JSNA topic report: sexual and reproductive health

Sexual health is an important area of public health.

Most of the adult population of England is sexually active and access to quality sexual health services improves the health and wellbeing of both individuals and populations.

The Government has set out its ambitions for improving sexual health in its existing publication: A Framework for Sexual Health Improvement in England (2013).

An updated framework is due in 2022.

In 2021, the Department for Health and Social Care launched the HIV Action Plan setting out its plans to achieve an 80% reduction in new HIV infections in England by 2025.

Its aim is to ensure that partners across the health system and beyond, maintain and intensify work around four core themes – prevent, test, treat and retain.

This includes:

• preventing people from getting HIV
• ensuring those who get HIV are diagnosed promptly
• preventing onward transmission from those with diagnosed infection
• delivering interventions which aim to improve the health and quality of life of people with HIV and tackle stigma

The provision and evidence base for integrated sexual health services is supported by accredited training programmes and guidance from relevant professional bodies including:

• Faculty of Sexual and Reproductive Health (FSRH)
• British Association for Sexual Health and HIV (BASHH)
• British HIV Association (BHIVA)
• Royal College of Obstetricians and Gynaecologists (RCOG)
• National Institute for Health and Care Excellence (NICE)
• relevant national policy and guidance issued by the Department of Health and Social Care (DHSC) and UK Health Security Agency (UKHSA) formerly Public Health England (PHE)

Service delivery should reflect local requirements; however, guidance recommends, fully integrated consultant led sexual health services that include primary and secondary prevention and contraceptive care.

Open access services, rapid access to diagnosis and treatment and promotion of outreach primary prevention to educational establishments and high-risk groups are all recommended. In addition, and in line with national guidance, sexual and reproductive health services must be evidence based and:

• recognise the 3 key areas of safety, effectiveness and patient experience
• maintain a focus on primary prevention including the use of condoms and effective contraception and the delivery of vaccinations
• ensure new areas of innovation are identified, implemented where appropriate and evaluated
• offer appropriate digital technologies to support access to services and information
• implement evidence-based interventions and new models of service delivery which are flexed to meet the needs of key groups

Public Health England (now UKHSA) published a report Sexual and reproductive health: return on investment tool on the economic return on investment (ROI) of Sexual and Reproductive Health for 15 to 24 year olds.

The report found that the benefits of spending on STI testing interventions significantly outweigh the costs (even though more diagnoses can lead to higher treatment costs in the short-term).

These estimates are likely to underestimate the true ROI of STI interventions, as they do not capture the benefits of secondary cases averted by additional testing and treatment. Early testing for HIV reduces treatment costs.

In 2016, the cost of HIV treatment per annum when HIV is diagnosed quickly was estimated to be around £14,000 per case compared with £28,000 per case when diagnosed late. Investment in STI prevention will not only provide health benefits but also provide a long-term financial benefit to the healthcare system by reducing healthcare costs as a result of avoided new infections and delayed disease progression (Projected Lifetime Healthcare Costs Associated with HIV Infection - PubMed).

According to a Public Health England (PHE) report, Health matters: reproductive health and pregnancy planning, 78% of women of reproductive age require support with contraception and/or preconception at any one time.

Provision of contraception reduces the number of unplanned pregnancies which have high financial cost to both individuals, the health service and to the state.

PHE published a report in 2018 (Contraception: Return on Investment-PHE) estimating the ROI for publicly funded contraception in England. The report advised:

• publicly funded contraception is a highly cost-effective public health intervention
• all forms of contraception should be made available to provide the full range of choice for women
• longer acting methods, including implants and intra-uterine devices, are and the most cost-effective

The effectiveness of the barrier method and oral contraceptive pills depends on their correct and consistent use. However, the effectiveness of Long-Acting Reversible Contraception (LARC) methods does not rely on user competence and once fitted can last for up to 10 years depending on device. The combination of reliability and cost effectiveness has led to the National Institute for Clinical Excellence (NICE) issuing guidance to professionals so they can help women make an informed choice about their contraception and seek to increase the uptake of LARC as a proportion of all contraception.

Benefits for contraception are usually measured as the number of pregnancies averted by its use, or as the cost savings that result from these averted pregnancies. The PHE ROI report identified that the averted costs can be broadly categorised into healthcare costs and wider costs to the public sector. There will also be lifetime costs to the parent which were not included in the analysis. The report found that summing all cost categories gives a cost saving per averted pregnancy of £23,909 over 10 years.

This includes:

• healthcare costs of £6,591
• Public Health costs of £398
• education costs of £7,714
• Housing Benefit costs of £519
• children in care costs of £1,035

The report further found that return on investment for averted birth costs:

• from a healthcare perspective, the ROI is £1.51 for every £1 spent after one year (this grows to £2.82 for every £1 spent over 5 years and £3.68 over 10 years)
• the ROI for total cost savings across the public sector is £1.86 after one year, £4.64 over 5 years and £9.00 over 10 years for every £1 spent

The analysis only refers to direct savings to public sector budgets and not the wider societal impacts of unplanned pregnancy and therefore gives a conservative estimate of ROI. In the longer term there are increasing savings from averted education and welfare costs, resulting in an ROI of £1.82 over 5 years and £5.32 over 10 years.

Overall, spending through the Public Health grant is up to 4 times as cost effective as NHS spending ( Martin, S., Lomas, J. & Claxton, K., 2019. 'Is an Ounce of Prevention Worth a Pound of Cure? Estimates of the Impact of English Public Health Grant on Mortality and Morbidity'. CHE Research Paper 166. York: University of York)

The analysis suggests that cuts to contraceptive services will cost national and local government in both the short term and long term, through increase in healthcare, education and welfare costs from unplanned pregnancies.

Building on the ROI contraception tool published in 2018, ROI evidence is now available for maternity and primary care settings. For every £1 invested on the maternity intervention, there is a saving of £32 for the public sector. Investment in the provision of additional LARC by GPs has even greater potential cost savings, with an ROI of £48 for every £1 invested (Contraception return on investment tool-PHE)