Key findings

• This report summarises the latest available sexual and reproductive health data for Bristol. As a response to the COVID-19 pandemic, the Government implemented national and regional lockdowns and social and physical distancing measures since March 2020. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider these factors, especially when comparing with data from pre-pandemic years.
• Overall, the number of new sexually transmitted infections (STIs) diagnosed among residents of Bristol in 2020 was 3,263. The rate was 700 per 100,000 residents, higher than the rate of 562 per 100,000 in England, and similar to the average of 692 per 100,000 among its nearest neighbours.
• Bristol ranked 35th highest out of 149 upper tier local authorities (UTLAs) and unitary authorities (UAs) for new STI diagnoses excluding chlamydia among young people aged 15 to 24 years in 2020, with a rate of 718 per 100,000 residents aged 15 to 64, worse than the rate of 619 per 100,000 for England.
• The chlamydia detection rate per 100,000 young people aged 15 to 24 years in Bristol was 1,126 in 2020, worse than the rate of 1,408 for England.
• The rank for gonorrhoea diagnoses (a marker of high levels of risky sexual activity) in Bristol was 59th highest (out of 149 UTLAs/UAs) in 2020. The rate per 100,000 was 80.5, better than the rate of 101 in England.
• Among specialist sexual health service (SHS) patients from Bristol who were eligible to be tested for HIV, the percentage tested in 2020 was 54.6%, better than the 46.0% in England.
• The number of new HIV diagnoses among people aged 15 years and above in Bristol was 26 in 2020. The prevalence of diagnosed HIV per 1,000 people aged 15 to 59 years in 2020 was 2.4, similar to the rate of 2.3 in England. The rank for HIV prevalence in Bristol was 49th highest (out of 148 UTLAs/UAs).
• In Bristol, in the three year period between 2018 - 20, the percentage of HIV diagnoses made at a late stage of infection (all individuals with CD4 count ≤350 cells/mm³ within 3 months of diagnosis) was 40.7%, similar to 42.4% in England.
• The total rate of long-acting reversible contraception (LARC) (excluding injections) prescribed in primary care, specialist and non-specialist SHS per 1,000 women aged 15 to 44 years living in Bristol was 51.5 in 2020, higher than the rate of 34.6 per 1,000 women in England. The rate prescribed in primary care was 44.0 in Bristol, higher than the rate of 21.1 in England. The rate prescribed in the other settings was 7.4 in Bristol, lower than the rate of 13.4 in England.
• The total abortion rate per 1,000 women aged 15 to 44 years in 2020 was 15.1 in Bristol, lower than the England rate of 18.9 per 1,000. Of those women under 25 years who had an abortion in 2020, the proportion who had had a previous abortion was 28.1%, similar to 29.2% in England.
• In 2019, the conception rate for under-18s in Bristol was 12.7 per 1,000 girls aged 15 to 17 years, similar to the rate of 15.7 in England.
• In 2019/20, the percentage of births to mothers under 18 years was 0.7%, similar to 0.7% in England overall.

Figure 1. Chart showing key sexual and reproductive health indicators in Bristol 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 South West UKHSA Centre.

Compared to England:

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

Key for spine bars

Introduction

STIs

As STIs are often asymptomatic, frequent STI screening of groups with greater sexual health needs is important and should be conducted in line with national guidelines. Early detection and treatment can reduce important long-term consequences, such as infertility and ectopic pregnancy. Vaccination is an intervention that can be used to control genital warts, hepatitis A and hepatitis B, however, 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.

There was an increasing trend in diagnoses of chlamydia, gonorrhoea and syphilis in England from 2010 until 2019, while diagnoses of genital warts have decreased since 2013 due to the protective effect of HPV vaccination.¹ Increasing diagnosis rates for chlamydia among people aged 15 to 24 years are largely driven by changes in testing activity through the National Chlamydia Screening Programme (NCSP), although ongoing high levels of condomless sex will have played a role. The NCSP data tables provide additional data on chlamydia testing coverage, positivity and diagnostic rates (for those aged 15 to 24 years).²

Since March 2020, in response to the Coronavirus Disease 2019 (COVID-19) pandemic, the UK Government implemented strict non-pharmaceutical interventions (NPIs) in the form of national and regional lockdowns, as well as social and physical distancing measures including an emphasis on staying at home. Sexual health services (SHS) in England had substantially reduced capacity to deliver face-to-face consultations but underwent rapid reconfiguration to increase access to STI testing via telephone or internet consultations. STI testing and diagnoses decreased across all infections between 2019 and 2020. Over this period, larger decreases in diagnoses were observed for STIs that are usually diagnosed clinically at a face-to-face consultation, such as genital warts or genital herpes, when compared to those that could be diagnosed using remote self-sampling kits such as chlamydia and gonorrhoea.³ In 2020, STIs continued to disproportionately impact gay, bisexual and other men who have sex with men (MSM), young people aged 15 to 24 years, and people of Black Caribbean ethnicity.

