Research and analysis

Spotlight on sexually transmitted infections in London: 2022 data

Updated 5 March 2024

Applies to England

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Summary

This report focusses on sexually transmitted infections (STIs) in London. HIV is reported on separately. Please access the UK Health Security Agency’s (UKHSA) report on STIs and screening for chlamydia in England for a national perspective (1).

STIs remain an important public health problem in London. Out of all the regions it has the highest rate of new STIs in England, with a rate of 1,397 diagnoses per 100,000 population, twice as high as the rate of 694 per 100,000 in England.

More than 120,000 new STIs were diagnosed in London residents in 2022 (122,912), which accounts for nearly one third of new STIs in England (31%).

Of the 20 upper tier local authorities in England with the highest STI rates in 2022, 16 were in London. There was considerable geographical variation in rates across the capital. Rates by local authority ranged from 491 new STI diagnoses per 100,000 population in Bexley to 3,655 new STI diagnoses per 100,000 population in the City of London.

The rate of new STIs among people who lived in the most deprived areas (1,934 per 100,000) was more than 3 times higher than the rate for people who live in the least deprived areas (497 per 100,000).

Overall, men continue to have higher rates of new STIs than women (1,901 and 863 per 100,000 residents, respectively).

Where country of birth was known, 57% of London residents diagnosed with a new STI in 2022 (excluding chlamydia diagnoses reported via CTAD) were UK-born.

Access to sexual health services

Access to sexual health services (SHSs) impacts on trends in STI diagnoses. Overall, STI testing (excluding chlamydia in those aged under 25 years) in London in 2022 increased by 16% compared to 2021 and was 2% higher than prior to the COVID-19 pandemic in 2019. There was also an increase in the STI positivity of testing reported in London, from 8.0% in 2021 to 8.8% in 2022. 

There was an increase in the number of sexual health service (SHS) consultations (which include asymptomatic screening via the internet) in London in 2022 compared to 2021 (8% increase from 1,370,589 to 1,478,616).

Of all consultations in 2022:

• over half (53%, n=778,772) were via the internet (compared to 21% in 2019)
• 44% (644,832) were delivered face-to-face
• 4% (55,012) were via telephone

Compared to 2021, rises were seen in 2022 in consultations via the internet (17% increase) and face to face (5% increase), but there were 40% fewer telephone consultations. In 2022, the number of face to face consultations was 32% lower than in 2019. For heterosexual men, 64% of their consultations were online, compared to 59% for heterosexual women and 42% for gay, bisexual and other men who have sex with men (GBMSM). 

Overall trends

The number of new STIs diagnosed in London residents increased by 21% between 2021 and 2022. While the number of genital warts diagnoses decreased by 3%, rises were seen in the other major STIs:

• gonorrhoea by 36%
• chlamydia by 19%
• genital herpes by 16%
• syphilis by 8%.

Gonorrhoea increased in all age groups, however, the highest rates were among those aged 20 to 24 years, and 25 to 34 years.

While the overall number of new STIs diagnosed in London in 2022 was 18% lower than the pre-COVID-19 pandemic year of 2019, the numbers of gonorrhoea and syphilis diagnoses in 2022 exceeded those reported in 2019.

National chlamydia screening detection rate indicator

UKHSA recommends working towards achieving a minimum chlamydia detection of 3,250 per 100,000 females aged 15 to 24 years (detection rate indicator or DRI) as part of the Public Health Outcomes Framework (PHOF). In 2022, the chlamydia detection rate among female London residents aged 15 to 24 years was well below this, at 2,137 per 100,000 female residents. The proportion of London male and female residents aged 15 to 24 years screened for chlamydia increased from 20.0% in 2021 to 20.5% in 2022.

Populations with greater sexual health needs

Gay, bisexual and other sex who have sex with men

Gay, bisexual and other sex who have sex with men (GBMSM) continue to experience health inequalities related to STIs. The estimated new STI diagnosis rate for GBMSM London residents in 2022 was 21,133.3 per 100,000, 15 times higher than the rate observed for Londoners as a whole. However, this rate for GBMSM is likely to be an overestimate, due to under-reporting of gay and bisexual sexual orientations in the census, from which the denominator is derived.

Where gender and sexual orientation are known, GBMSM account for 49% of London residents diagnosed with a new STI (excluding chlamydia diagnoses reported via CTAD), 86% of cases diagnosed with syphilis and 73% of cases diagnosed with gonorrhoea.

The number of new STIs diagnosed in GBMSM in 2022 was 31% higher than in 2021, and over this period there was a 39% increase in gonorrhoea and 14% increase in syphilis diagnoses.

Mpox is a zoonotic infection, caused by the mpox virus, that previously occurred mostly in West and Central Africa and is transmitted through close contact (including through sexual contact). Previous cases in the UK had been either imported from countries where mpox is endemic or contacts with documented epidemiological links to imported cases. In 2022, there was a very large outbreak of mpox with community transmission in the UK, mainly in GBMSM. London was most affected, with case numbers peaking in July, before falling to low numbers by November. By the end of December 2022 more than 2,400 cases had been reported, 69% of the England total (2).

