Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

These recommendations should be read together with relevant NICE guidance on sexual health and contraception (see the NICE topic page on sexual health).

1.1 Reducing the risk of people getting and transmitting sexually transmitted infections (STIs)

Accessing sexual health services

1.1.1 Form a network of services, including online services, providing sexual healthcare for an area. Ensure that:

  • everyone is signposted to, and can access, the care they need

  • local pathways are in place to link people, including underserved communities, to the best possible care

  • details of the network are kept up to date and all staff understand what each service offers.

1.1.2 Determine the most appropriate settings for services and interventions in consultation with groups with greater sexual health or access needs (see also recommendations in section 1.2). Include online and non-clinical settings.

1.1.3 Reduce barriers to services for groups with greater sexual health or access needs by:

Meeting the needs of groups with greater sexual health or access needs

1.1.4 Target interventions at groups with greater sexual health or access needs. Identify local needs and priorities using data from the Joint Strategic Needs Assessment (JSNA) and other data sources.

1.1.5 Engage with groups with greater sexual health or access needs to understand how best to meet their sexual health and wellbeing needs. Take into account factors such as existing barriers to access (for example, for people with learning difficulties, or because of their gender or sexuality), language and other socioeconomic factors, including deprivation.

Co-producing interventions to reduce STI transmission

1.1.6 Co-produce (plan, design, implement and evaluate) services and interventions in consultation with the groups that they are for, in line with NICE's guideline on community engagement.

1.1.7 Ensure that interventions are culturally competent. This includes being delivered in a suitable language for people whose main language is not English. It might also involve recognising that people may be engaged in activities that are stigmatised by their communities (therefore, discretion may be particularly important for them).

1.1.8 Ensure that interventions include some or all of the following components:

  • information and education about:

    • STIs

    • the impact of alcohol and drugs on sexual decision making

  • information about:

    • sexual health services available, including that they are free, confidential and open access

    • the rates of STIs to explain why some groups are at higher risk

    • the impact of stigma

  • sex-positive approaches to providing advice on the consistent and correct use of barrier methods, including providing external condoms in different sizes and textures, and internal condoms (see NICE's guideline on sexually transmitted infections: condom distribution schemes)

  • risk assessment and risk-reduction activities, for example developing personalised risk-reduction plans, identifying triggers and setting goals

  • Information–Motivation–Behavioural skills (IMB) model approaches and motivational interviewing techniques to guide conversations about risk reduction or safer-sex practices and address informational, motivational and skills-based barriers to change

  • activities to increase sexual self-efficacy (for example, talking about sexual consent, negotiating the use of barrier methods and negotiating sexual preferences) and broader self-efficacy (for example, self-esteem)

  • activities exploring the links between emotion and sexual behaviour, and coping skills (for example, using cognitive behavioural approaches)

  • a plan for follow up (for example, repeated contact to review progress or make new plans).

1.1.9 Take into account the recommendations in the NICE guidance on behaviour change (see the NICE topic page on behaviour change) when co-producing interventions to reduce STIs.

1.1.10 Tailor interventions to the needs of the groups identified. Take into account safety concerns (such as sexual violence or coercion), stigma and discrimination. See also the NICE guideline on domestic violence and abuse: multi-agency working.

Delivering and evaluating interventions to reduce STI transmission

1.1.11 Deliver interventions to reduce STIs across a range of services, including within broader support interventions and community services (for example, in drug and alcohol services, abortion care services, HIV care and mental health services).

1.1.12 Think about whether one-to-one or group delivery is the most appropriate for the community the intervention is aimed at, and the content and aims of the intervention. Take into account people's preferences and any resource impact.

1.1.13 Ensure that people have the opportunity to have interventions that are delivered by peers or other trusted people they can relate to, who share a cultural or group background with the target group.

1.1.14 When delivering interventions:

  • Avoid making assumptions about people or judging them. This could include using inclusive language (until the person expresses a preference) and recognising a range of relationships and sexual behaviours.

  • Be sex and identity positive (for example, by using gender-affirming language and being respectful of their sex life). Focus on self-worth and empowering people to have autonomy over their bodies and their sexual decision making.

1.1.15 Commissioners and providers should regularly evaluate interventions, including the methods used to co-produce them, to determine their effectiveness and acceptability and identify gaps to make service improvements across the pathway. For example, this could be done through a health equity audit.

1.2 Improving uptake and increasing the frequency of STI testing

Self-sampling

1.2.1 Offer a range of STI testing options based on local need, including remote self-sampling, in-person attendance at specialist clinics or in community pharmacies, primary care, and outreach services.

1.2.2 Offer people without symptoms remote self-sampling as an alternative option to clinic attendance. Self-sampling should test for the same infections as those tested for at the clinic.

1.2.3 Ensure that local service websites give up-to-date information on which testing options are available in their area.

1.2.4 Ensure that self-sampling kits meet the NHS Accessible Information Standard and are inclusive (for example, addressing the needs of trans and gender-diverse people, and making instructions and guidance available in different languages or different formats such as diagrams, photos, or videos targeted at people with learning difficulties).

