Overview of 2018 surveillance methods
NICE's surveillance team checked whether recommendations in sexually transmitted infections (STIs) and under-18 conceptions: prevention (NICE guideline PH3) remain up to date.
The surveillance process consisted of:
Feedback from topic experts via a questionnaire.
Examining previous surveillance input from experts.
A search for new or updated Cochrane reviews and national policy.
A search for ongoing research.
Examining related NICE guidance and quality standards.
Examining the NICE event tracker for relevant ongoing and published events.
For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
We searched for new Cochrane reviews related to the whole guideline. We found 2 relevant Cochrane reviews published between February 2007 and August 2018.
One review (Carvalho et al. 2011) examined the effects of behavioural interventions on condom use among women who are HIV positive. A second review (Ota et al. 2011) considered behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. Both reviews concluded that there was limited evidence to assess the effectiveness of the behavioural interventions on condom use. Although these interventions are within the scope of the guideline, these topics are not currently covered by the recommendations.
A further 8 Cochrane reviews were relevant to the guideline because they covered contraceptive use; however, these reviews are also relevant to the NICE guideline on contraceptive services for under 25s. To avoid future, potential overlaps, new evidence for prevention of under‑18 conceptions would be covered by NICE guideline PH51.
We checked for relevant ongoing research; of the ongoing studies identified, 3 studies were assessed as having the potential to impact a future update of the guideline:
In 2017, there were approximately 422,000 diagnoses of STIs made in England, around the same number that was reported in 2016. Most were among heterosexual people under 25, black and minority ethnic groups, and men who have sex with men (Sexually transmitted infections and screening for chlamydia in England, 2017 Public Health England 2018). The report highlights large increases in gonorrhoea (22%; from 36,577 to 44,676) and syphilis (primary, secondary and early latent stages) diagnoses (20%; from 5,955 to 7,137), between 2016 and 2017.
A recent Public Health England report presents national survey findings from commissioners of sexual health and reproductive health services. It identifies that there is increasing demand for some services, reduced capacity and fragmentation of commissioning. It also highlights concern about a move away from prevention with reduced resources increasingly focused on treatment (Sexual health, reproductive health and HIV: commissioning review Public Health England 2017).
In response to the rapid expansion in providers of telephone, video-link or online sexual health services, the British Association for Sexual Health and HIV (BASHH) and Faculty of Sexual and Reproductive Healthcare (FSRH) have recently consulted on new standards for online and remote providers of sexual and reproductive health services (2018).
The Education Secretary recently set out plans for relationships education in primary schools, and relationships and sex education in secondary schools, from September 2019 (Schools to teach 21st century relationships and sex education, Department for Education 2017). This topic could be relevant to future guideline development and is within the guideline referral remit.
These developments combined indicate that the current guideline does not directly address or reflect some contemporary issues in sexual health and prevention for STIs.
At the last surveillance review in 2014 (review decision 2014), topic experts were consulted and they identified the following guideline issues:
The recommendations are general and probably not applicable to all service settings beyond sexual health clinics. Recommendation 2, which covers one-to-one sessions lasting 15–20 minutes, is likely to be unrealistic for most settings.
The scope should be broadened out beyond one-to-one approaches, to include testing and digital approaches.
The recommendations need to reflect current structures and relevant evidence.
More recent NICE guidelines have superseded parts of PH3.
In addition, the experts recommended the guideline was 'fully updated with a focus on the optimal methods of condom distribution and increasing condom use in those at increased risk of STIs'. This proposal resulted in the development of the NICE guideline on STIs: condom distribution schemes.
We considered the views of topic experts, including those who helped to develop the guideline. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to NICE guideline PH3. We sent questionnaires to 14 topic experts and received 7 responses. The topic experts were recruited to the NICE Centre for Guidelines 'Expert Advisers Panel' to represent their specialty.
All 7 experts indicated that the guideline should be updated. Experts highlighted the following issues with the guideline:
The recommendations are too narrow in their focus on one-to-one interventions. Structured discussions for 15–20 minutes and repeat sessions are unrealistic in most settings.
Changes are needed to reflect that the commissioning landscape has changed since the guideline was developed.
The role of pharmacists in screening should be clarified.
The guidance should clarify support for all vulnerable young people.
The role of discussion and offer of pre-exposure prophylaxis (PrEP).
Technologies for prevention of STIs (such as telephone and digital support) should be covered.
There is no acknowledgement of the impact of social media (both positive and negative).
There is overlap between the current guideline recommendations and NICE guidelines that were published at a later date. The following guidelines were identified as covering similar approaches:
Community pharmacies: promoting health and wellbeing (NICE guideline NG102)
Physical health of people in prison (NICE guideline NG57)
Contraceptive services for under 25s (NICE guideline PH51)
To manage these overlaps, any future update of NICE guideline PH3 will no longer cover under‑18 conceptions, because this topic is covered in detail in recommendations within the NICE guideline on contraceptive services for under 25s. The future update of PH3 will also be developed to complement all other NICE guidelines that address the prevention of STIs to present a coherent suite of guidance that reflects a pathway of care.
NICE is currently developing a guideline on behaviour change: digital and mobile health interventions (publication expected in August 2020). The guideline will cover digital and mobile health behaviour change interventions, including for 'unsafe sexual behaviour'. When NICE guideline PH3 is updated, care will be taken to ensure the guidelines are complementary.
We received 1 comment regarding implementation of the guideline from a topic expert: "The current guideline is very out-of-date. Whilst still referenced under Service Standards in the most recent national service specification for specialist integrated sexual health services, it is no longer actively considered to inform commissioning or service delivery".
Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance decision was to update all of the guideline, we did not consult.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
The guideline includes out-of-date language and references; these will be addressed in the planned update.
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