Shigella is a gut infection that can cause severe diarrhoea, with fever and abdominal pain. It is caused by a bacteria found in faeces. Sex that may involve anal or faecal contact is one way that the infection can spread. GBMSM are at increased risk. Following a fall in 2020, the number of Shigella infections among presumptive GBMSM in London has risen since the first quarter of 2021 and reports in the second quarter of 2022 were much higher than observed pre-pandemic in 2019.

Young people

STIs disproportionately affect young people. London residents aged between 15 and 24 years accounted for 29% of all new STI diagnoses in 2022, and the group with the highest rate were those aged 20 to 24 years.

The pandemic appears to have differing impacts by age group, with younger age groups having much lower STI rates in 2022 than in 2019. In 2022, the new STI diagnosis rate was still 44% lower for Londoners aged 15 to 19 years compared to 2019, although the 2022 rate (1,774.5 per 100,000 population aged 15 to 19 years) was 14% higher than the rate in 2021. A similar picture was seen for Londoners aged 20 to 24 years with a rate of 4,554.1 in 2022, 31% lower than that seen in 2019, but 17% higher than in 2021. By contrast the rate among those aged 35 to 44 years (1,638.4) in 2022 was only 2% lower than the 2019 rate and 22% higher than the 2021 rate.

A steep decline (80% decrease between 2018 and 2022) has been seen in genital warts diagnosis rates in females aged 15 to 19 years, although a slight rise was seen from 2021 to 2022. The long-term fall follows the introduction in 2008 for young females of vaccination against human papillomavirus (HPV), the virus which causes genital warts.

Black Caribbean residents

People from the black Caribbean ethnic group experience health inequalities related to STIs. Although only 9% of new STIs are in black Caribbean residents, they have the highest rate: 2,857 per 100,000, which is twice the rate seen in the white ethnic group. However, compared to other ethnic groups, the black Caribbean ethnic group also saw the largest fall in its diagnosis rate when 2022 is compared to 2019. The rate of 2,857.3 per 100,000 black Caribbean population was 29% lower than in 2019, but 12% higher than in 2021.

The white ethnic group has the highest number of new STI diagnoses: 61,201 (56%) and a new STI diagnosis rate of 1,293.6, 14% lower than in 2019 but 24% higher than in 2021.

Implications for prevention

STI diagnoses are on the rise in London. The number of gonorrhoea diagnoses, which can be a marker of higher risk sexual behaviour in the community, now exceed the pre-pandemic level. There are marked health inequalities relating to STIs, with GBMSM, black ethnic groups, and young people among the populations with greater sexual health needs.  

STI prevention efforts should include a range of measures. Proactive health promotion and high quality health education improve risk awareness and encourage safer sexual behaviour and testing. Consistent and correct condom use substantially reduces the risk of being infected with an STI. Immunisation reduces the risk of being infected with certain infections. STI screening, open access to SHSs for rapid STI diagnosis and treatment with robust contact tracing, allows earlier diagnosis and reduces the length of time that people can transmit to others. Such measures need to be effectively commissioned, including targeting programmes and resources for those groups highlighted above who have the greatest sexual health needs.

Following the disruptions in service delivery during the pandemic, the number of sexual health screens (for chlamydia, gonorrhoea, syphilis and HIV) has now increased to levels just above that seen in 2019. Considerable changes have occurred in how SHS consultations are delivered over this period, with a reduction in face-to-face consultations, which in 2022 remained much lower than in 2019. There has been an increase in online consultations, which now account for more than half and offer a different option, including for asymptomatic screening.

Different population groups access services differently. Heterosexual people have a higher proportion of their SHS consultations online than GBMSM. Since 2019, the largest proportional increase in the number of consultations has been in GBMSM and the lowest increase observed for heterosexual men. Service providers will be aware that the impact of changes in consultation medium differs by sexual orientation, and it will remain important to understand whether the changes in how people use services has affected the equity of access to needed services (3, 4).

There has likely been an increase in STI transmission in the community. Although the number of sexual health screens rose in London between 2021 and 2022, the rise in STI diagnoses outpaced the rise in testing. In addition, there was an increase in STI test positivity. These trends may reflect better targeted testing of people more likely to have an STI, or more likely, an increase in transmission.

The large rise in gonorrhoea in 2022 was seen in both GBMSM and in heterosexual people, with increases in all age groups. Improved testing alone cannot explain this increase. Increases were seen in all English regions, with the number diagnosed in England in 2022 being the largest annual number reported since records began.

The high rates of STIs among young people aged 20 to 24 years are likely to be due to greater rates of partner change (5). The pandemic appears to have had a greater impact on STIs in younger age groups, particularly those aged 15 to 19 years, with a larger reduction in STIs seen in this group since 2019, albeit with numbers increasing again in 2022. This could have been an impact of reduced opportunities for socialising and access to services.

Implementation of good quality evidenced based Relationship Education in primary schools, as well as inclusive Relationships, Sex and Health Education (RSHE) in all secondary schools is expected to support young people with the information and skills to prepare to look after their sexual health before sexual debut and beyond (6, 7, 8).

