'We’re under tremendous strain with the rise in numbers of STIs'

My HIV test kit arrived in nondescript packaging, delivered by the postie. I had ordered the self-test kit online three days before. Funded by the Scottish Government and delivered through the Terrence Higgins Trust, these kits can be sent out to any address in Scotland for free.

Taking the test was reminiscent of taking a Covid test. Using a mouth swab (along the gums, rather than back of the throat), you pop the test into a small tube and wait 20 minutes. One line means a negative result; two lines means positive. Easy.

Self-sampling kits are also available for a raft of other sexually transmitted infections (STIs). Like the HIV test, it takes a matter of minutes online to order. The test for chlamydia and gonorrhoea requires a sample to be sent off to the local sexual health clinic and results came back within two weeks.

But I’m lucky because of where I live. The Scottish Government has committed to a national rollout of an online postal self-sampling service but has yet to deliver it, and so in many locations face-to-face appointments remain the only option.

We’ve got rates of gonorrhoea that have not been higher since pre-war

That mirrors a wider postcode lottery when it comes to sexual health services. Alan Eagleson, head of services at the Terrence Higgins Trust Scotland, says: “The landscape on access to sexual health services is inconsistent across Scotland, with different levels of provision in different health board areas.”

Some health boards, explains Eagleson, “may only have part-time sexual health consultant cover. They may also be sharing cover between more than one health board area, limiting their ability to offer clinic appointments.

“A further issue that we hear about in a lot in rural areas is people are concerned about confidentiality – although clinicians are bound to confidentiality, people are still concerned about attending the local sexual health service where they may know the person who works behind reception, for example.”

While ensuring self-sample kits are available across the country isn’t the whole answer – they are only suitable for people without symptoms and some will prefer face-to-face appointments anyway – it is one part of the puzzle to increase testing for common STIs. That’s important because of the role testing plays in preventing the spread of infections.

Scotland has been wrestling with rising numbers of STIs in recent years. Gonorrhoea cases grew by a whopping 137 per cent between 2013 and 2019. The number of diagnoses dropped in 2020 and 2021, but this was due to fewer tests being done during the coronavirus pandemic – 2022 saw another huge increase, 49 per cent higher than 2019 levels.

Chlamydia cases were also rising before the pandemic, with a 14 per cent increase between 2016 and 2019. Again, diagnoses fell during the pandemic years before rising again in 2022.

Syphilis has also seen a surge in cases, reaching a record 455 diagnoses in 2018. In 2019 there was a slight decrease – described as “encouraging news” by statisticians – but those are the most recently published figures for Scotland so it is unclear whether that trend continued.

People can’t access an appointment for sexual health screening within the timescales

Professor Claudia Estcourt, a professor of sexual health and HIV at Glasgow Caledonian University, explains this trend is not just in Scotland, but across the Western world. “Across the four countries of the Union and other countries, we have seen rises in key STIs. We’ve got rates of gonorrhoea that have not been higher since pre-war – the First World War.

“We have also got rates of syphilis and rates of hospital admissions – because people get complications from these infections – which have outstripped anything I’ve seen in my career. And also, we’re seeing conditions that we haven’t seen for many years, such as disseminated gonococcal infection.”

What’s behind the increase is unclear and Covid put a pause to work examining possible causes. Estcourt explains experts had started investigating why gonorrhoea, for example, had started to rise in heterosexual women. “Unfortunately all of the public health resource disappeared into Covid-19, so we didn’t really get much chance to investigate.”

The pandemic also impacted on the capacity of the NHS to test for STIs. Estcourt explains some health boards had to reduce it “in some cases up to 90 per cent as the laboratories, by necessity, had to shift to most of their workload being related to Covid testing”.

This increase has put significant strain on sexual health services, and finite budgets means funding that would normally be spent on prevention ends up being shifted to treatment. Estcourt says this has created a “vicious cycle”.

“It becomes very difficult to prioritise somebody for prevention when you have to see somebody who’s got an acute infectious STI within a very short time frame. That’s really trying to do more for less, and it’s really difficult when it’s not just that our budgets are reduced, our workload has also increased because of the increase in the numbers of STIs. You can’t square circles,” she says.