This report has been compiled using data from SHS and ‘community-based’ settings routine returns to the GUMCAD STI and CTAD Chlamydia surveillance systems.

‘Sexual health services’ refer to services offering specialist (level 3) STI-related care such as genitourinary medicine (GUM) and integrated GUM and sexual and reproductive health (SRH) services. They also include other services offering non-specialist (level 1 or level 2) STI-related care and community-based settings such as young people’s services, internet services, termination of pregnancy services, pharmacies, outreach, and general practice. Further details on the levels of sexual healthcare provision are provided in the BASHH Standards for the Management of STIs (Appendix B).

Burden and trend of new STIs

A total of 3,263 new STIs were diagnosed in residents of Bristol in 2020. 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:

• The decrease in STI testing and diagnoses in 2020 due to the reconfiguration of sexual health services during the COVID-19 pandemic response
• Recent decreases in genital warts diagnoses are due to the protective effect of HPV vaccination, and are particularly evident in the younger age groups (25 and younger) who have been offered the vaccine since the national programme began

Figure 2. Chart showing key STI indicators in Bristol 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 South West UKHSA Centre.

Compared to England:

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

Key for spine bars

Table 1. Rates per 100,000 population of new STIs in Bristol and England: 2019-2020

Diagnoses	2019	2020	% change 2019 to 2020*	Rank among 16 similar UTLAs/UAs†	Rank within England: 2020‡	Value for England: 2020
New STIs	1,164.7	700.4	-39.9%	7	31	562.2
New STIs (exc chlamydia aged <25)1	1,241.9	717.9	-42.2%	7	35	619.0
Chlamydia	502.6	342.4	-31.9%	10	34	285.9
Gonorrhoea	133.6	80.5	-39.7%	11	59	100.9
Syphilis	14.9	17.8	19.6%	3	27	12.2
Genital warts	148.0	72.8	-50.8%	4	21	48.6
Genital herpes	85.5	41.6	-51.3%	7	48	36.3
As a response to the COVID-19 pandemic, since March 2020 the Government implemented national and regional lockdowns and social and physical distancing measures. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider these factors, especially when comparing with data from pre-pandemic years.
* Percent change not provided where the value in 2019 was 0.
† These are Bristol and its 15 statistical nearest neighbours, excluding those where values were suppressed due to small numbers. First rank has the highest value. Nearest neighbours are derived from CIPFA’s Nearest Neighbours Model.
‡ Out of 149 UTLAs/UAs in England, excluding those where values were suppressed due to small numbers. City of London and Isles of Scilly are always excluded. First rank has the highest value. Where the value was 0, ranks are based on order of local authority names.
1 Population is restricted to those aged 15-64 years

Table 2. Number of new STIs by year, Bristol

Diagnoses	2012	2013	2014	2015	2016	2017	2018	2019	2020
New STIs	4,709	5,018	4,909	4,689	4,822	4,617	5,438	5,397	3,263
New STIs (exc chlamydia aged <25)1	3,128	3,446	3,549	3,426	3,478	3,273	3,864	3,995	2,329
Chlamydia	2,324	2,345	2,063	2,019	2,239	2,292	2,641	2,329	1,595
Gonorrhoea	173	239	366	380	277	286	495	619	375
Syphilis	22	29	40	40	30	44	64	69	83
Genital warts	710	857	795	820	790	768	781	686	339
Genital herpes	360	434	405	316	348	287	357	396	194
1 Population is restricted to those aged 15-64 years

Figure 3. Map of new STI diagnoses (excluding chlamydia in under 25-year olds) per 100,000 population aged 15–64 years in Bristol by Middle Super Output Area: 2020

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 UKHSA GUMCAD STI Surveillance System and from routine non-specialist sexual health services’ returns to the CTAD Chlamydia Surveillance System. As a response to the COVID-19 pandemic, since March 2020 the Government implemented national and regional lockdowns and social and physical distancing measures. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider this reconfiguration, especially when comparing with data from pre-pandemic years.