Many areas in England continue to provide condom schemes which distribute condoms to young people (mostly aged under 20 years) and other groups most at risk through a variety of outlets (9) and condoms are provided free from sexual health clinics for all ages. Easy access to condoms for everyone without barriers can encourage consistent use.

The National HPV Vaccination Programme introduced vaccination against Human papillomavirus (HPV), the virus which causes genital warts, for young females in 2008 and for young males in 2019. Prior to the pandemic the programme achieved high coverage in young females and was successful in producing a longer-term decline in genital warts in those aged 15 to 19 years since 2009. However, vaccination was disrupted by the pandemic, with low coverage in 2019 to 2020, and a small rise was seen in genital warts diagnoses in females between 2021 and 2022. By 2021 to 2022, HPV vaccination coverage had risen, but not to the levels seen prior to the pandemic.  

The National Chlamydia Screening Programme (NCSP) is also targeted at young people. In June 2021, the NCSP changed to focus on reducing reproductive harm of untreated infection primarily in young women (10) and programmes are recommended to achieve the new DRI in order to do so. However, many areas have yet to change the focus of their programmes towards reducing harm in females.

In 2022, the population rates of STI diagnoses remained high among people of black ethnicity, but this varies within black ethnic groups. Research has found, that when compared to all other ethnic groups, there were no unique clinical or behavioural factors explaining the disproportionately high rates of STI diagnoses among people of black Caribbean ethnicity; this ethnic disparity in STIs is likely influenced by underlying socioeconomic factors and the role they play in the structural determinants of the health of this community (11).

Among GBMSM, diagnoses of STIs increased markedly in 2022. There is evidence of a rebound in sexual mixing among GBMSM between 2020 and 2021, and this is likely to have contributed to the rise in STIs within this population in 2022 (12). The high and increasing levels of gonorrhoea and infectious syphilis suggest that rapid STI transmission is occurring in dense sexual networks without consistent condom use, including those living with HIV. Condomless sex increases the risk of infection of a range of infections that can be transmitted sexually, including hepatitis B and C.

As GBMSM continue to experience high rates of STIs they remain a priority for targeted STI prevention and health promotion beyond HIV prevention, including full immunisation against hepatitis A, hepatitis B, HPV and mpox.

There is a continued need to strengthen public health measures to reduce transmission of syphilis across the city. National clinical guidelines recommend frequent testing in GBMSM at higher risk (13), but surveillance data has suggested that this is not uniformly occurring, especially in GBMSM living with HIV. There have also been concerns about poor knowledge and awareness of syphilis among GBMSM (14). The Syphilis Action Plan includes recommendations to address the increase in syphilis in England (15).

The rise in Shigella infections in 2023 among presumptive GBMSM to levels higher than observed pre-pandemic is concerning. This rise in the context of reports of extensively drug resistant infection (16) must result in a continued focus on culturally competent messages for GBMSM regarding practicing good hygiene during and after sex and recognising the symptoms (17).

The 2022 mpox outbreak predominantly affected GBMSM in London, with more than 2,000 cases reported by the end of December 2022. A large and coordinated effort was needed to control the outbreak, including managing individual cases and their contacts and implementing the mpox vaccination campaign. SHSs were instrumental in responding, including delivering vaccination to protect high risk GBMSM. More than 50,000 vaccinations were delivered in 2022 in London, and at the time of publication, vaccination was available in London for those eligible, including GBMSM.

Established HIV prevention activities may also impact on wider STI control. The London HIV Prevention Programme (LHPP) promotes combined prevention choices for Londoners (18) and was able to support the mpox outbreak response. An England wide HIV Prevention Programme runs campaigns to improve knowledge, understanding and interventions among populations most at-risk of HIV in England, particularly aimed at GBMSM and people of black ethnicity and other groups in whom there is a higher or emerging burden of infection (19).

UKHSA’s main messages

Commissioners and providers of SHSs have an important role in communicating messages about safer sexual behaviours and how to access services.

Main prevention messages

Using condoms consistently and correctly protects against HIV and other STIs such as chlamydia, gonorrhoea, and syphilis – condoms can also be used to prevent unplanned pregnancy.

Regular screening for STIs and HIV is essential to maintain good sexual health – everyone should have an STI screen, including an HIV test, on at least an annual basis if having condomless sex with new or casual partners. In addition:

• women, and other people with a womb and ovaries, aged under 25 years who are sexually active should have a chlamydia test annually and on change of sexual partner
• gay, bisexual and other men who have sex with men (GBMSM) should have tests for HIV and STIs annually or every 3 months if having condomless sex with new or casual partners

HIV pre-exposure prophylaxis (PrEP) is available for free from specialist SHSs and can be used to reduce an individual’s risk of acquiring HIV.

HIV post-exposure prophylaxis (PEP) can be used to reduce the risk of acquiring HIV following some sexual exposures – PEP is available for free from most specialist SHSs and most emergency departments.

People living with diagnosed HIV who are on treatment and have an undetectable viral load are unable to pass on the infection to others during sex – this is known as ‘Undetectable=Untransmittable’ or ‘U=U’.

