Sexual health - a role for pharmacy
Cuts to sexual health services continue, while STIs are still rising, with cases of syphilis and gonorrhoea at their highest levels in decades. Pharmacy staff are ideally placed to offer their customers confidential sexual health advice and recommendations to help prevent STIs, and encourage early testing and treatment.
Planned cuts to sexual health services funding could cost the NHS an extra £1 billion by 2025, thanks to the increasing number of STI cases, say the British Association for Sexual Health & HIV (BASHH). Access to services has been reduced since 2013, with more than half of BASHH members reporting decreases in the level of service access in the last year. Yet demand for services is rising, with 422,000 cases of STIs diagnosed last year, with cases of syphilis rising by 20 per cent and gonorrhoea up by 22 per cent. Over 1.3 million Chlamydia tests were carried out last year and there were 126,000 diagnosed cases among 16-24-year olds, yet there has been an 8 per cent fall in the testing levels due to reduced service access.
The rise in cases of syphilis and gonorrhea is alarming, at its highest rate for decades. There have been new reports of cases of drug-resistant gonorrhoea in England, which serves as a reminder of the importance of promoting safe sex and seeking early help for signs of an STI.
Protection and testing
“Society is changing in terms of our attitudes towards sex, including number of sexual partners and casual sex” says Dr Mark Lawton, sexual health consultant and chair of the BASHH media group. “Condom usage is not as good as it could be and we need to encourage more widespread use of these once again. Pharmacies can help by encouraging their customers to get tested for STIs, making tests available in-store, as well as promoting condom usage. There are some screening programmes in local pharmacies and we’d like to see this extended – talk to your local authority and see what services you can offer your customers.”
Pharmacy teams are a key resource in promoting good sexual health through a variety of services. “They regularly have contact with vulnerable groups such as women asking for emergency contraception and pregnancy testing services, women who are sexually active but not using a barrier method of contraception, men and women aged 16-24, and drug users,” says consultant STI scientist Dr Hamish Mohammed at Public Health England. “Community pharmacies are conveniently located in the heart of communities and provide a safe haven for individuals seeking anonymous and informal advice from a trusted professional without having to make an appointment, especially for populations living in deprived areas.” He highlights the value of consultation rooms when offering sexual health services. “Our research uncovered that sexual health is a challenging topic for young adults to discuss, with 56 per cent of men and 43 per cent of women saying it was difficult to discuss STIs with friends,” he says.
The most commonly diagnosed STIs last year were Chlamydia (48 per cent of all new diagnoses), first episode genital warts (14 per cent), gonorrhoea (11 per cent) and non-specific genital infections (8 per cent). In 2017/18 there were 1.79 million contacts with sexual and reproductive health services by 1.14 million individuals, a decrease of 5 per cent on the previous year and 28 per cent less than 10 years ago.
The number of women using the services for contraception has fallen during the last three years, with a 32 per cent drop in emergency contraception in the last 10 years. This indicates that people are going elsewhere for advice, and pharmacies are ideally placed to help. A large proportion of women who access SRH services use a long acting reversible contraceptive (LARC, 41 per cent), and over the last 10 years usage of these has steadily grown – 30 per cent of under 20s and 55 per cent of over 35s now choose this method. Implants are the most common LARC, while condoms are used by 14 per cent as a main method of contraception.
The Viagra Connect effect
The launch of OTC sildenafil (as Viagra Connect) last spring was the biggest news to hit the sexual health market in years. But has it triggered the anticipated interest and growth in the sector?
“Men are substantially less likely than women to visit their GP. However, the introduction of Viagra Connect has offered them a new and convenient way to manage their erectile dysfunction,” says Aurore Bourdeau, senior brand manager for Viagra Connect. “It also presents a new opportunity for pharmacists to engage male customers in a broader conversation related to sexual health, such as premature ejaculation, contraception and STI testing.”