Contains Ordnance Survey data © Crown copyright and database right 2020
Contains National Statistics data © Crown copyright and database right 2020

Figure 4. Rates per 100,000 population of new STIs (excluding chlamydia in under 25-year olds) in 16 similar local authorities and the South West UKHSA Centre, compared to England: 2020

Similar refers to statistical nearest neighbours, derived from CIPFA’s Nearest Neighbours Model

Figure 5. Rates per 100,000 population by diagnosis by year in Bristol compared to rates in the South West UKHSA Centre and England: 2012 to 2020

Please note the charts have different y axis scales.

Figure 6. Rates per 100,000 population of gonorrhoea in 16 similar local authorities and the South West UKHSA Centre, compared to England: 2020

Similar refers to statistical nearest neighbours, derived from CIPFA’s Nearest Neighbours Model

Figure 7 shows rates of syphilis per 100,000 population for Bristol, compared to national, regional, and neighbouring rates. The UKHSA has conducted an in-depth examination of the national epidemiology of syphilis from 2010-2019,⁴ in alignment with the Syphilis Action Plan (2019).⁵

Figure 7. Rates per 100,000 population of syphilis in 16 similar local authorities and the South West UKHSA Centre, compared to England: 2020.

Similar refers to statistical nearest neighbours, derived from CIPFA’s Nearest Neighbours Model

Chlamydia detection

In June 2021, the National Chlamydia Screening Programme (NCSP) changed to focus on reducing the harms from untreated chlamydia infection.⁶ These harms occur predominantly in young women and other people with a womb or ovaries - this includes transgender men, non-binary people assigned female at birth, and intersex people with a womb or ovaries. Therefore, opportunistic screening should focus on these groups, combined with reducing time to test results and treatment, strengthening partner notification and re-testing after treatment.

In practice this means that chlamydia screening in community settings (e.g. GP and Community Pharmacy) will only be proactively offered to young women and other people with a womb or ovaries. Services provided by sexual health services remain unchanged and everyone can still get tested if needed.

Given the change in programme aim, the Public Health Outcome Framework (PHOF) Detection Rate Indicator (DRI) benchmarking thresholds have been revised and will be measured against females only. A new female-only PHOF benchmark DRI will be included in the PHOF from January 2022 (to be reported in 2023).

This report covers 2020 data and uses the previous population DRI recommending that local areas achieve a detection rate of at least 2,300 per 100,000 residents (aged 15 to 24 years). 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 chlamydia detection rate in 15 to 24 year olds in 2020 in Bristol was 1,126 per 100,000 population (881 positives out of 12,347 screened), lower than the 2,300 target. 15.8% of 15 to 24 year olds were tested for chlamydia, compared to 14.3% nationally. The detection rate per 100,000 and its rank among CIPFA nearest neighbours and England are shown in Table 3.

Table 3. Chlamydia detection rate per 100,000 population and percentage screened in 15 to 24 year olds in Bristol and England: 2020

	2019	2020	% change 2019 to 2020*	Rank among 16 similar UTLAs/UAs†	Rank within England: 2020‡	Value for England: 2020
Detection rate
Total	1,745.2	1,126.5	-35.5%	15	110	1,408.4
Women	2,281.5	1,505.4	-34.0%	15	114	1,888.5
Men	1,189.8	731.7	-38.5%	14	105	916.4
Percentage screened
People aged 15-24	20.9	15.8	-24.6%	5	42	14.3
As a response to the COVID-19 pandemic, since March 2020 the Government implemented national and regional lockdowns and social and physical distancing measures. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider these factors, especially when comparing with data from pre-pandemic years.
* Percent change proportional to the value in 2019, not a change in percentage points. Percent change not provided where the value in 2019 was 0.
† These are Bristol and its 15 statistical nearest neighbours, excluding those where values were suppressed due to small numbers. First rank has the highest value. Nearest neighbours are derived from CIPFA’s Nearest Neighbours Model.
‡ Out of 149 UTLAs/UAs in England, excluding those where values were suppressed due to small numbers. City of London and Isles of Scilly are always excluded. First rank has the highest value. Where the value was 0, ranks are based on order of local authority names.