Vaccination against human papillomavirus (HPV), hepatitis A, hepatitis B and mpox will protect against disease caused by these viruses and prevent the spread of these infections:

• GBMSM can obtain the hepatitis A and hepatitis B vaccines from specialist SHSs – these vaccines are also available for other people at high risk of exposure to the viruses
• GBMSM aged up to and including 45 years can obtain the HPV vaccine from specialist SHSs

Specialist sexual health services are free and confidential and offer testing and treatment for HIV and STIs, condoms, vaccination, HIV PrEP and PEP:

• clinic-based services are commissioned for residents of all areas in England
• online self-sampling for HIV and STIs is widely available
• information and advice about sexual health including how to access services is available at NHS Sexual Health Services and from the national sexual health helpline on 0300 123 7123

Charts, tables and maps

Figure 1. New STI diagnosis rates by UKHSA region of residence, England, 2022

Data sources: GUMCAD, CTAD

Figure 1 is a column chart showing new STI diagnosis rates by English region for the year 2022. Rates are by 100,000 population and are not age-restricted.

The chart shows that London not only has the highest new STI diagnosis rate of all English regions (1,397.3) but that its rate is more than twice that of the region with the next highest rate (the North West with 661.8).

Figure 2. Number of diagnoses of the 5 main STIs, London residents, 2018 to 2022

Data sources: GUMCAD, CTAD

Note 1: Any increase in gonorrhoea diagnoses may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in GBMSM. Any decrease in genital wart diagnoses may be due to a moderately protective effect of HPV-16/18 vaccination. Any increase in genital herpes diagnoses may be due to the use of more sensitive NAATs. Increases or decreases may also reflect changes in testing practices.

Figure 2 is a line chart showing trends in the diagnoses of 5 main STIs (syphilis, gonorrhoea, chlamydia, genital herpes and genital warts) in London residents from 2018 to 2022. The chart shows that chlamydia (51,732 diagnoses) is the most prevalent STI. It also shows that, while most STIs remain at lower levels than at the beginning of the 5-year period (and before the pandemic), gonorrhoea and syphilis have rebounded to higher levels.

Figure 3. Diagnosis rates of the 5 main STIs, London residents, 2018 to 2022

Data sources: GUMCAD, CTAD

See note 1.

Figure 3 is a line chart. Like the previous chart it shows trends in the 5 main STIs, but as rates rather than numbers. For 2022, these ranged from 44.9 per 100,000 population for syphilis to 588.1 for chlamydia.

Table 1. Percentage change in new STI diagnoses, London residents

Diagnoses	2022	Percentage change 2018 to 2022	Percentage change 2021 to 2022
New STIs	122,912	-8%	21%
Syphilis	3,947	12%	8%
Gonorrhoea	33,728	34%	36%
Chlamydia	51,732	-11%	19%
Genital herpes	6,366	-25%	16%
Genital warts	7,036	-45%	-3%

Data sources: GUMCAD, CTAD

See note 1.

Table 1 summarises the changes seen in the previous 2 charts. It is especially useful for less prevalent STIs such as syphilis as changes for these can be hard to see in charts which are scaled to include infections with much higher numbers, such as chlamydia. The table shows the number of diagnoses of new STIs and each of the 5 main STIs for London residents in 2022. Two columns follow this one. The first shows percentage change from 2018 (the first year of the 5-year period used for these reports) to 2022, while the second shows percentage change from 2021 to 2022.

While the number of new STIs was 8% lower in 2022 (122,912 diagnoses) compared to 2018, there had been a 21% increase when 2021 was compared to 2022, reflecting the rebound that is being seen in diagnoses. Syphilis (3.947 diagnoses) and gonorrhoea (33,728 diagnoses), 2 bacterial STIs of particular concern as they are often linked with higher risk sexual behaviours and dense sexual networks, were respectively 12% and 34% higher than in 2018 and 8% and 36% higher than in 2021. Only one of the 5 main STIs saw a year-on-year decline in diagnoses in 2022 and that was genital warts (7,036 diagnoses) which fell by 3% and was 45% lower than in 2018.

Figure 4. Rates of new STIs per 100,000 residents by age group (for those aged 15 to 64 years only) and gender in London, 2022

Data sources: GUMCAD, CTAD

Figure 4 is a pyramid chart which shows rates of new STIs by age group and gender in 2022. Rates are by 100,000 population in each age group for each gender and only Londoners aged 15 to 64 years are included. This reflects the sensitivity of data relating to those aged under 15 years and the need to prevent the disclosure of small numbers.

The distribution by age and gender is skewed towards females in the youngest age group (aged 15 to 19 years), is similar for both males and females aged 20 to 24 years and is increasingly skewed towards males in age groups for those aged 35 years and over. The highest rates for females and males were 4,180.3 and 4,716.8 (20 to 24 year age group in both cases).

