not included in the rankings in this document. Where comparisons are made to Hackney or Cornwall, please note that the data for these areas may have been combined with City of London and Isles of Scilly respectively. Please check the online Profiles.

For an introductory guide on sexual health data sources, please access https://www.gov.uk/government/publications/sexual-and-reproductive-health-in-england-local-and-national-data.

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STIs

As STIs are often asymptomatic, frequent screening of risk groups is important. Early detection and treatment can reduce important long-term consequences, such as infertility and ectopic pregnancy. While vaccination is a measure that can be used to control genital warts, hepatitis A and hepatitis B, control of other STIs relies on consistent and correct condom use, behaviour change to decrease overlapping and multiple partners, ensuring prompt access to testing and treatment, and ensuring partners of cases are notified and tested.

Over the past decade, diagnoses of gonorrhoea and syphilis have increased considerably in England, most notably in males, while diagnoses of genital warts have decreased.² The full-scale implementation of the National Chlamydia Screening Programme (NCSP) in 2008 led to increases in diagnoses rates in men and women. More STI testing in sexual health services and through the NCSP with routine use of more sensitive diagnostic tests, such as nucleic acid amplification tests (NAATs), will partly explain increases in the early part of the decade, although ongoing high levels of condomless sex will have played a role.

The burden of STIs in England continues to be greatest in young people, gay, bisexual and other men who have sex with men (MSM) and black ethnic minorities. Of all age-groups, the highest STI diagnosis rates in England are in young people aged 15-24 years.

The number of STI diagnoses in MSM has risen sharply in England over the past decade. Several factors may have contributed to this, including behavioural changes such as an increase in partner numbers and condomless anal intercourse, as well as, for some high risk MSM, 'chemsex' (the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience) and group sex facilitated by geosocial networking applications. More screening of extra-genital (rectal and pharyngeal) sites in MSM using NAATs will also have improved detection of gonococcal and chlamydial infections, although this will have had less impact in recent years as these developments have become more established.

High levels of gonorrhoea transmission are of particular concern due to the emergence of extensively drug resistant gonorrhoea (XDR-NG) in England. In 2018, a case of infection with Neisseria gonorrhoeae with ceftriaxone resistance and high-level azithromycin resistance was detected in a UK resident man who had acquired the infection from Thailand³; later that year, two additional cases of infection with a strain of N. gonorrhoeae with ceftriaxone resistance and intermediate azithromycin resistance were detected in two women in different regions of England, both of whom had overlapping sexual networks with UK residents who had travelled to Ibiza, Spain.

This report has been compiled using routine STI data, the majority of which comes from specialist sexual health services.⁴ Chlamydia test and diagnosis data from community services are sourced from the CTAD Chlamydia Surveillance System. Please see the link below for further details on chlamydia data from community services and for additional data on chlamydia testing coverage, positivity and diagnostic rates (for those aged 15-24 years).⁵ Diagnoses of all STIs made in specialist and non-specialist sexual health services are reported using the GUMCAD STI Surveillance System.

Burden and trend of new STIs

A total of 4,485 new STIs were diagnosed in residents of Staffordshire in 2019. It should be noted that if high rates of gonorrhoea and syphilis are observed in a population, this reflects high levels of risky sexual behaviour.

When interpreting trends, please note:

• Recent decreases in genital warts diagnoses are due to the protective effect of HPV vaccination, and are particularly evident in the younger age groups, offered the vaccine since the national programme began
• An increase in genital herpes diagnoses may be due to the use of more sensitive NAATs

Figure 2. Chart showing key STI indicators in Staffordshire compared to the rest of England

The local result for each indicator is shown as a circle, against the range of results for England shown as a grey bar. The line at the centre of the chart shows the England average, the diamond shows the average for the West Midlands PHE Centre.

Compared to England:

• Better
• Similar
• Worse
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• Lower
• Similar
• Higher
• or
• Not compared

Key for spine bars

Figure 3. Map of new STI diagnoses (excluding chlamydia in under 25-year olds) per 100,000 population aged 15–64 years in Staffordshire by Middle Super Output Area: 2019

Please note that this data is not available on the online Sexual and Reproductive Health profiles. Data is sourced from routine specialist and non-specialist sexual health services' returns to the PHE GUMCAD STI Surveillance System and from routine non-specialist sexual health services' returns to the CTAD Chlamydia Surveillance System.