Tara Dew, category merchandising manager, Alliance Healthcare, is already seeing the effects. “The sexual health category continues to perform extremely well and there is a direct correlation with the launch of Viagra Connect. The launch has provided convenient access to medication, without the need for a prescription, for appropriate users. The sales of these products benefit from prominent positioning, and we recommend they are located at eye level.”
Alphega Pharmacy member Muhammed Zaheer, of Chesters Pharmacy in Birmingham, says: “During a sale of Viagra Connect we have the opportunity to offer other Umbrella services (our partnership in Birmingham) such as free condoms, STI kits and alternative herbal products if sildenafil is contra-indicated.”
It’s been a positive step for pharmacies. “A large proportion of Viagra Connect’s sales have been made in store as opposed to online,” says Ms Bourdeau. “This is a positive trend and shows men feel comfortable about speaking to a pharmacist about erectile dysfunction. This is because a journey to help normalise the condition has been started, in addition to the training provided to pharmacy staff and the availability of private consultation rooms to help manage these sensitive conversations.” says Aurore Bourdeau.
Update on emergency contraception
A recent survey by HRA Pharma, makers of ellaOne, found 46 per cent of women surveyed had unprotected sex in the last year, but only 27 per cent took EHC. In September 2018, HRA launched their ‘My morning after’ campaign to help break taboos and embarrassment which surround EHC.
An integral part of the campaign is to normalise the experience of accessing the morning after pill in pharmacies. “According to HRA’s latest research, 31 per cent feel embarrassed to ask for it, 26 per cent would wait until no other customers were in the pharmacy and 24 per cent admitted lying to their doctor or pharmacist, saying the condom had split when they hadn’t used one. This is because they were worried the truth would cause them to be judged,” says Emma Marsh, senior brand manager at HRA Pharma.
The campaign includes the website mymorningafter.co.uk which includes real life stories and educational content. HRA also launched a consultation checklist card, which gives women the option to answer questions discreetly. Pharmacist Deborah Evans helped develop the card. “It will help pharmacies be time-efficient and responsive to the customers, as well as help women feel less embarrassed,” she says. To request the checklist card call 01284 715298 or email ellaOnepharmacist@precision.email.
Build a better sexual health category
“Our research shows many women want their experience in the pharmacy to be as brief as possible and therefore it’s important to convey the EHC options clearly and concisely. Efficacy is the most important factor, so staff should explain that ellaOne is 2.5 times more effective than levonorgestrel,” says Emma Marsh, senior brand manager at HRA Pharma.
“Ensure clear signposting. Customers can find asking for EHC embarrassing and this will reassure them they’ve come to the right place.”
Pharmacists should remain objective yet understanding and offer women the option to speak privately.
Pharmacy role as sexual health advisors
Chester Pharmacy in Birmingham works with Umbrella, which provides sexual health services in Birmingham as part of University Hospitals Birmingham NHS Foundation Trust. “We have a thriving, confidential sexual health services. After many training sessions with Umbrella, a lot of emphasis was placed on safeguarding. As the service grew more popular, we were seeing a wider spectrum of the population,” says Muhammed Zaheer.
“When speaking to my pharmacy team, I emphasise the need for discretion when dealing with sexual health. They can achieve this by taking customers away from the general queueing area, ideally using the consultation room. I advise staff to grasp a good knowledge base of the products we offer and services we provide, which builds confidence.”
Team members play a key role in raising awareness of sexual health with customers. “They can do this through their conversations when they receive enquiries about products, and by offering sexual health awareness campaigns to offer a less direct approach,” says Lucy Morris, service development pharmacist at Numark. “Make every conversation count and consider broader sexual health. For example, if a customer is asking for EHC, consider opportunities for safe sex advice, contraceptive choice consultation, Chlamydia screening/treatment.”
BASHH's Dr Lawton says plain speaking works best. “If you come across as embarrassed, you won’t instil confidence in your customer. Be matter of fact, using terms your customers will understand, not medical jargon.”