A report by the Terrence Higgins Trust last year proved the point. It found pressures across Great Britain meant there was an “emerging trend of gatekeeping” for face-to-face appointments, yet at the same time many services did not have sufficient alternatives like drop-in services, online appointments or postal testing.

Eagleson says: “Across the board, what we’re hearing is that people can’t access an appointment for sexual health screening within the timescales that are laid out in national guidelines.”

First Minister Humza Yousaf was asked about increasing access to sexual health services, including testing, at a session of First Minster’s Questions earlier this year. He said the government was working with health boards “to ensure that they take appropriate approaches that are tailored to local needs”.

He also pointed to the recently published Sexual Health and Blood Borne Virus Action Plan and funding to improve access to information and resources.

Public Health Scotland last summer launched its #SafeIsSexy campaign, focusing on the importance of getting tested, partner notification and being educated about one’s own sexual health.

But there are concerns that public messaging won’t be enough against a backdrop of rising infections and financial pressures.

If we think that there’s pressure now and inequitable access now, it’s not going to get better in a hurry

Dr Bridie Howe, a sexual health consultant in NHS Highland, warns insufficient funding will have a knock-on impact. She says: “If your workload goes up and your funding goes down, you have to start thinking about where you prioritise. Waiting lists for long-acting, reversible contraception – for example the coil and implant waiting lists – have gone up across the country, some more than others.”

Howe, who also chairs the Scottish branch of the British Association for Sexual Health and HIV, also warns the situation is likely to get worse as recruitment challenges begin to bite. “There is a workforce crisis that’s imminent in terms of sexual health specialists, specifically genitourinary medicine.

“The training programme is underfilled across the country, Scotland as well as England. Training is five years and we’re seeing empty training posts, which means that when we see a wave of retirees in five years’ time, there’s not going to be people to fill those because there’s nobody starting the training now.

“If we think that there’s pressure now and inequitable access to specialist sexual health services now, it’s not going to get better in a hurry unless there is a drive to fill those places and to recruit into the training programme.”

Despite this troubling backdrop, there have been some positive developments in sexual health in recent years.

The HPV vaccine has proven hugely successful in preventing the development of cervical cancer in women – a study published in January found no cases had been detected in women immunised at age 12-13 since the rollout of the programme in 2008.

HPV is one of the most common STIs and most clear up on their own with no further issues, but some strains can cause genital warts or, later in life, head, neck and anogenital cancers.

New HIV diagnoses have continued to drop, particularly among gay, bisexual and other men who have sex with men (GBMSM). As a result, more heterosexual people were diagnosed with HIV in Scotland in 2022 than among GBMSM for the first time.

Howe explains this is likely due to a mixture of improved testing, the rollout of prevention drug PrEP on the NHS in 2017, and new medication for HIV+ people which can prevent transmission.

Howe also anticipates the new 4CMenB vaccine – which provides protection against gonorrhoea and was approved by the Joint Committee on Vaccination and Immunisation last year – to shortly be available on the NHS. However, she continues to have concerns about funding for this and other measures.

“Unfunded measures that have been put into place, such as PrEP and all of these vaccines – apart from hepatitis B – which have started since 2017, all of these are unfunded and when something’s unfunded, it puts financial pressure on a department at the same time as funding cuts, which means that their just isn’t the manpower behind all of this…

“We’re really keen to access further prevention with the 4CMenB vaccine. But we’re asking, is that going to be another unfunded intervention that we have to manage?”

Likewise, she also wonders whether the Scottish Government’s target to eliminate HIV transmission by 2030 will be sufficiently funded. That ambition was announced in 2020 but with a delivery plan not yet published, there are warnings that Scotland is falling behind.

At a recent meeting of the Scottish Parliament’s Equalities, Human Rights and Civil Justice Committee, which is conducting a short inquiry into the 2030 target, MSPs were told Scotland had been a leader, that it was a gamechanger. The use of the past tense by witnesses was notable. MSPs were told the ambition was “way beyond” what could realistically be delivered as it stands, with an “enormous” gap in financial commitment in particular.