1.2.5 Widen access to self-sampling kits. For example, by having a system for people to order a kit online or by phone, or providing self-sampling kits through 'pop-up' or outreach services.

1.2.6 Monitor the provision and return rates of kits to identify any groups that have low rates of accessing or returning them. Take action to try to address the reasons for the low rates.

Tailoring interventions

1.2.7 Tailor interventions and information to the target users of the service. Where possible, ensure that interventions are available for other groups who may be excluded by this targeting. (See also recommendation 1.1.10.)

1.2.8 Recognise people's individual needs. Be aware that membership of a particular group does not imply that a person is necessarily at higher risk of an STI. Address this with cultural sensitivity and competency within the context of sex-positive approaches.

1.2.9 Consider personalising automated recall messages using low-level tailoring, for example adding the name of the person and clinician to the message. However, be aware of any potential risks of personalising messages, such as where there may be safety concerns.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on tailoring interventions to improve the uptake and increase the frequency of STI testing.

Full details of the evidence and the committee's discussion are in:

1.3 Partner notification

1.3.1 Advise people diagnosed with an STI about the importance and benefits of partner notification, the possibility of sex partners being infected even if asymptomatic, and the risk of reinfection. Encourage them to engage in partner notification, regardless of where they are tested, and discuss the different methods of partner notification with them.

1.3.2 Help people decide how to notify their sex partners. Discuss ways of having these potentially difficult conversations and suggest ways to deliver this information. Discuss the best method of partner notification in light of the person's relationship status and other circumstances. Alternative methods of disclosure may need to be used in different contexts (for example, those who may be at risk of domestic violence, or if the person expresses a need for anonymity).

1.3.3 If a person feels unable to tell their sex partners about the STI or is showing signs of difficulty dealing with their diagnosis, refer them to specialist sexual health services that can offer them more support with partner notification.

1.3.4 Ensure that there is a clear referral pathway to specialist sexual health services that can help with partner notification so that people can be referred seamlessly and without the need for self-referral.

1.3.5 Partner notification on behalf of a person with an STI should be carried out by professionals with expertise in contact tracing and counselling in line with the British Association for Sexual Health and HIV (BASHH) statement on partner notification for sexually transmitted infections.

1.3.6 Consider how geospatial networking apps (for example, Grindr or Tinder) may be used for partner notification, for example by:

  • suggesting that people who use geospatial networking apps to find sex partners use the apps to notify partners about contacting a sexual health service for STI testing

  • using app profiles to inform contacts of their need to be tested when notifying partners on behalf of a person with an STI.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on partner notification.

Full details of the evidence and the committee's discussion are in evidence review E: partner notification methods to prevent or reduce STIs.

1.4 HPV and hepatitis A and B vaccination in gay, bisexual and other men who have sex with men

1.4.1 Be aware that gay, bisexual and other men who have sex with men are not the only groups eligible for human papillomavirus (HPV), hepatitis A and hepatitis B vaccination (see NHS information on HPV vaccine eligibility, hepatitis A vaccine eligibility and hepatitis B vaccine eligibility).

1.4.2 Consult local gay, bisexual and other men who have sex with men to identify their needs and the barriers to vaccine uptake and course completion.

1.4.3 Opportunistically promote HPV, hepatitis A and hepatitis B vaccination with gay, bisexual and other men who have sex with men who are eligible for the vaccines. Give them information on HPV, hepatitis A and hepatitis B vaccination, including:

  • the diseases and their potential severity

  • the risks and benefits of vaccination, including individual benefits and, if relevant, population benefits (protecting other people in their community)

  • the importance of having all doses of a vaccination course.

1.4.4 Where possible, consider providing HPV and hepatitis vaccination during other routine health appointments for gay, bisexual and other men who have sex with men.

1.4.5 Identify gay, bisexual and other men who have sex with men who do not return for follow-up vaccinations (second and third doses), and send reminders that highlight the importance of completing the course.

See also the NICE guideline on vaccine uptake in the general population.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on HPV and hepatitis A and B vaccination in gay, bisexual and other men who have sex with men.

Full details of the evidence and the committee's discussion are in evidence review F: increasing uptake of hepatitis A, hepatitis B and HPV vaccinations in gay, bisexual and other men who have sex with men.

1.5 Pre-exposure prophylaxis for HIV

These recommendations should be read together with NICE's guideline on HIV testing: increasing uptake among people who may have undiagnosed HIV.

Raising awareness of pre-exposure prophylaxis for HIV

1.5.1 Raise awareness of pre-exposure prophylaxis (PrEP) among local groups with greater sexual health or access needs:

  • Use methods designed to target specific populations (for example, social media and relevant local organisations or groups).

  • Follow the advice in NICE's guideline on community engagement.

  • Pay particular attention to groups in which PrEP is less well-known or uptake is lower, such as trans people, cisgender women, young people (aged 16 to 24), people with a Black African or Caribbean family background and people from a lower socioeconomic status background.

1.5.2 Give relevant local community groups support and information resources to help them raise awareness of PrEP and increase trust in services.

1.5.3 Ensure that people in groups with greater sexual health or access needs understand that PrEP is for HIV prevention only and that it does not protect against other STIs, therefore barrier methods are also important. See NICE's guideline on sexually transmitted infections: condom distribution schemes.