Figure 5. Rates of gonorrhoea per 100,000 residents by age group (for those aged 15 to 64 years only) in London, 2018 to 2022

Data sources: GUMCAD

Figure 5 is a line chart showing trends by age group in diagnoses of gonorrhoea. As with the previous chart, only Londoners aged 15 to 64 years are included. It shows that younger age groups appear to have been more impacted by disruptions to service access and probably opportunities for social contact during the COVID-19 pandemic, compared to older age groups.

The 20 to 24 year age group continue to have the highest gonorrhoea diagnosis rates (852.9 per 100,000 population in 2018 and 957.3 in 2022), however the 25 to 34 year age group, which had a considerably lower rate than the 20 to 24 year age group in 2018 (640.7) had a rate only just a little lower by 2022 (946.4).

By contrast, the rate for the youngest age group, those aged 15 to 19 years, fell from 440.4 in 2018 to 297.7 in 2022. The fall for this group began in 2020, the main pandemic year and continued in 2021. The rate for 2022 was an increase but only back to around the level seen in 2020.

Figure 6. Rates of genital warts per 100,000 residents aged 15 to 19 years by gender in London, 2018 to 2022

Data sources: GUMCAD

Figure 6 is a line chart showing trends in genital warts diagnoses by gender for London residents aged 15 to 19 years. Although rates remain low, for the first time in recent years a rise was seen in females, for whom the rate rose from 28.9 per 100,000 population to 33.1. In 2018, the rate among females was 174.8, considerably higher, but this increase is nevertheless of concern. Disruptions to the HPV vaccination programme are known to have occurred during the pandemic, especially in 2020. The rate for males continued to fall and reached 20.3 in 2022, down from 98.2 in 2018 and 23.5 in 2021.

Figure 7. Rates of new STIs by ethnic group per 100,000 residents in London, 2022

Data sources: GUMCAD, CTAD

Figure 7 is a column chart showing rates of new STI diagnoses by ethnic group among London residents in 2022. White, black Caribbean and black African are shown as separate groups with other groups combined into an ‘all other ethnic groups combined’ group. The chart shows that the black Caribbean ethnic group has the highest new STI diagnosis rate with 2,857.3 per 100,000 population. The rates for the white and black African groups are similar and much lower than the black Caribbean rate at 1,293.6 and 1,345.5 respectively. The ‘all other ethnic groups combined’ group had the lowest rate with 926.3.

Table 2. Proportion of London residents diagnosed with a new STI by ethnicity, 2022

Ethnic group	Number	Percentage excluding unknown
White	61,201	56%
Black Caribbean	9,869	9%
Black African	9,379	9%
All other ethnic groups combined	28,031	26%
Unknown	14,432

Data sources: GUMCAD, CTAD

Table 2 summarises the number of new STI diagnoses by ethnic group and the percentage that each group makes up of all new STI diagnoses where ethnic group is known. The white ethnic group, which is larger than the other groups, accounted for 61,201 new STI diagnose or 56% of those with a known ethnicity. The black Caribbean and black African groups accounted for 9% of new STI diagnoses respectively, while the heterogenous ‘all other ethnic groups combined’ group accounted for 26%.

Figure 8. Proportions of London residents diagnosed with a new STI by world region of birth (note 2), 2022

Data sources: GUMCAD data only

Note 2: Data on country of birth is not collected by CTAD. All information about world region of birth is based on diagnoses made in specialist and non-specialist services which report to GUMCAD.

Figure 8 is a column chart showing the proportion of London residents who were diagnosed with a new STI by their world region of origin. This chart is based only on diagnoses reported to GUMCAD as CTAD, the dataset which reports data about community tests and diagnoses of chlamydia, does not collect information about country of birth. The proportions include all GUMCAD new STI diagnoses where country of birth was reported.

The chart shows that over half of Londoners diagnosed with a new STI in 2022 were born in the UK (57%) with the next most common world region of birth being the European Union (EU) at 17%. These proportions have remained relatively stable over the period 2018 to 2022. No category saw an increase or decrease of more than 1% over the 5-year period except for Central and South America and the heterogenous ‘Other Country’ category for which increases of 2% were recorded.

Figure 9. Rates of new STIs per 100,000 residents by decile of deprivation (note 3) in London residents, 2022

Data sources: GUMCAD, CTAD

Note 3: Deciles run from 1 to 10 in order of decreasing deprivation.

Figure 9 is a column chart which shows the new STI diagnosis rate by 100,000 population for each decile of deprivation in 2022. Deciles run from 1 to 10 in order of decreasing deprivation and are calculated at the level of lower super output area (LSOA) of residence, a unit of geography containing around 1,500 residents, across England. All new STI diagnoses in London residents reported with an LSOA of residence code that could be linked to Index of Multiple Deprivation (IMD) data for 2019 are included. The rates are not adjusted for the underlying population demographics for example age distribution.

The chart shows that new STI diagnosis rates are highest in LSOAs which fall into the decile of highest deprivation (1,934 per 100,000 population) and then fall with each decile, reaching 497 for the decile of lowest deprivation.

Figure 10. Diagnoses of the 5 main STIs among heterosexual people (note 4), London residents, 2018 to 2022

Data sources: GUMCAD data only

Note 4: Data on sexual orientation is not collected by CTAD. For women, both heterosexual and bisexual sexual orientations are included.