Variation in rates of chlamydia detection (Figure 8) 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. Map of chlamydia detection rate per 100,000 population in 15 to 24 years in Bristol by Middle Super Output Area: 2020

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). As a response to the COVID-19 pandemic, since March 2020 the Government implemented national and regional lockdowns and social and physical distancing measures. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider this reconfiguration, especially when comparing with data from pre-pandemic years.

New STI diagnoses in Bristol by MSOA

Contains Ordnance Survey data © Crown copyright and database right 2020
Contains National Statistics data © Crown copyright and database right 2020

Figure 9. Chlamydia detection rate per 100,000 population in 15 to 24 year olds in 16 similar local authorities and the South West UKHSA Centre, compared to England: 2020

Similar refers to statistical nearest neighbours, derived from CIPFA’s Nearest Neighbours Model

In the five years from 2015 to 2020, there was a 29% decrease in the chlamydia detection rate among 15 to 24 year olds in Bristol. From 2019, the decrease was 35%.

Figure 10. Chlamydia detection rate per 100,000 population in 15 to 24 year olds by year in Bristol, the South West UKHSA Centre and England

Other infections transmitted sexually

Some bloodborne viruses can be spread through sex as well as by other routes, e.g. hepatitis B, hepatitis C. Some gastro-intestinal infections, typically linked to contaminated food or water can also be spread faecal-orally during sexual activity: these are called sexually transmissible enteric infections (STEIs) e.g. hepatitis A and Shigella.

Over the last decade, the number of cases of sexually-transmitted Shigella among MSM in England has increased,⁸ with concerning increases in antimicrobial resistance. Cases of shigellosis can be severe, leading to dehydration and sepsis. Due to its presentation as an enteric illness, most symptomatic cases present to primary care (GPs, A&E) rather than SHS. Only a minority of MSM are thought to be aware of Shigella and how to avoid it, however, surveillance shows transmission of these infections is commonly associated with high-risk behaviours such as sexualised drug-use (including ‘chemsex’) and multiple casual sex partners.

Lymphogranuloma venereum (LGV), an invasive form of chlamydia, is a sexually transmitted infection which disproportionately affects MSM. In the past decade, the number of LGV diagnoses has increased substantially in England. Historically, LGV was mainly concentrated among MSM living with HIV. However, in recent years, a greater proportion of cases have been among MSM who are HIV negative.⁹

Hepatitis A vaccination is available for MSM in SHS. 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.¹⁰ This resulted in work to raise awareness of how to prevent infection through hygiene measures (e.g. washing hands after sex)¹¹ and recommendations around hepatitis A vaccination of MSM attending SHS. This outbreak highlights how quickly and widely an infection can become established in key populations if prevention measures such as vaccination are not undertaken.

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 (50%), followed by sex between men (17%).¹² 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.

Most people in England acquire hepatitis C through injecting drug use.¹³ 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 testing in SHS 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=untransmissible [U=U]).

Data reported in 2020 were impacted by the changes in how people accessed health services, and their reconfiguration during the COVID-19 pandemic, which also resulted in data reporting delays.

In 2020, an estimated 97,740 (95% credible interval (95% Crl) 96,400 to 100,060) people were living with HIV in England and an estimated 4,660 in 2020 (95%CrI 3,640 to 6,980) were unaware of their infection.¹⁴ The quality of care received by people living with HIV remained high. For the first time, the UNAIDS 95-95-95 targets¹⁵ were met with 95% of all people diagnosed, 99% of those in care on treatment and 97% of those receiving treatment being virally suppressed in both the UK and England. This means that 91% of all people living with HIV and accessing care were virally suppressed in 2020, surpassing the 73% UNAIDS 90-90-90 substantial target as well as the 86% UNAIDS 95-95-95 substantial target.

The number of all new HIV diagnoses decreased by 33% in England (from 3,950 in 2019 to 2,630 in 2020¹⁴). The number of diagnoses first made in England (76% of all diagnoses) also fell by 33% (from 2,950 in 2019 to 1,990 in 2020). The remaining 24% of new diagnoses were among people who had had their initial HIV diagnosis abroad.

Among MSM, the number of HIV diagnoses first made in England decreased by 41% from 1,500 in 2019 to 890 in 2020 (adjusted for missing probable route of exposure). Taken together with only small declines in testing and a continuing availability of PrEP, the fall in diagnoses in MSM suggests a continued year-on-year reduction in transmission in this group. These declines in diagnoses were less apparent among MSM who were living outside London, those of Black, Asian, Mixed or Other ethnicity ethnic groups, and those born abroad.

