Promoting long-acting reversible contraceptives and HIV testing: more work for harassed GPs?

The UK needs to focus on sexual health as 2007 statistics showed another bad year. There were 40 298 conceptions in women aged <18 years (rate 42 per 1000), of which 51% were terminated. Nearly 8000 of these pregnancies were in girls aged <16, a rate that (despite government spin) has changed little since 2001. Of 271 000 chlamydia tests in young people aged <25 years who were screened by the English National Chlamydia Screening Programme, 9.5% of tests in females and 8.4% in males were positive. There were also 702 new diagnoses of HIV in young people aged 16–24 years (incidence 10 per 100 000). Nearly half (48%) of these were in men who have sex with men, most of whom were white and probably infected in the UK. A similar proportion were in heterosexuals, mainly black Africans who were most likely infected abroad. However, there are some grounds for optimism. Most genitourinary medicine clinics are now achieving the 48-hour access target. The National Chlamydia Screening Programme reported that nearly 25% of under 25s were screened for chlamydia in 2008, although men and ethnic minorities were under-represented. It is likely that many more chlamydia tests could be done in general practice, particularly in high-risk young people with a recent change of sexual partner or history of chlamydial infection in the past 3 months. (It can takes less than 3 minutes of a GP’s or practice nurse’s time to organise a young person to complete the form and take a self-administered sample.) But the UK still has the highest rate of sexually transmitted infections (STIs) and teenage pregnancies in Europe. GPs have a responsibility for sexual health as part of holistic care. But as well as screening for STIs, why are we now being asked to promote both long-acting reversible contraceptives (LARC: IUCDs, contraceptive implants, or injections) and HIV testing? HIV can now expect to live to age 70. However, to date very few primary care trusts (PCTs) seem to have focused on this serious public health challenge. Treating someone with symptomatic HIV costs around £14 000 per annum, and the total cost of HIV to the NHS in 2005 was estimated as £400 million compared with £165 million for all other STIs combined. In the UK, high-risk areas for HIV are London (rate 4 per 1000 population aged 15–59 years), other major cities, and the south coast of England (Figure 1). GPs working in these areas might consider offering HIV testing more frequently, particularly to men who have sex with men, for whom annual testing is recommended, and those of black African origin in whom HIV prevalence is around 5%. PROMOTION OF LARC LARC methods are more cost-effective than the combined oral contraceptive pill because they reduce the likelihood of unplanned pregnancy. Condoms and oral contraceptives need consistent and correct use and have annual failure rates of around 15% and 8% respectively, compared with 0.1% for intrauterine contraceptive devices (IUCDs) and 0.05% for contraceptive implants. IUCDs and implants are also more cost-effective than injectable contraceptives, which depend on women returning for a repeat injection every 3 months. However, in the UK only around 12% of women currently use LARC, and unfounded anxieties about side effects are common. As LARC are more effective than other methods and actually have relatively few side effects, it seems sensible for GPs and nurses to consider encouraging wider use, particularly in women who have recently had one or more pregnancy terminations. But it is clearly crucial to make it easy for women to access these treatments as soon as possible. Thus, having a doctor in the practice who can fit these devices or close links with the local family planning clinic could be beneficial.