Steph Broughton and Rudi Pitroff Presentation to LNNM Conference 2017

1. Integrate
To combine two or more things in
order to become effective.
Cambridge Dictionary

2. Inclusive Healthcare
Inclusive health is about health for all humankind; it
requires health services that are efficacious and
equitable, as well as affordable.
Tropical Medicine and International Health, volume 17
no 1 pp 139–141 January 2012

3. Equitable means that services are provided on
the basis of people’s needs – that those most in
need can access the service as easily as those
least in need.
Affordable – both to the individual and the
community – means that services are
provided in the most cost-effective way
possible.

4. Preliminary Evaluation of the
Sexual and Reproductive Health
provision at CDAT
Rudi Pittrof MSc MRCOG MFSRH DipGUM
DTM&H FHEA
Consultant in Community Sexual Health and HIV, GSTT
Stephanie Broughton RN BBV CNS

5. Integration in Practice
Community
Sexual health
(GSTT)
Health
Inclusion
Team
(GSTT)
Acute
Sexual
Health
(GSTT)
Addiction
Service
(SLaM &
Lifeline)

6. CDAT +- 600 patients (400 men and 200 women)
high level of homeless and transient people.
5 day / week on-site substitute opiate dispensary.
Best thought of as a high dependency unit.

7. The sexual health in CDAT patients
matters because:
• High rates of STIs and
unplanned pregnancies
in users of drug and
alcohol services.
• Poor utilisation of SRH
services  high unmet
need.
• Complex patients.
• National policy.
• Commissioning priority.

8. Hidden Harm
recommendation 25
• 25. Contraceptive services
should be provided through
specialist drug agencies
including methadone clinics and
needle exchanges. Preferably
these should be linked to
specialist family planning
services able to advise on and
administer long-acting
injectable contraceptives,
contraceptive coils and
implants.

9. High rates of unplanned pregnancies and high
unmet contraceptive needs
• In Australia over ¼ (29%) of female
users of CDAT like services reported
>5 pregnancies, high rates of adverse
pregnancy outcomes (miscarriage,
termination and stillbirth) and poor
uptake of contraception, with only
54.7% of sexually active women not
wanting to get pregnant using a
method.
Black, Stephens, Haber & Lintzeris (2012) Unplanned pregnancy and contraceptive use in
women attending drug treatment services Aust NZ J Obstet Gynaecol Apr 52; (2); 146-50

10. • Women with addictions are at high risk of
unplanned pregnancy , having their children
taken into care and sexual violence.
Heil S, Jones H, Arria A, Kaltenbach K, Coyle M, Fischer G, Stine S, Selby P & Martin P (2011)
Unintended Pregnancy in Opioid-abusing Women J Subst Abuse Treatment 2011 40 (2) 199-
202
Lincoln, Liebschutz, Chernoff, Nguyen & Amaro (2006) Brief screening for co-occurring disorders
among women entering substance abuse treatment Substance Abuse, Treatment, Prevention
and Policy 1:26
Simpson M, McNulty J, Different needs: women’s drug use and treatment in the UK, Int J Drug
Policy, 2008, 19, pp.169-175
Lincoln, Liebschutz, Chernoff, Nguyen & Amaro (2006) Brief screening for co-occurring disorders
among women entering substance abuse treatment Substance Abuse, Treatment, Prevention
and Policy 1:26

11. Among injecting drug users: High rates of STIs
and BBVs and STI/HIV risk Behaviour
• In Australia; high prevalence of hepatitis C
(74%), STIs (8%)and Chlamydia (6%) and past
exposure to hepatitis A and B was common.
Bradshaw, Pierce, Tabrizi, Fairley & Garland (2005) Screening injecting drug users for sexually
transmitted infections and blood borne viruses using street outreach and self-collected sampling
Sex Transm Infect 81: 53-58
Tross, Hanner, Hu, Pavlicova, Campbell & Nunes (2009) Substance Use and High Risk Sexual
Behaviors among Women in Psychosocial Outpatient and Methadone Maintenance Treatment
Programs American Journal of Drug & Alcohol Abuse 35:368-374

12. • Depleted practical & emotional resources, anticipated drug-use
stigma, sexual history taking, undergoing tests, and coping with
results presented discrete emotional concerns for substance-
misusing women (SMW).
• Minimisation of risk and perceived incompatibility between drug use
and sexual well-being .
• Social, emotional and fiscal support is likely to be instrumental in
enabling SMW to access sexual health services.