With access to local sexual health services reduced, it makes sense for pharmacies to offer STI self-test kits to their customers. “STI self-test kits are highly sought after and can be ordered via the Umbrella website or a local pharmacy. We have lots of posters and leaflets to increase awareness of this service and others we provide,” says Mr Zaheer.
Self-test kits offer an additional retail (and service) opportunity for pharmacies. “As appointments become harder to get, self-test kits offer an alternative route, allowing customers anonymity and reassurance,” says Ms Morris. “Patients must have clear guidelines on how to use self-testing kits effectively to ensure accuracy and how to understand results. Patients using a self-test should be advised ‘Regardless of the result, if your symptoms persist, contact a health professional for advice.’ “
PHE's sexual health campaign
Last year PHE launched a campaign 'Protect against STIs – use a condom' to reduce the rate of STIs among young people. Over half of all STI diagnoses are among 16-24-year olds. It was the first government sexual health campaign for eight years. “Recent YouGov survey findings revealed that almost half of sexually active young people said they had had sex with someone new for the first time without using a condom, while one in 10 sexually active young people said they had never used a condom,” says Dr Mohammed.
In November, a new version of the campaign was launched with a focus on readiness for sex, being prepared by always carrying condoms. PHE says that last year’s campaign was a great success, equaling or exceeding targets, including campaign awareness, intent to use a condom and reported condom use among 16-24 year olds. The new burst of the campaign included social media, PR and school/college activity. The aim is to connect with inexperienced young people before their sexual health behaviours develop.
Pharmacies can help raise awareness by displaying campaign posters and leaflets, letting customers know where they can get free condoms and that they can buy condoms from their pharmacy. Resources are available from campaignresources.phe.gov.uk
“It’s important for pharmacy teams to remind their customers that STI prevention is more effective than treatment, and everyone can substantially reduce their risk by using condoms consistently and correctly,” says Dr Mohammed. “A recent project in Cumbria, funded by the National HIV Prevention Innovation Fund, enabled people to request a free, rapid HIV test from selected pharmacies, and this demonstrated pharmacies as a viable setting for increasing coverage of HIV testing, with almost half of the people tested never having been tested before.”
Older women and sexual health
While the launch of Viagra Connect last year has put the spotlight on older men’s sexual health, another growth area is menopausal sexual health.
Eleanor Gardner, medical sales manager at The Yes Yes Company says: “In the last year there has been much more conversation about the menopause and increased understanding that vaginal dryness will affect enjoyment of sex. The real shift happens post-menopause, when lack of oestrogen causes dryness. Women are slowly becoming more aware that if they still want a sex life then they need to use a vaginal moisturiser or lubricant.”
The trend for natural and organic products has meant that women are looking for lubricants that have natural ingredients. They are looking for products that are organic, free from hormones and parabens, and are pH friendly, says Ms Gardner. While many women go to their GP to discuss menopause symptoms, few will discuss vaginal health unless the doctor mentions it. “Pharmacists can help by either handing out leaflets to women or if they come in for an HRT prescription, telling them you offer a confidential service where they can discuss symptoms and how to manage these.”
Vaginal dryness is also discussed in new research from Durex, published as the brand launches a new campaign – tagline ‘Let’s lube’ – for its Naturals Intimate Gel lubricant. According to the research, three quarters of British women (73 per cent) have experienced sexual discomfort – whilst just over half of men (57 per cent) have noticed a female partner feel discomfort during sex – with 31 per cent of them saying this makes them less likely to want sex, and 9 per cent saying it has had a negative impact on their relationship with their sexual partner.
Durex say that when experiencing sexual discomfort, only a third would use a lubricant, despite the fact that nine in ten women say that sex feels better when they use it, and that 80 per cent agree that sex is beneficial for health and wellbeing (99 per cent among new mums).