It is unclear how the COVID-19 pandemic has affected the rates of sexually transmitted infections (STIs) in the UK. There was a decline during the first COVID-19 lockdown in March 2020, but there was also decreased testing or case reporting (Latini et al, 2020). Before the pandemic there were rising trends of STIs in the UK in certain at-risk groups such as men who have sex with men (MSM), the 15–24-year age group and people aged 45–64 (Family Planning Association (FPA), 2016; Royal College of Nursing (RCN), 2019).
Nurses working across sexual health services are facing challenges due to significant changes during the past decade (RCN, 2013; 2021). Not only has a struggling service had to change during a pandemic, but people's behaviour has changed, too. The reality is that, despite the various lockdowns, people did not stop engaging in sexual activity (Coombe et al, 2021). This highlights the importance of ensuring availability of sexual and reproductive health services at this time (Coombe et al, 2021). Some have predicted huge increases in rates of infection (Jenness et al, 2021; RCN, 2021).
Service change
The COVID-19 pandemic led to rapid adaptation of health and public health systems on a global scale (Simões et al, 2020). For example, in Beirut, Lebanon, the largest STI and HIV clinics have remained open for emergencies (Maatouk et al, 2021). Despite COVID-19, access to remote consultations was available but the clinic noted a major reduction in STI testing rates. In New York, US, seven of eight sexual health clinics remained open only for limited and emergency services (New York City Department of Health, 2020).
Nagendra et al (2020) looked at the potential impact of the availability of sexual and reproductive health services during the pandemic in the US and found a significant decrease in the regular services they were able to provide. This mirrors the findings of Tao et al (2021), who reported that from September 2019 to May 2020 there was a significant decrease in rates of STI visits and treatments. The reduction in treatments has been due to a reduction in services and accessibility, and a reluctance to break lockdown restrictions.
It is difficult to predict the combined impact of all these factors on longer-term HIV and STI epidemic trajectories. Bonet et al (2021) found that the disruptions in STI testing during the COVID-19 led to a decrease in tests but an increase in positive test results. Positive test results for gonorrhoea rose by 1.7% and chlamydia by 10.4%, although the number of tests fell considerably overall (Bonet et al, 2021). Van Aar et al (2021) found that levels of HIV fell.
In Europe, Simões et al (2020) reported a decrease in testing volume due to closures during lockdown, with reduced staff and accessibility, a reduction in actual serological tests, laboratories over-burdened and fewer referrals to specialists. Hyndman et al (2021) studied sexual behaviours in HIV-negative MSM in London and found high rates of sexual activity and STI diagnoses during lockdown. They suggested that changes to services for this high-risk group are required to address high rates of psychological and STI-related morbidity and the challenges faced by this population in accessing services (Hyndman et al, 2021).
‘Despite changes in sexual and reproductive health services, nurses across all parts of the UK NHS have a vital role to play in the prevention and treatment of STIs’
The initial response to the pandemic was to offer sexual and reproductive health services virtually (Lewis et al, 2021). Despite this, there were barriers to STI and pregnancy prevention and growing inequalities in certain risk groups, such as young people, due to pandemic restrictions (Lewis et al, 2021). The biggest issue was accessibility.
Van Wees et al (2022) suggest the STI risk during the pandemic was low in most heterosexuals, but there are specific subgroups of people who engaged in high-risk behaviour during this period, lockdown and post-lockdown. In comparison, Reid et al (2021) suggest that fear of contracting COVID-19 and of judgement for having sex against restrictions helped deter people from engaging in sexual behaviour. In a survey of 565 British adults aged 18–32, Wignall et al (2021) found that there was an overall decrease in sexual behaviour due to the social restrictions.
Long-term predictions
Many of the effects on the sexual and reproductive health services were not the direct result of COVID-19 infection, but of the consequences of a stretched health service (World Health Organization (WHO), 2020). Jenness et al (2021) suggest that if sexual behaviour rebounds while there is a disruption in services, there may be an excess of hundreds of HIV cases and thousands of STI cases in Atlanta's male population alone.
In Africa there is a bleaker picture. A report by UNAIDS (2020) found that the target of 73% of people living with HIV on treatment was reduced by 11.8% in 2019 due to COVID-19 – although this will now be higher as the pandemic intensified. The report also suggests it is likely that there will be potential long-term disruptions from COVID-19 (UNAIDS, 2020). Hillis et al (2020) argue that it will be reasonable, post pandemic, to expect a surge of offline sex-seeking behaviours and high- risk sexual activity, with a corresponding increase in STIs. More concerning is that global disruption of services due to COVID-19 and the movement of resources away from essential sexual and reproductive healthcare are expected to increase risks of maternal and child morbidity and mortality (Rasmussen et al, 2019).
Existing sexual health services
Sexual health services are delivered in various settings, providing care across specialised services as well in primary care and third sector organisations, encompassing genitourinary medicine, sexual and reproductive health, psychosexual medicine and counselling, abortion services and HIV (RCN, 2019; 2021). Despite changes in sexual and reproductive health services, nurses across all parts of the NHS have a vital role to play in the prevention and treatment of STIs (Bungay et al, 2017; RCN, 2019). The role of the nurse is specialised and varied in these settings (RCN, 2019).