Note 5: It is important to consider whether there have been any changes to testing or vaccination practices when interpreting increases or decreases in STIs. Increases in gonorrhoea may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in GBMSM. Decreases in genital wart diagnoses may be due to the moderately protective effect of HPV-16/18 vaccination.

Increases in genital herpes diagnoses may be due to the use of more sensitive NAATs.

Figure 10 is a line chart showing trends in the diagnoses of 5 main STIs (syphilis, gonorrhoea, chlamydia, genital herpes and genital warts) in heterosexual London residents from 2018 to 2022. The data comes from GUMCAD only as CTAD does not collect information on sexual orientation. It is important to be aware of this when interpreting the number of chlamydia diagnoses. All 5 major STIs fell in 2020, but all bar genital warts have subsequently increased. Cases of syphilis, which can be a marker of higher risk sexual behaviour in the community, are now at a higher level that seen prior to the pandemic.

Table 3. Percentage change in new STI diagnoses in heterosexual people (note 4) resident in London

Diagnoses	2022	Percentage change 2018 to 2022	Percentage change 2021 to 2022
New STIs	40,320	-45%	16%
Chlamydia	9,975	-62%	19%
Gonorrhoea	7,535	-11%	37%
Genital warts	5,127	-53%	-0.4%
Genital herpes	4,436	-38%	13%
Syphilis	463	35%	7%

Data sources: GUMCAD data only

See note 5 for Figure 10.

Table 3 summarises the changes seen in the previous chart. The table shows the number of diagnoses of new STI and each of the 5 main STIs for heterosexual London residents in 2022. The data comes from GUMCAD only as CTAD does not collect information on sexual orientation. It is important to be aware of this when interpreting the number of chlamydia diagnoses. Two more columns follow. The first shows percentage change from 2018 (the first year of the 5-year period used for these reports) to 2022, while the second shows percentage change from 2021 to 2022.

Syphilis was the only one of the 5 main STIs where numbers were higher in 2022 than in 2018, however, all but genital warts increased between 2021 and 2022. Gonorrhoea had the greatest proportional increase (37% increase).

Figure 11. Diagnoses of the 5 main STIs among GBMSM (note 6), London residents, 2018 to 2022

Data sources: GUMCAD data only

Note 6: Data on sexual orientation is not collected by CTAD. All information about GBMSM is based on diagnoses made in specialist and non-specialist services which report to GUMCAD and exclude chlamydia diagnoses via online services.

Note 7: It is important to consider whether there have been any changes to testing or vaccination practices when interpreting increases or decreases in STIs. Increases in gonorrhoea may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in GBMSM. Decreases in genital wart diagnoses may be due to the moderately protective effect of HPV-16/18 vaccination. Increases in genital herpes diagnoses may be due to the use of more sensitive NAATs.

Figure 11 is a line chart showing trends in the diagnoses of 5 main STIs (syphilis, gonorrhoea, chlamydia, genital herpes and genital warts) in GBMSM London residents from 2018 to 2022. The data comes from GUMCAD only as CTAD does not collect information on sexual orientation. It is important to be aware of this when interpreting the number of chlamydia diagnoses.

The chart shows that gonorrhoea (22,897 diagnoses), rather than chlamydia, is the most prevalent STI among GBMSM. It also shows that both syphilis (3,133 diagnoses) and gonorrhoea, 2 important bacterial STIs which often increase in response to increases in higher risk sexual behaviours, are both now at higher levels than before the pandemic. Rises were seen for all 5 main STIs when 2022 is compared to the previous year 2021, with gonorrhoea diagnoses increasing by more than a third.

Figure 12. Diagnosis rates of the 5 main STIs among GBMSM (note 8), London residents, 2018 to 2022

Data sources: GUMCAD, CTAD

Note 8: Data on sexual orientation is not collected by CTAD. All information about GBMSM is based on diagnoses made in specialist and non-specialist services which report to GUMCAD and exclude chlamydia diagnoses via online services. The denominators for rates are based on sexual orientation information collected by the 2021 census and for each region the same estimate has been used for all years in the chart.

Note 9: It is important to consider whether there have been any changes to testing or vaccination practices when interpreting increases or decreases in STIs. Increases in gonorrhoea may be due to the increased use of highly sensitive nucleic acid amplification tests (NAATs) and additional screening of extra-genital sites in GBMSM. Decreases in genital wart diagnoses may be due to the moderately protective effect of HPV-16/18 vaccination. Increases in genital herpes diagnoses may be due to the use of more sensitive NAATs.

Figure 12 is a line chart. Like the previous chart it shows trends in the 5 main STIs for GBMSM Londoners, but as rates rather than numbers. For 2022, these ranged from 388.6 per 100,000 population for genital warts to 11,391.5 for gonorrhoea.

These rates are much higher than those seen for the population as a whole, but must be interpreted with caution as they rely on self-reporting of sexual orientation to the 2021 census. Due to homophobia, gay and bisexual sexual orientations are likely to be under-reported in the census and this will reduce the size of the denominator, causing the rates to be likely overinflated. It is also worth noting that we have had to use the same denominator for all years.