In 2020, 1,010 people who probably acquired HIV through heterosexual contact were first diagnosed with HIV in England (after adjusting for missing exposure information), a 23% decrease from 1,320 in 2019. The decline was 40% among White heterosexuals (from 470 in 2019 to 280 in 2020) and 40% among Black Caribbean heterosexuals (from 50 to 30) but less pronounced among Black Africans (25%, 400 to 300) and among Asians (17%, 60 to 50). Among heterosexual men and women born abroad but diagnosed with HIV in England, 49% were estimated to have acquired HIV after arrival in England. Since there was a very large decline in HIV testing among heterosexuals in 2020 compared to previous years, it is likely that much of the observed decline in diagnoses in this group was due to reduced testing rather than reduced transmission.

In 2020, the number of people who tested for HIV at SHS in England fell by 30% from 1,320,510 in 2019 to 927,760.¹⁴ 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 2020, particularly in Black African heterosexual men and women and those aged over 50 years.

From 2021, HIV surveillance includes three new indicators:

• HIV diagnosed prevalence rate per 1,000 population aged 15 years and over (alongside HIV diagnosed prevalence rate per 1,000 population aged 15 to 59).
• New HIV diagnoses among persons first diagnosed in the UK rate per 100,000 aged 15 years and over (alongside all new HIV diagnoses, including those first diagnosed outside the UK).
• ART coverage in adults accessing HIV care (%).

The purpose of these indicators is to include older patients living with HIV, to measure HIV transmission in the UK more accurately and to monitor the proportion of people living with transmissible levels of virus, respectively.

England has set an ambition to end HIV transmission, AIDS and HIV-related deaths by 2030. The England HIV Action Plan 2022-2025 set out intermediate commitments for the next 4 years to achieve the 2030 ambition, including how HIV transmission will be reduced by 80% by 2025.¹⁶ To achieve these aims, a combination prevention approach will be implemented focusing on prevent, test, treat and retain. This approach 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 Bristol 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 South West UKHSA Centre.

Compared to England:

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

Key for spine bars

HIV treatment and care

In 2020, there were 747 Bristol residents aged 15 to 59 years and 857 residents aged 15 years and over who were seen at HIV services (the prevalence of diagnosed HIV). The diagnosed prevalence per 1,000 residents aged 15 to 59 years was 2.4, similar to 2.3 per 1,000 in England. The rank of Bristol was 49th highest (out of 148 UTLAs/UAs). Since 2019, the decrease in Bristol was 4%; in the 5 years since 2015, the increase was 2%.

Figure 13. Diagnosed HIV prevalence per 1,000 population aged 15 to 59 years by year in Bristol compared to rates in the South West UKHSA Centre and England: 2011 to 2020.

Figure 14. Diagnosed HIV prevalence per 1,000 population aged 15 to 59 years in 16 similar local authorities and the South West UKHSA Centre, compared to England: 2020

Similar refers to statistical nearest neighbours, derived from CIPFA’s Nearest Neighbours Model

The percentage of people (aged 15 years and over) in Bristol accessing HIV care who were prescribed ART in 2020 was 97.0%, worse than 98.7% in England. The percentage of people in Bristol newly diagnosed with HIV in the three-year period between 2018 - 20 who started antiretroviral therapy (ART) promptly (within 91 days of their diagnosis) was 85.1%, similar to 83.1% in England.

The percentage of adults in Bristol accessing HIV care in 2020 who were virally suppressed (undetectable viral load) was 95.5%, similar to 97.4% in England.

The Sexual and Reproductive Health Profiles also provides these data at lower tier local authority geographies.

Figure 15. Map of diagnosed HIV prevalence among people of all ages in Bristol by Middle Super Output Area: 2020

Please note that this data is not available on the online Sexual and Reproductive Health Profiles. Data is sourced from the UKHSA HIV and AIDS Reporting System (HARS). As a response to the COVID-19 pandemic, since March 2020 the Government implemented national and regional lockdowns and social and physical distancing measures. These measures affected sexual behaviour and health service provision, which is reflected in sexual and reproductive health indicator data. Interpreting data from 2020 should consider these factors, especially when comparing with data from pre-pandemic years.

HIV prevalence in Bristol by MSOA

Contains Ordnance Survey data © Crown copyright and database right 2020
Contains National Statistics data © Crown copyright and database right 2020