Rising to the challenge
As outlined in the previous section, the challenges faced by SHBBV services, and the future consequences in terms of population sexual and reproductive health, are extensive and must not be downplayed. However, it is just as important to recognise the exceptional effort that public health workers, clinicians, third sector services, counsellors, academics and service users have made to respond to these challenges. While some services had to be stopped immediately, the work to redesign them, and to provide alternative solutions wherever possible, was also rapid.
The examples are numerous, and NHS Boards and other services found different approaches, but all across the country, innovations that might not have been considered viable in January 2020 were rolled out at pace, providing vital lifelines. In some cases these were procedural or administrative, for example providing users with increased duration of medications on prescription such as oral contraceptives or HIV pre-exposure prophylaxis (PrEP) drugs. Others involved pilots of new ways of working or expansion of existing services. Some of these are highlighted below.
For treatment of people diagnosed with HIV, rapid service re-design with mitigations successfully maintained routine out-patient care with reduced capacity during lockdown. Remote consulting systems were used where possible, with in-person access offered for urgent or complex problems and newly diagnosed patients. Treatment supply was maintained in all cases through a combination of medication delivery using national contracts or local pharmacy collection arrangements. These clinical efforts were complemented by third sector organisations, which provided information and support, and in some instances delivered medication to those unable to leave home.
Similarly, clinical nurse specialists used telephone consultations to carry out assessment for hepatitis C treatment (HCV) in patients who had already completed appropriate blood tests, which enabled people to be initiated onto treatment using remote working. NHS Lothian Community BBV Clinical Nurse Specialists undertook a pilot from November 2020 to January 2021 using an Xpert Cepheid machine, which can provide HCV polymerase chain reaction fingerstick rapid testing. 70 tests were performed in outreach settings with 8 positives being identified and entered into the treatment pathway.
An emphasis on remote services also helped to maintain access to abortion services. Face-to-face appointments were replaced, where appropriate, with telephone assessment and greater flexibility was introduced for access to allow mifepristone (the first drug taken for a medical abortion) to be taken at home, also where this was clinically indicated.
Case Study: NHS abortion care
NHS Lothian provides abortion care to just over 2600 women annually. Until March 2020 this involved an in-person clinical consultation and a routine ultrasound scan to assess gestational age. Women took mifepristone at the clinic (as required by law), but those less than 10 weeks' gestation had the option to self-administer the second part of the treatment, misoprostol, at home.
In March 2020, Ministerial approvals were amended in Scotland, England and Wales, permitting home use of mifepristone. In Scotland, new clinical guidelines supported telemedicine provision of medical abortion at home without ultrasound in certain circumstances, up to 11 weeks and 6 days' gestation. Chalmers Sexual and Reproductive Health Centre in Edinburgh moved wholly to provision of this model of abortion care on 1 April 2020. In the following three months, 826 women had a teleconsultation and 758 women proceeded to abortion (some continued pregnancy after consult). 663 (87%) had a medical abortion at home and the remainder had either a medical or surgical abortion in a hospital setting.
In NHS Lothian, a formal evaluation of over 650 women using the service indicated the safety and acceptability of Telemedicine Early Medical Abortion at Home. Of the abortion at home group, 20% required a pre-abortion ultrasound to confirm location or gestation of pregnancy following clinical history. 98% had a complete abortion and only 2.4% of women made unscheduled attendances to the hospital, which is the same as the previous in-person care model. Women reported high levels of preparedness to use the medications in their own homes. Similarly 95% of women rated the abortion experience as 'somewhat' or 'very' acceptable and 89% stated that they would opt to have treatment at home again if they needed another abortion.
In testing, there was an increased use of remote testing for STIs and BBVs, including postal testing kits and remote self-sampling, or self-sampling at clinical sites to reduce face-to-face appointments and interactions. There was also rapid development of postal free condom services in most NHS Board areas to mitigate the closure of local venues and the reduction in contraception appointments and STI/BBV testing.
Assertive outreach for PWID was quickly developed in some areas, combining a range of services to focus on user needs. NHS Lothian, for example, provided vapes for all people in homeless settings who were previously unable to afford them and who were using drug and alcohol services, where lung and general health issues are key indicators linked to mortality. This brings an opportunity to assess and improve access to harm reduction tools and primary preventative care outside traditional injecting based services.