Contains Ordnance Survey data © Crown copyright and database right 2019
Contains National Statistics data © Crown copyright and database right 2019

Chlamydia detection

The Public Health Outcome Framework (PHOF) includes an indicator to assess progress in controlling chlamydia in sexually active young adults under 25 years old: the annual detection rate among the resident 15-24 year old population. The detection rate reflects both coverage and the proportion testing positive at all sites, including sexual health services diagnoses as well as those made outside of sexual health services.

Since chlamydia is most often asymptomatic, a high detection rate reflects success at identifying infections that, if left untreated, may lead to serious reproductive health consequences. The detection rate is not a measure of prevalence. PHE recommends that local areas achieve a rate of at least 2,300 per 100,000 resident 15-24 year olds, a level which is expected to produce a decrease in chlamydia prevalence. Areas already achieving this rate should aim to maintain or increase it. Areas not currently achieving this rate should work towards it. High detection levels can only be achieved through the ongoing commissioning of high volume, good quality screening services across primary care and sexual health services.

The chlamydia detection rate in 15-24 year olds in 2019 in Staffordshire was 1,660 per 100,000 population (1,558 positives out of 13,689 screened), lower than the 2,300 target. 14.6% of 15-24 year olds were tested for chlamydia, compared to 20.4% nationally. The detection rate per 100,000 and its rank in West Midlands PHE Centre and England are shown in Table 3.

Variation in rates of chlamydia detection may represent differences in prevalence, but are influenced by screening coverage and whether most at risk populations are being reached (i.e. the proportion testing positive) (Figure 8).

Figure 8. Map of chlamydia detection rate per 100,000 population in 15-24 years in Staffordshire by Middle Super Output Area: 2019

Please note that this data is not available on the online Sexual and Reproductive Health profiles. Data is sourced from the CTAD Chlamydia Surveillance System (CTAD).

New STI diagnoses in Staffordshire by MSOA

Contains Ordnance Survey data © Crown copyright and database right 2019
Contains National Statistics data © Crown copyright and database right 2019

In the five years from 2014 to 2019, there was a 2% decrease in the chlamydia detection rate among 15-24 year olds in Staffordshire. From 2018, the increase was 12%.

STI testing in sexual health services

In 2019 the rate of STI testing (excluding chlamydia in under 25 year olds) in sexual health services in Staffordshire was 13,189 per 100,000 aged 15 to 64 years, a 10% increase compared to 2018. This is lower than the rate of 19,654 per 100,000 in England in 2019. The positivity rate in Staffordshire was 2.0% in 2019, lower than 2.4% in England.

Other infections transmitted sexually

Other infections can be spread through sexual intercourse in addition to other routes, e.g. hepatitis B, hepatitis C and some infections are spread faecal-orally during sexual activity - termed sexually transmissible enteric infections (STEI) e.g. hepatitis A and Shigella.

In 2016 an outbreak of hepatitis A was identified among MSM in England and across Europe. Between July 2016 and April 2017 266 cases associated with the outbreak had been identified in England, 74% of these among MSM.⁶ This resulted in work to raise awareness of how to prevent infection through hygiene measures (e.g. washing hands after sex)⁷ and recommendations around hepatitis A vaccination of MSM attending sexual health services. This outbreak highlights how quickly and widely an infection can become established in at risk groups if prevention measures such as vaccination are not undertaken.

Over the last decade, the number of Shigella cases among MSM in England has increased. Shigella among MSM is an example of a STEI associated with higher risk behaviours, such as 'chemsex' and multiple partners. Most MSM cases present to primary care rather than sexual health services. PHE and other agencies undertook activity to raise awareness among MSM of Shigella and how to avoid it between Spring and Summer 2017 in London, Brighton and Manchester.⁸ Only a minority of MSM are thought to be aware of Shigella and how to avoid it.

In England, hepatitis B is most often acquired sexually. Where information on risk exposures was recorded on acute and probable acute cases of hepatitis B, the most commonly reported risk was heterosexual exposure (55%), followed by sex between men (15%).⁹ Vaccination can prevent infection and is recommended for MSM, for individuals with multiple sexual partners and for individuals who place themselves at risk through sexual activity when travelling to high prevalence countries. Following recent clusters of acute hepatitis B in men who did not initially disclose sex with men, an enhanced surveillance questionnaire for acute hepatitis B cases was developed in 2017 to improve completeness of risk factor information on cases with undisclosed risk factors to support targeted control and prevention measures.