Table 4. Percentage change in new STI diagnoses in GBMSM (note 6) resident in London

Diagnoses	2022	Percentage change 2018 to 2022	Percentage change 2021 to 2022
New STIs	42,478	19%	31%
Syphilis	3,133	3%	14%
Gonorrhoea	22,897	45%	39%
Chlamydia	10,013	-6%	23%
Genital herpes	939	11%	45%
Genital warts	781	-37%	3%

Data sources: GUMCAD data only

See note 7 for Figure 11.

Table 4 summarises the changes seen in the previous 2 charts. The table shows the number of diagnoses of new STI and each of the 5 main STIs for GBMSM London residents in 2022, based on GUMCAD data. Two more columns follow. The first shows percentage change from 2018 (the first year of the 5-year period used for these reports) to 2022, while the second shows percentage change from 2021 to 2022.

The only one of the 5 main STIs where numbers remained significantly lower than before the pandemic was genital warts diagnoses. The 781 diagnoses seen for 2022 was 37% lower than the 1,246 diagnoses seen in 2018. The number of new STI diagnoses in GBMSM Londoners was 19% higher in 2022 (42,428) compared to 2018 and 31% higher than in 2021. New diagnoses of syphilis were 3% higher in 2022 compared to 2018 and 14% higher than 2021, while the rises seen for gonorrhoea and genital herpes were even more marked. Gonorrhoea diagnoses were 45% higher than in 2018 and had risen by 39% when compared with 2021, while genital herpes diagnoses were 11% higher than in 2018 and had risen by 45% compared to 2021, although the number of diagnoses for this infection was still relatively low (939) among GBMSM compared to most of the other 5 main STIs.

Figure 13a. Rate of new STI diagnoses per 100,000 population by local authority of residence, London residents, 2022

Data sources: GUMCAD, CTAD

Figure 13a is a column chart which displays the rate of new STI diagnoses by London local authority of residence. Rates are by 100,000 population. Local authorities are shown in descending order. The overall London rate and England rate are represented as lines.

The local authority with the highest rate was the City of London (3,655.1), although the rate had a much wider confidence interval than those for other local authorities, due to the much smaller population. Bexley had the lowest rate (491.2). The ordering of the local authorities reflects a tendency for inner London local authorities to have higher rates than outer London local authorities. Inner London local authorities tend to have more diverse populations, especially in relation to sexual orientation, ethnicity and country of origin, in comparison with outer London local authorities. They may also have higher socio-economic deprivation scores. Twenty-five of London’s 33 local authorities had new STI rates that were greater than the rate for England as a whole.

Figure 13b. Rate of new STI diagnoses (excluding chlamydia diagnoses in residents aged under 25 years) per 100,000 population by local authority of residence, London, 2022

Data sources: GUMCAD, CTAD

Prior to 2023, this figure showed rates for the population aged 15 to 64 years, excluding chlamydia in those aged 15 to 24 years.

Figure 13b is another column chart. Like the previous chart it displays the rate of new STI diagnoses by London local authority of residence, however for this version of the rate, chlamydia diagnoses in those aged under 25 years are excluded. This is because this age group is actively targeted for screening for chlamydia and it is also the most prevalent STI. Variations in the implementation of screening may distort the new STI rate and removing diagnoses for the affected age group helps us address this issue. As with the previous chart, the London and England rates are superimposed on the chart as lines.

The ordering of local authorities does not change markedly in this version of the chart. This may be partly due to disruptions to screening programmes since the pandemic. The City of London had the highest rate (3,214.2 per 100,000, however, with wide confidence intervals) and Bexley the lowest (371.1). Twenty-eight of London’s 33 local authorities had a rate higher than that for England as a whole.

Figure 14. Chlamydia detection rate per 100,000 female residents aged 15 to 24 years by local authority of residence, London, 2022

Data sources: GUMCAD, CTAD

Prior to 2023, this figure showed rates for the whole population aged 15 to 24 years, regardless of gender.

Figure 14 is another column chart. Rates are shown in descending order as with the previous charts and show the chlamydia detection rate in young females and those aged 15 to 24 years, the age group targeted for chlamydia screening. Rates are by 100,000 female population in this age group. Previous reports showed this rate unrestricted by gender, but it has been changed to females only from this year to reflect a change of emphasis in the screening programme itself.

Although there are more inner London local authorities in the left hand (higher rate) part of the chart and more outer London local authorities at the other end, there is more geographic variation for this rate. For example, Bromley (1,901.5), an outer London local authority is in the middle of the chart. Hackney had the highest chlamydia detection rate (3,833) and Redbridge the lowest (1,152.5).

Figure 15. Rate of gonorrhoea diagnoses per 100,000 population by upper-tier local authority of residence, London residents, 2022

Data sources: GUMCAD

Figure 15 is also a column chart. It shows rates of gonorrhoea diagnoses by 100,000 population. The rates are not gender-specific but as gonorrhoea is a more common STI among GBMSM, Local authorities with larger GBMSM populations will tend to have higher rates. This is also true to some degree of local authorities with larger black Caribbean populations as this population also has a higher burden of gonorrhoea.