Nurses have safely prescribed medication such as antibiotics for sexual health for a number of years (Black, 2013). The Standards for Medicines Management in Sexual and Reproductive Health Services are produced by the Faculty of Sexual and Reproductive Healthcare (FSRH), which supports health professionals to deliver the gold standard in safe contraceptive prescription, as well as clinical and service standards (FSRH, 2018). Its aim is for all sexual health services to ensure that patients have direct access to a prescription or medication (FSRH, 2014).
The UK government's key aim when considering sexual health is ‘to improve the sexual health and wellbeing of the whole nation by reducing inequalities and improving health outcomes as outlined in their framework for sexual health improvement’ (Department of Health, 2013: 3).
The nurse has a pivotal role in supporting patients who are often stigmatised or vulnerable, identifying patients at risk (Kuzma et al, 2016; RCN, 2021) and reducing inequality identified during the COVID-19 pandemic (Howarth et al, 2021; Lewis et al, 2021). Future recommissioning and development of services need to support public health planning to mitigate against health risks after the pandemic (Howarth et al, 2021).
These are not new challenges as barriers to accessing STI services were present before the pandemic. One example is pre-exposure prophylaxis (PrEP), highly effective for HIV prevention. The availability of PrEP has been slow across Europe and the ‘gap’ between self- reported use and expressed need was large across European countries (Hayes et al, 2019). There have been ongoing calls for investment in sexual and reproductive healthcare for several years, which included standardised training of staff, accessibility to services and development of new services (FPA, 2017). Despite these challenges, many STI programmes have still tried to run skeleton services to support patient needs (Jenness et al, 2021).
‘Whatever the service provision before the pandemic, now is the time to re-evaluate what can be done to improve accessibility and equality of sexual health services’
In 2020, the FSRH released a statement that said: ‘The Provision of effective contraception and abortion care remains essential during the COVID-19 pandemic irrespective of the COVID-19 restrictions in place.’ It suggests all essential services should be delivered remotely or through digital consultation and face to face where clinically necessary and/or feasible. Sexual health services are, therefore, provided by a mix of modalities of consultations. This includes telemedicine for abortion care, remote/electronic prescribing for contraception and hormone replacement therapy (HRT) and provision of online patient information (FSRH, 2020).
Some clinics are using telemedicine visits to extend PrEP prescriptions when the medication is well tolerated without regular laboratory testing, but there is a need for more research in the area (Napoleon et al, 2020). Simões et al (2020) suggest that there should be major investment in integrated testing for STI so that there can be a recovery of testing, particularly for those in the higher risk of groups of acquiring more than one infectious disease. There is certainly a need for innovative testing and treatment approaches as we navigate after the pandemic (Napoleon et al, 2020).
As sexual health and reproductive services are restored, it has been suggested that services should be co-created with specific groups, such as young people (Lewis et al, 2021). Van Wees et al (2022) state that specific individuals who show impulsive behaviour, have low health goals and poor prevention attitudes should be prioritised for STI testing. They suggest that behavioural interventions should be tailored to these patients' psychological characteristics (van Wees et al, 2022). There certainly is a need to continue education to reduce false beliefs and provide a targeted message about STI and HIV prevention (Duteil et al, 2019).
Whatever the service provision before the pandemic, now is the time to re-evaluate what can be done to improve accessibility and equality of sexual health services. Nurses, midwives and health practitioners are vital across sexual and reproductive health services to the delivery of high-quality care, but more needs to be done to support ongoing education and to re-evaluate the service to ensure it is fit for purpose (RCN, 2021). Before the pandemic, service provision was moving towards delivery of care via digital platforms and online portals (RCN, 2018). This progress has fast tracked throughout the past 2 years, but there is still a need to have ‘clearly identified safety and quality benchmarks as any other healthcare provision’ (RCN, 2018). Patel and Munro (2019) say that there needs to be a continuity of standards for all online and remote providers of sexual and reproductive health services. Certainly the FSRH/ BASHH Standards for Online and Remote Providers of Sexual and Reproductive Health Services were published in 2019 to support this.
Hall et al (2020) argue that there is a need for a sexual and reproductive health and justice policy agenda at the heart of our COVID-19 response. This would ensure that there is universal health for pregnant women and at-risk and marginalised groups through a designated sexual and reproductive health service. The call is to policy makers to increase telemedicine and provide evidence-based care for those using the service (Hall et al, 2020).
Conclusion
The issues experienced in the UK NHS during the COVID-19 pandemic were similar to those in many countries across the world, but more so in the developing south. Despite navigating the pandemic with the various lockdowns, people did not stop engaging in sexual activities – although less than in pre-pandemic times (Coombe et al, 2021; Jenness et al, 2021). This highlights the importance of ensuring availability of sexual and reproductive health services at this time (Coombe et al, 2021). There are predictions of a huge increase in rates of infection (Jenness et al, 2021; RCN, 2021). Therefore, there is a need to evaluate the existing service and explore how we can deliver accessible, equitable and high-quality sexual health services in the future.
Key Points
- The pandemic has been challenging for nurses working in sexual health services
- It is unclear how COVID-19 has had an impact on rates of sexually transmitted infections
- Despite not accessing services during the pandemic, people did not stop engaging in sexual activities
CPD reflective questions
- What are the long-term predictors for sexual health services in the UK?
- Identify your local sexual health services
- What are your local barriers to sexual health and contraceptive health services?
- How do you think your local sexual health services could be delivered?