14. The overall aims of the clinic were:
• to reduce the number of babies and children born to
drug/alcohol dependent parents who are then not brought up
by at least one of their biological parents
• to reduce the spread of HIV and other sexually transmitted
diseases in the drug/alcohol using population in Southwark
• to enable women with drug and alcohol problems to delay
child birth and to help improve their chances of successful
conception when the time is right
• to enhance recovery in drug/alcohol dependent patients by
optimising their health and preventing the destabilising
impact of having a baby removed
• to reduce the number of children adversely affected by drugs
and alcohol whilst in-utero

15. The primary outcome measure for the clinic:
• the initiation and continuation of long-acting reversible
contraceptive methods (LARC)
Secondary outcomes are
• identification and treatment of sexually transmitted
disease in women and men,
• provision of cervical smear tests
• provision of other contraception methods
• provision of other health advice/treatment/referral as
necessary

16. Robust care pathways.
• Make it really easy for CDAT patients to attend
one of the best sexual health services in the UK.
• No wait. VIP treatment – 10 min down the road.
Burrell Street
CDAT

17. EASY
Access
Clinic 33
• Despite ease of access and reassurance by
keyworkers CDAT patients did not present
themselves to Burrell Street using the specific
“VIP” care pathway for them.
• In April and May 2013 clinic 33 had no
competition with the “inreach service” and
still saw only +- 1 patient per month.

18. Women’s Health Clinic
We can look after all your health needs between the knees
and the belly button – we’ve got it covered:
Get world class care for the bits that other doctors don’t talk
about: family planning, pregnancy worries, problems
falling pregnant, performance problems, bowel and
bladder problems; we do smear tests or sort your period
problems.
Free, and as quick and confidential as possible!
When? Every Thursday 9.30am to 1.30pm
Where? Blackfriars CDAT, 151 Blackfriars Rd, SE1 8EL
How it works: Easy – 1) Write your first name on the back of a
leaflet available from your keyworker  2) Hand the slip to
CDAT reception with additional info as necessary  3) Take a
seat in the waiting room  4) Reception will call you when it is
your turn.
See you soon –
Dr Rudi Rudiger Pittrof, (consultant in community sexual
health)

19. Men’s Health Clinic
We can look after all your health needs between the knees
and the belly button – we’ve got it covered: Get world class
care for the bits that other doctors don’t talk about. We can
look after infections, infertility and performance problems,
bowel problems, bladder problems and we can check for
prostate and testicular cancer. Free, and as quick and
confidential as possible!
When? Every Thursday 9.30am to 1.30pm
Where? Blackfriars CDAT, 151 Blackfriars Rd, SE1 8EL
How it works: Easy – 1) Write your first name on the back
of a leaflet available from your keyworker  2) Hand the slip
to CDAT reception with additional info as necessary  3)
Take a seat in the waiting room  4) Reception will call you
when it is your turn.
See you soon –
Dr Rudi (Rudiger Pittrof, consultant in community
sexual health)

20. Inreach service
• April 2013 onwards: RP attends team meetings on
Thursday mornings.
• April to May 2013. While waiting for his honrary
contract RP shadows key workers and doctors to better
understand their work and the need of the patients
and writes protocols.
• 6.6.2013 Men’s Clinic and Women’s clinic opens
parallel to the patient coffee morning.
• July 2013 management team meeting including anyone
who is anything.
• 5. 12.2013 Contingency management to encourage
patients

21. Contingency Management
(5.12.13 onwards)
• Supported by NICE guidance
• Clinical ethical advisory
group approved
• £2 for attendance and taking
STI and BBV screen
• £5 for start of implant or
IUD/IUS
• £5 for cervical smear.

22. Activity (06-13 to 02/14)
• 24 clinics without contingency management
• 9 clinics with contingency management.
• Total 127 consultations (84 in first 6/12)
• 89 different patients, 33 men (4 MSM), 56 women
• Mean number of patients seen: without contingency
management:3.5/clinic (range 1 to 7)
• Mean number of patients seen: with contingency
management:4.3/clinic (range 2 to 7)

23. Activity STI/HIV
• 54 STI tests –
– 1 new early syphilis diagnosis and Rx (CS)
– Treatment of late latent syphilis 2 years after diagnosis.
– 1 PID and Rx (CSW)
• 49 HIV tests  1 new diagnosis  3 consultations now receiving care.
• 1 New Hep C diagnosis.
• 11 doses of Hep B vaccine given
• One Hep C and HIV post patient who defaulted from care  2
consultation  reengaged with HIV care.
• One Hep C and HIV pos (x 5 yrs) patient who never accessed HIV care
now had his first HIV consultation at CDAT.
• One Hep C and HIV pos defaulted from HIV care about to reengage.
• Two sexual dysfunction consultations.

24. Activity - reproductive health
• 20 smear tests
• 13 Implants
• 4 IUS
• 2 IUD (TT380)
• 6 DMPAs (5 start, 1 repeat)
• 1 sterilisation referral
• 6 supplies of oral contraception (1 year each)
• 5 stand by emergency contraception supplies.
• Menopause, menstrual problems, infertility and
galactorrhoea consultations, post assault support,
incontinence.
• 23 letters

25. Years of LARCs provided per clinic
24 clinics
9 clinics

26. Costs and Benefits
(least cost effective assumptions I could find in the literature).
• Weber et al reported high pregnancy rates
among female injection-drug users in
Vancouver, Canada.
• In their sample (N=104) incidence of
pregnancy was 6.46 per 100 person-years,
despite a 67% use of some form of
contraception.
Weber AE, Tyndall MW, Spittal PM, Li K, Coulter S, O'Shaughnessy MV, Schechter MT.
High pregnancy rates and reproductive health indicators among female injection-drug users in
Vancouver, Canada. Eur J Contracept Reprod Health Care. 2003 Mar;8(1):52-8.