National guidance was quickly produced on contingency planning for people who use drugs and COVID-19 by Scottish Drug Forum and partners including the Sexual Health and BBV Prevention Leads Group and with support from Scottish Government. It was shared with all Alcohol and Drug Partnerships and all drug services in Scotland. The guidance helped local areas and services to adapt practice, particularly the provision of opiate substitution treatment (OST) and injecting equipment provision (IEP).
Although there is no evidence yet that COVID-19 has had a significant impact on the national rate of drug deaths in Scotland, the continued growth in numbers of deaths has triggered the creation of a new ministerial portfolio with a Minister for Drugs Policy set up in January 2021. With the new portfolio has come a national drugs mission to improve and save lives. This mission is backed up with an additional £50 million per year for alcohol and drugs services. One of the key aims of the mission is to increase the numbers of PWID who seek support from services. This will have a beneficial impact on the numbers of people who can be tested for BBV, ensuring alcohol and drugs services are working closely with BBV initiatives.
Case study: NHS GGC WAND initiative
NHS Glasgow Greater and Clyde and third sector partners launched an incentive based harm reduction initiative to further reach out to people who inject drugs (PWID) at a time where service provision remained limited. The WAND initiative encourages clients to participate in 4 key harm reduction interventions and was designed to address key issues PWID within Glasgow City Centre face, including drug related death, injecting related complications and BBVs.
The Assessment of Injecting Risk (AIR) tool, a comprehensive assessment tool accessed from any internet enabled device, is aimed specifically at people injecting street drugs. It helps to identify a wide range of injecting-related harms and their causes, and allows in-depth conversations regarding necessary harm reduction. The process is interactive and has demonstrated improved interaction from both specialist workers and clients. The AIR tool uses smart logic to support staff in asking appropriate questions related to current injection activity.
To encourage clients to continue the programme, when all interventions are completed the client is provided with a 'Pay Point' voucher. Although this initiative increased workload, harm reduction staff reported feeling skilled, reinvigorated and focused as the positive interaction of the assessment process improved service users engagement and gave staff greater role validation. The Glasgow Drug Crisis Centre ensured this activity was given priority even with the backdrop of tight Covid-19 restrictions.
In September 2020, there were 377 WAND assessments completed. Most clients had not been tested for BBVs in the previous 6 months, notably HIV (53% - 201 people) and Hep C (50.1% - 191 people). Only a 1/5th were carrying Naloxone with them at the time of the assessment even though a third had overdosed in the past 12 months (126 people).
Case Study: HIV Scotland/Waverley Care Self-Test
A diversified approach to HIV testing delivery can help reach many communities across Scotland, especially those that are considered to be 'harder to reach' or not already engaging with NHS HIV testing services. On 15 April 2020, HIV Scotland and Waverley Care began piloting a national HIV Self-Testing programme called HIV Self-Test Scotland. The programme aimed to cut across communities to ensure that everyone who needed it during the COVID-19 pandemic had equal and equitable access to a free HIV test kit, regardless of their location, sexual identity, or practice.
The service has confirmed that access to the free provision of HIV self-testing can play a role in overcoming barriers to frequent HIV testing, and that online ordering for postal delivery is a feasible and acceptable means of delivering tests.
Overall, the programme demonstrates demand for HIV self-testing across Scotland and among key population groups, including gay and bisexual and men who have sex with men; PWID; heterosexual people; non-binary individuals and people who live in remote or rural settings. Between 15 April 2020 and 12 February 2021, 6551 orders have been made through HIV Self-Test Scotland, representing nearly 600 tests being performed per month.
Although the range of responses to the pandemic is broad, the commonalities are a willingness to adapt, and to respond quickly to the needs of those most vulnerable. These traits must be harnessed as we move forward. Clinicians, academics and third sector leads have identified that recovery should take account of and focus on:
- Remote services – a range of options should be provided for SHBBV care with expansion of remote self-management where feasible and appropriate. This will allow people with straightforward needs to be managed online, by telephone, or by video assessment as desired. This should free up physical services to manage those with more complex needs in person.
- • Exploration of abortion care changes – the scope for maintaining telephone assessment and remote prescribing where appropriate beyond the pandemic will continue to be encouraged and the potential for women to take mifepristone at home will be informed by the planned evaluation of the current approach to early medical abortion at home.