1.5.4 Co-produce materials that target specific information gaps and causes of stigma within the target population.

1.5.5 Use peer support to normalise PrEP use, reduce all forms of stigma (originating from the person themselves, professionals and the wider society) and increase trust in services.

1.5.6 Tell trans people undergoing medical transition that there are no clinically significant interactions expected between PrEP and the common hormones used in this process, and that using PrEP is not expected to affect their transition.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on raising awareness of PrEP for HIV.

Full details of the evidence and the committee's discussion are in evidence review G: effectiveness, cost effectiveness, acceptability and unintended consequences of PrEP for HIV.

Service design for PrEP services

1.5.7 Ensure that services offering PrEP are welcoming and accessible (see recommendation 1.1.5) for all the different population groups who are eligible, for example by co-designing services with the key population groups. Ensure that tailoring services to specific communities does not exclude or alienate other eligible groups.

1.5.8 Raise awareness among healthcare professionals (particularly those in primary care, community settings and gender identity clinics) about which groups of people are eligible for PrEP. This could be done through continuing education or through commissioning (for example, through local networks [see recommendation 1.1.3]).

1.5.9 Provide protected time for healthcare professionals who have day-to-day contact with people eligible for PrEP to have training on relevant issues.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on service design for PrEP services.

Full details of the evidence and the committee's discussion are in evidence review G: effectiveness, cost effectiveness, acceptability and unintended consequences of PrEP for HIV.

Access to PrEP services

1.5.10 Services that do not provide PrEP should connect people who are interested in PrEP and eligible for it to a service that can prescribe it.

1.5.11 Ensure there are clear referral pathways between services that do not provide PrEP and those that do.

1.5.12 Make provision for people who want to be referred to services outside their local area or community.

See also recommendation 1.1.3.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on access to PrEP services.

Full details of the evidence and the committee's discussion are in evidence review G: effectiveness, cost effectiveness, acceptability and unintended consequences of PrEP for HIV.

Prescribing PrEP

Recommendations 1.5.13 to 1.5.19 support recommendations in the British HIV Association (BHIVA) and BASHH guidelines on the use of PrEP for HIV and should be implemented with reference to them.

1.5.13 Offer PrEP to people at higher risk of HIV, using the criteria in the BHIVA/BASHH guidelines.

1.5.14 Support people who are taking PrEP, for example in decisions around the use of barrier methods and attending follow-up appointments. Continue to offer them all other relevant sexual health services, such as information, behavioural support and condom provision.

1.5.15 Support people who are taking PrEP to get regular HIV testing and STI screening (every 3 months).

1.5.16 Give people taking PrEP tailored information and education on effectiveness, adherence, side effects and monitoring risks (see NICE's guideline on shared decision making).

1.5.17 Follow up people taking PrEP in line with the good practice points and monitoring recommendations in the BHIVA/BASHH guidelines.

1.5.18 Monitor the kidney function of people taking PrEP, and any other adverse health events.

1.5.19 Help people taking PrEP to maximise adherence to treatment. Follow the general principles in NICE's guideline on medicines adherence and address factors specific to the use of PrEP, including those listed in the BHIVA/BASHH guidelines.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prescribing PrEP.

Full details of the evidence and the committee's discussion are in evidence review G: effectiveness, cost effectiveness, acceptability and unintended consequences of PrEP for HIV.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local Act Personal Care and Support Jargon Buster.

Groups with greater sexual health or access needs

These groups have higher rates of sex partner change or less contact with the healthcare system than average.

People are most at risk of STIs if they are involved in higher rates of condomless sex with multiple partners or frequently change partners. There may be more people practising these behaviours in some groups than others, but this does not mean that everyone in the group is necessarily at higher risk. For example, gay, bisexual and other men who have sex with men are a higher risk group for STIs and HIV, but this does not mean that every person in that group is at higher risk.

Some people find it more difficult to access sexual health services because of the location of services (most services are in urban rather than rural settings) or because they do not know that they are eligible for free services (for example, some refugees or asylum seekers may not know this). Others may find it difficult to access services either because they do not know about them, because of physical accessibility issues, or because of language barriers, learning difficulties or stigma.

Pre-exposure prophylaxis (PrEP)

A medicine that people at risk of HIV take to prevent them getting HIV. Normally it involves taking tablets every day (daily PrEP) but in some cases, it may mean taking tablets at particular times (event-based or on-demand PrEP).

Remote self-sampling

The person collects a sample themselves outside the clinic environment (for example, a swab or a urine sample) and sends it to a lab for analysis. This is different to self-testing, for which the person conducts the test and reads and interprets the result themselves.

Sex-positive approaches

Being non-judgemental, openly communicating and reducing embarrassment around sex and sexuality. Recognising the diversity of sexual experiences that exists and that sex can be an important and pleasurable part of many people's lives.

Sexual self-efficacy

A person's sense of control over their sexual life and sexual health, and their ability as an individual to have safe, consensual and satisfying sex.

  • National Institute for Health and Care Excellence (NICE)