27. • Selwyn et al showed that 44% of HIV negative
pregnant intravenous drug users decided to
have a termination.
Selwyn PA, Carter RJ, Schoenbaum EE, Robertson VJ, Klein RS, Rogers MF.
Knowledge of HIV antibody status and decisions to continue or terminate pregnancy among
intravenous drug users. JAMA. 1989 Jun 23-30;261(24):3567-71.
Costs and Benefits
(least cost effective assumptions I could find in the literature).

28. Woodvine Unit pregnancy outcome
11, 42%
14, 54%
1, 4%
living with mum
separated/foster
care
parenting
assessment

29. Presumed pregnancy outcomes per year
for 100 women of our target group.

30. • Two published sources agree that the lifetime
cost of keeping a child in foster care in the UK
is approximately £670,000- £680,000.
Harker R (2012) Children in Care in England: Statistics Standard Note SN/SG/4470, accessed
29/10/2013 http://www.parliament.uk/briefing-papers/SN04470
Holmes & Soper (2010) Update to the Cost of Foster Care Loughborough University
http://www.lboro.ac.uk/media/wwwlboroacuk/content/ccfr/publications/update-cost-foster-
care.pdf (accessed 1/11/2013)
Costs and Benefits
(least cost effective assumptions I could find in the literature).

31. • Mean subdermal implant continuation rate:
24 months Teunissen et al 2013
• Mean IUS continuation rate: 54 months Backman et
al 2001
Teunissen AM, Grimm B, Roumen FJ. Continuation rates of the subdermal contraceptive Implanon and
associated influencing factors. Eur J Contracept Reprod Health Care. 2013 Dec 13
Backman T, Huhtala S, Tuominen J, Luoto R, Erkkola R, Blom T, Rauramo I, Koskenvuo M. Sixty thousand
woman-years of experience on the levonorgestrel intrauterine system: an epidemiological survey in
Finland. Eur J Contracept Reprod Health Care. 2001 Jan;6 Suppl 1:23-6.
Costs and Benefits
(least cost effective assumptions I could find in the literature).

32. Contraception
provided
Number Possible duration of
use of method (yrs)
Anticipated years of
contraception use
DMPA 6 1.5 1.5
IUS 4 20 10
IUD 2 20 10
Implant 13 39 19.5
Oral contraception 6 6 0
Total 86.5 41
Costs and Benefits
(least cost effective assumptions I could find in the literature).
It is realistic to assume that of the 86.5 years of
contraception provided at least 41 years will be used.

33. • Years of highly effective contraception x pregnancy incidence : 41 x 6.5 /100 =
– 2.8 pregnancies prevented.
• TOP rate in HIV negative IVDUs 44%  54% birth rate
– 1.5 births prevented.
• 45% of children live with their biological mother – 55% live in the care system.
– 0.8 children in care prevented.
• Lifetime costs of a child in foster care £670,000- £680,000 assuming that some
placement will be cheaper than foster care and discounting future costs
330,000 to 340,000 per child in the care system.
• 0.78x £330,000 = £ 259.589
Costs and Benefits
(least cost effective assumptions I could find in the literature).
Using the least favourable assumptions the work
done in this pilot project will result in savings for
social services of £270,000

34. This calculation did not include:
• Savings from interruption of HIV and syphilis transmission
– What are the economic benefits of treating for early syphilis in a sex worker
who needs £200/day for her drugs?
– What are the savings from diagnosis once case of early HIV infection?
• Savings from avoided medical care for the mother and
baby.
• Savings from work we will do between now (13.2.14)and
31.3.14
The most important benefits are however not measurable in £s:
The anguish avoided form experiencing a child being taken into
care, the disability avoided that would have resulted from
intrauterine exposure to a toxic cocktail of drugs.

35. Highlights
• LARC contraception provided included patients who:
– Already had two children removed,
– Had 8 children removed, continued sex-working,
– Suffered severe domestic violence, a recent life
threatening infection and major surgery and presented
with incomplete miscarriage,
– Received a new diagnosis of HIV from the clinic
– Was raped by a stranger whilst ‘scoring’ drugs,
– Is thinking of putting her flat on fire to burn out the
“paedophile” in the floor above.

36. Clinic with benefits
• Excellent learning and teaching opportunities.
• Template for other services.
• One of the very few real KHP clinical activities.
• Excellent use of the existing teams
…INTEGRATING SERVICES FOR INCLUSIVE
HEALTHCARE!!