Most people in England acquire hepatitis C through injecting drug use.¹⁰ However, MSM are also a risk group for hepatitis C transmission. MSM living with diagnosed HIV, especially those reporting high risk sexual practices, are disproportionately affected by hepatitis C compared to HIV-negative MSM; therefore guidance for hepatitis C screening has been targeted towards this group.

HIV

Free and effective antiretroviral therapy (ART) in the UK has transformed HIV from a fatal infection into a chronic but manageable condition. People living with HIV in the UK can now expect to have a near normal life expectancy if diagnosed promptly and they adhere to treatment. In addition, those on treatment are unable to pass on HIV, even if having unprotected sex (undetectable=untransmittable [U=U]).

In 2019, an estimated 105,200 (95% Crl 103,300 to 108,500) people were living with HIV infection in the UK¹¹ and the UNAIDS 90:90:90 targets¹² have been met. An estimated 94% of people living with HIV in the UK were diagnosed, 98% of those diagnosed were on treatment, and 97% of those on treatment were virally suppressed. Overall, 89% of people living with HIV in 2019 had an undetectable viral load and were unable to pass on their infection.

A decline in new HIV diagnoses among gay and bisexual men has been observed since 2015 in the UK, following an earlier fall in underlying new HIV infections in this group that began in 2012.¹³ The reduction in transmission highlights that combination HIV prevention is working. Current key components of combination HIV prevention in the UK include: condom provision, pre-exposure prophylaxis (PrEP), expanded HIV testing and prompt initiation of treatment after diagnosis (treatment as prevention). This decline is predominantly observed in London.

New HIV diagnoses in both black African and black Caribbean heterosexuals in the UK have been decreasing steadily over the past 10 years. However, declines have been observed for the first time among non-black African and non-black Caribbean heterosexual men.

Despite these promising data, significant challenges remain. Though HIV testing activity at sexual health services nationally has continued to increase in 2019, and despite over 1.3 million people being tested for HIV in 2019, there were still many missed opportunities for testing identified. Over 250,000 sexual health services attendees were not offered a test for HIV in 2019, despite being recorded as eligible for testing.

The number of HIV diagnoses made at a late stage of infection in England has decreased over the decade. Despite this decline, the proportion of late diagnoses remained high in 2019, particularly in black African heterosexual men and women and those aged over 50 years.

With progressive strengthening of combination prevention, HIV transmission, AIDS and HIV-related deaths could be eliminated in the UK. The recent encouraging changes are dependent upon sustained prevention efforts. Combination prevention needs to be replicated for all those at risk of acquiring of HIV, whoever they are and wherever they live.

Figure 12. Chart showing key HIV indicators in Staffordshire compared to the rest of England

The local result for each indicator is shown as a circle, against the range of results for England shown as a grey bar. The line at the centre of the chart shows the England average, the diamond shows the average for the West Midlands PHE Centre.

Compared to England:

• Better
• Similar
• Worse
• or
• Lower
• Similar
• Higher
• or
• Not compared

Key for spine bars

HIV treatment and care

In 2019, the number of Staffordshire residents aged 15-59 years who were seen at HIV services (the prevalence of diagnosed HIV) was 443. The diagnosed prevalence per 1,000 residents aged 15-59 years was 0.9, better than 2.4 per 1,000 in England. The rank of Staffordshire was 124th highest (out of 149 UTLAs/UAs). Since 2018, the increase in Staffordshire was 4%; in the 5 years since 2014, the increase was 27%.

The percentage of people in Staffordshire newly diagnosed with HIV from 2017 - 19 who started antiretroviral therapy (ART) promptly (within 91 days of their diagnosis) was 80.0%, similar to 80.5% in England.

The percentage of adults in Staffordshire accessing HIV care in 2019 who were virally suppressed (undetectable viral load) was 98.3%, similar to 97.4% in England.

Data at UTLA/UA level is likely to mask inequalities. For further information within an UTLA, use of the Sexual and Reproductive Health Profiles is encouraged as lower tier local authority information is available.