Integrated Outreach Working with Street Based Sex Workers in London, Find&Treat, UCLH & SHOC team, Mortimer Market Centre

Our case study links to all five inclusion health draft principles:

1) Commit to action on inclusion health

2) Understand the characteristics and needs of inclusion health groups locally

3) Develop the workforce for inclusion health

4) Developing integrated and accessible services for inclusion health

5) Demonstrate impact and improvement for inclusion health

Background:

This programme of work began in response to the progressive defunding of sexual health outreach services, rising health inequalities and the halting of delivery of outreach services during the pandemic. Homelessness and problematic drug use are key factors that initiate engagement in street-based sex work They often overlap and lead to multiple social exclusion, destabilising an individual and increasing their vulnerability. During the COVID-19 pandemic, the numbers of people engaging in sex work has increased due to increased poverty levels. an increasing number of women have fallen into homelessness, sexual exploitation and street-based work due to financial instability. In parallel, there was reduced activity of sexual health outreach services and clinic based sexual health. This was on a background of already significant cuts to sexual health services due to budget cuts, that occurred in the years prior to the pandemic.
The Find&Treat, UCLH team, a pan-London, peer-centred inclusion health outreach team partnered with the SHOC sex worker health promotion team from Mortimer Market Centre, CNWL to deliver night outreach services for street based sex workers in North London. This team has grown to include joint working with drug services and the development of a rapid access housing pathway for vulnerable women.

Methods:

The Find&Treat outreach van was used to deliver monthly night outreach services.This programme provides integrated point of care HIV/HepC/HepB/Syphilis/Gonorrhoea. Chlamydia testing and treatment alongside addressing safeguarding, housing and social care needs. Vaccines including COVID vaccination have been delivered through this programme. Needle exchange and naloxone provision on the outreach van.

The locations where the Find&Treat van setup are known for street-based sex work. The sessions run from 9pm to 3am. The outreach teams engage with clients beforehand to inform of the presence of the outreach van and testing. Warm drinks and food were provided along with a convenience pack containing sanitary products, socks, masks, toiletries and condoms.

Health offer:

Mobile chest radiography was offered to all clients with immediate reporting. All patients are offered pregnancy testing, point of care testing for HIV, hepatitis C antibody and RNA, syphilis and follow up bloods as necessary and point of care STI screening for Neisseria gonorrhoea (NG) and Chlamydia trachomatis (CT) using Cepheid NAAT triple site testing. Treatments for STIs are provided, in line with local clinic policy. Emergency contraception and referral for HIV PrEP is offered to all who needed it. Supported referrals into local contraception services and sexual assault services are also made.

Vulnerability assessment:

Safeguarding referrals are made to local teams and all are offered support from an independent sexual violence advocate.

Housing:

Women who experience homelessness are able to access immediate housing assessment and accommodation in the night through a pathway set up with the rough sleeping team at the Greater London Authority and St Mungo's teams.

Drug services:

Patients are able to access rapid access pathways to Opiate Substitution Therapy via local drug services.

Outcomes

98 street based sex workers screened. High levels of sexually transmitted infections, experience of violence and mortality.

Outcomes included cross-organisational learning, training of sexual health promotion team to be able to deliver point of care testing in outreach setting, development of rapid access to drug and housing support pathways.

Health:

STI results and treatment below, majority of those with an STI have been treated. 2 new HIV diagnoses one started treatment, one awaited, 4 Hep B diagnoses, referred to clinic, 1 new HCV diagnosis, treated and cured.

2 pregnant women; re-engaged with maternity services and drug services

Housing & Drug Services:

23 rough sleeping: 12 now in temporary accommodation

57 reported crack/heroin use: 22 now engaged with drug service, 4 now in detox programme

Experience of violence:

7 deaths (2 murders, 3 likely overdose, 2 unknown), 2 experienced attempted murder (reported), 4 kidnapping (2 reported), 5 missing, 37 people victim of recent sexual assault, 63 victims of domestic violence

Conclusion:

This is an organic programme of work, brought together by dedicated outreach teams and peer support workers in response to high levels of need. It continues but remains unfunded and not formally commissioned due to fragmented commissioning of sexual health, HIV, hepatitis C, housing and drug services, and is at high risk of stopping due to precarious funding for the teams that lead this service.