- Maintaining easier access to medication – throughout the pandemic, postal and home delivery of medications turned out to be vital. These changes should continue to play a role in patient care and be tailored to priority groups.
- Continuing support for remote testing for STIs and BBVs. As above, increased use of self-testing and self-sampling showed potential to reach more people and to do so in more convenient, accessible ways that also free up staff time.
- E-prescribing for community pharmacy dispensing.
- Using virtual platforms for meetings, teaching and training and for rapid service development.
- Greater use of technology – teaching, training and rapid service development can be done differently and in ways that are more inclusive, and reach higher numbers.
- Ongoing collaboration – the partnerships between Health Boards and third sector organisations were a key component of the efforts to deliver care and redesign services, allowing their skillsets and reach to complement and supplement one another.
In working to build on these innovations, however, we must recognise the speed with which they were implemented, and the highly unusual circumstances that drove them. Their use during the pandemic has undoubtedly helped to support vital services at a time when they were most at risk, but it must also be recognised that some were introduced as temporary or interim measures.
In spite of the pressures and the pace of change, some outcome evaluation and user satisfaction work has been carried out. However, the long term impact of changes has not been evaluated and the complexities of access to and satisfaction with different care models for different groups is not yet understood.
Of most pressing concern is the need to evaluate and understand their impact on priority groups, and those who may already be most at risk. Already, there is some evidence that remote services are problematic for young people, who are less likely to engage with them due to concerns about confidentiality, lack of privacy in their home environment and being unsure about what online consultation would involve. Additionally many of the most vulnerable young people experience digital exclusion and are at risk of missing vital information and support as a result.
Case Study: Engagement with Young People
Young people's sexual health has been of great concern since the pandemic began. Prior to COVID-19 there had been increases in bacterial STIs and a reduction in uptake of vLARC in young people. Lockdown restrictions over the last year removed, reduced or changed modes of access to preventative measures that are known to support young people's sexual health. This included cessation of face-to-face interaction and move to online provision by teaching staff, social care staff, youth workers and other key adults that support young people.
Engagement with organisations working with young people identified that many young people were known to have continued to be sexually active despite the restrictions in place on mixing with other households. This coincided with an initial total suspension of young people's sexual health services and introduction of access methods to essential services that young people are more reluctant to use, such as telephone or video consultation. This raised the prospect that young people could find themselves pregnant, or at risk of an STI and unsure what if any sexual health services were available, or reluctant to engage with services that were available due to concern that they would be in trouble for breaking COVID-19 restrictions.
Rapid partnership working between NHS Board health improvement teams, Scottish Government and Public Health Scotland was undertaken to develop reassuring messages for young people highlighting that the NHS was still open for sexual health care, that they should come forward and wouldn't be judged or in trouble and that doing so in a timely manner mattered in relation to their choices. These key messages were targeted to young people in the summer though advertising placed on social media platforms known to be used by young people. These directed young people to further dedicated information on NHS Inform, highlighted the role of pharmacies and the postal condom services which had been established, and provided information on where local services were still open.
The key messages were also widely distributed to staff in organisations across Scotland working with young people. This process was repeated at the end of 2020 when most of Scotland entered Level 4 restrictions. While it is acknowledged that many of the most vulnerable young people experience digital exclusion, there was strong engagement by young people, with 25,000 active "click-throughs" from the digital resources. Recovering face to face service provision for young people and communicating consistently about how to access it is imperative and will require effective co-design approaches, with young people at the centre of the process.
Remote testing also will continue to be a valuable tool as we move forward, but much more must be done to understand the key demographics that are willing and able to engage with it; the barriers that prevent others from doing so; and how these can be overcome or alternative measures implemented so that inequalities are not inadvertently increased.
Recovery priorities must focus therefore on:
1. Ensuring the infrastructure exists to maintain positive innovations – for example continued support for technologies that are already being used, and a focus on the cultural changes that have allowed and supported digital meetings and training.
2. Increased research and ongoing support for academic institutions – the short and long term impacts of these innovations must be evaluated, and results widely shared so that best practice can be developed; inequalities monitored and mitigated; and the most effective innovations scaled up across Scotland where possible.
3. Dedicated focus on a user/ patient-centred approach – their voices must not be forgotten, and research must be focused on qualitative engagement with people who use services to understand their lived experience, not simply focused only on hard data and user trends.