Can you imagine a straight person turning to their parents, or somebody in an ethnic minority community, saying ‘I’m going for an HIV test?’

Eagleson adds: “We’ve got all the tools that we need to reach that target, but we won’t do it by accident. We are falling behind other nations of the UK. England has had a published, funded action plan since 2021. Wales has had a funded, published HIV Action plan since 2023.

“In Scotland, we announced the ambition to end new HIV transmissions by 2030 in 2020. In 2021 the HIV Transmission Elimination Oversight Group was established and produced a series of 22 recommendations on how HIV could be eliminated in Scotland by 2030. That was published on World AIDS Day 2022, and following that the Scottish Government got together a further expert group to look at how to deliver on those recommendations

“A draft plan has been produced and is pretty much ready to go, but it’s not yet been published, nor is it indicated how it will be funded.”

One of the main barriers to HIV transmission elimination is widening access to PrEP. The majority of people who take the medication now are GBMSM, but other groups who are considered at higher risk of contracting HIV and who may be eligible are people from black African communities, transgender people, people who inject drugs and those involved in prostitution.

Paul Robertson, a gay man living in Edinburgh who is HIV+, suggests the history of HIV is why so many in the LGBT community “have felt that they need to be educated on it – because it’s their lives, their health”. The positive side of this is it means gay men are often “extremely open” about accessing testing and taking PrEP.  “The challenge now is if we’re going to get to a place where there are zero new HIV infections in Scotland, it needs to stop being seen as a ‘gay disease’ and testing for HIV is something that we should all be doing.”

Robertson was diagnosed with HIV in 2019. He had been on PrEP a few years before, but had stopped because of the difficulties and costs of accessing the drug. This was before it was widely available on the NHS and he would have had to order it from overseas.

Unlike in previous decades, though, Robertson’s HIV status is not a death sentence – nor can he pass it on. “I take a pill every day and that means my viral load is something called undetectable – HIV in my blood can’t be detected by a test. When you have an undetectable viral load, I can’t pass it on to anybody.” This is true for the vast majority of HIV+ patients on medication in Scotland; 93 per cent of those receiving treatment have an undetectable viral load.

Still, despite these advances Robertson is acutely aware that stigma around HIV persists. “Can you imagine a straight person turning to their parents, or somebody in an ethnic minority community, saying ‘I’m going for an HIV test?’ It’s words that strike fear into the heart of anybody because of the history of it. We need to get past that and get to a place where the LGBT community is, where going for a test is a really normal thing to do.”

Experts agree, and that goes for STIs more broadly too. “What’s important is that people know that sexually transmitted infections are just infections that tend to affect your genital area, which unfortunately is stigmatised. For people like me who work in sexual health clinics, it’s just another bit of your body,” says Estcourt.

We’re under tremendous strain with the rise in numbers of STIs and currently also high levels of contraceptive need and abortion

Eagleson says a wider approach is needed. “At the core of quite a lot of what we’re talking about is rooted in stigma that surrounds sex – having sex, talking about sex, being confident about sex, using positive language about sex.”

He believes schools have a really important role to play here and he is calling for “comprehensive, inclusive sex education”.

Public Health Scotland is keen to collaborate with education bodies for this purpose, including reviewing the Curriculum for Excellence. Secondary schools were also asked to prioritise learning about STIs for older pupils during this academic year.

Ensuring young people have access to clear and accurate information is one of the ambitions included in the Scottish Government’s sexual health action plan. It also commits to improved monitoring, benchmarking, and publishing an HIV transmission elimination delivery plan.

I ask whether that action plan is good enough. Estcourt sums it up: “The plan is, but the plan needs to be implemented and evaluated, which is always the bottom line. With the current state of funding and resources in sexual health clinics, I think it would be really difficult for people to implement all of the elements of the plan. We’re under tremendous strain with the rise in numbers of STIs and currently also high levels of contraceptive need and abortion.

“There are very lofty aims, which are the right aims, but it would be very difficult for services to be able to deliver on those aims without additional funding.”