Lambeth had the highest gonorrhoea diagnosis rate in London in 2022 with 1,220.5, while Sutton had the lowest at 87.3. While some local authorities saw much greater increases than others in their gonorrhoea diagnosis rates over the 5-year period 2018 to 2022, only 2 saw a decrease (Croydon and Greenwich). All London local authorities saw an increase when 2022 is compared to the previous year.

Figure 16. Map of new STI rates per 100,000 residents by local authority in London, 2022

Data sources: GUMCAD, CTAD

Figure 16 is a map showing new STI diagnosis rates per 100,000 population for London local authorities. The higher rates in inner London local authorities described for figure 11a earlier can be seen clearly. Also visible are higher rates in some outer London boroughs. These tend not to be quite as high as those seen in inner London but are still considerably higher than those in nearby outer London local authorities. Examples are Waltham Forest in North London (1,194.4), Brent in West London (1,546.7), Newham in East London (1,207.6) and Croydon in South London (1,020.2). These may in part reflect changes in settlement patterns for migrant and economically disadvantaged communities. Where once these groups tended to be concentrated in ‘inner city’ areas which were seen as less desirable, now there is a tendency for them to be pushed outwards to areas of the city.

Figure 17. Map of new STI rates per 100,000 residents by middle super output area (MSOA) in London, 2022

Data sources: GUMCAD, CTAD

Figure 17 shows a map of new STI rates per 100,000 residents by middle super output area of residence in 2022. The map shows that even in inner London authorities which, as the previous map indicated, have higher rates of new STI diagnoses, there is considerable variation. An area just south of the River Thames encompassing Lambeth and north-east Wandsworth forms a large area with high diagnosis rates but there are also other areas throughout inner London.

Figure 18. STI testing rate (excluding chlamydia in those aged under 25 years) per 100,000 population in London residents aged 15 to 64 years, 2018 to 2022

Data sources: GUMCAD, CTAD

Figure 18 is a line chart showing trends in the STI testing rate for London and England from 2018 to 2022. Tests for chlamydia in those aged under 25 years are excluded. The line for London is considerably above that of the England line, which is to be expected. In 2022, London had a testing rate of 8,662.3 per 100,000 population aged 15 to 64 years, compared to England’s 3,856.1. The lines for both London and England show a noticeable downward turn in 2020, the main pandemic year, but both lines turn upward again from 2021 onwards. London’s rate has risen more steeply than England’s over the 5-year period: 19% compared to 7%.

Figure 19. STI testing positivity rate (note 10) (excluding chlamydia in those aged under 25 years) in London residents, 2018 to 2022

Data sources: GUMCAD, CTAD

Note 10: The numerator for the STI testing positivity rate now only includes infections which are also included in the denominator. These are: chlamydia (excluding diagnoses in those aged under 25 years), gonorrhoea, syphilis and HIV. Up to 2018 (data for 2017) it included all new STIs.

Figure 19 is a line chart like the one preceding it. It has 2 lines, one each for London and England, covering the 5-year period 2018 to 2022. Whereas figure 16 showed the STI testing rate, this chart shows the proportion of tests that were positive. As with the previous chart, chlamydia tests in those aged under 25 years are excluded. The line for London is higher than the line for England as a whole, but the difference is not so marked as seen for the testing rate. In 2022, 8.8% of STI tests in Londoners were positive, compared to 7.6% for England residents as a whole. Positivity dropped slightly for London in 2021 but the 2022 percentage is higher than that seen in 2018 when it was 8.6%, but still slightly lower than the 9.1% seen in 2019, the last pre-pandemic year.

Table 5. Number of diagnoses of new STIs by UKHSA region of residence, data source and data subset 2022

UKHSA region of residence	GUMCAD: Specialist SHSs	GUMCAD: Non-specialist SHSs (note 11)	CTAD (note 12)	Total
London	82,589	11,598	28,725	122,912
North West	33,005	5,925	10,192	49,122
South East	32,427	2,699	10,088	45,214
Yorkshire and Humber	20,361	3,283	9,734	33,378
West Midlands	18,965	4,920	5,982	29,867
East of England	16,850	6,310	6,377	29,537
South West	17,085	4,187	6,660	27,932
East Midlands	13,901	8,518	5,492	27,911
North East	10,605	1,687	3,387	15,679

Data sources: GUMCAD, CTAD

Table 5 summarises new STI diagnoses for each UKHSA English region in 2022 by the surveillance system through which they were reported and, for GUMCAD, whether they were reported by specialist or non-specialist SHSs. Of the 122,912 new STI diagnoses in London residents, about two-thirds were reported by specialist SHSs via GUMCAD while about 1 in 10 were reported via the same system but by non-specialist SHSs. Just under a quarter of new STI diagnoses were reported through CTAD. London’s proportion via CTAD was in line with most other UKHSA English regions. Its proportion via specialist SHSs was higher than most other regions, but not the highest, and its proportion via non-specialist SHSs was the second lowest.

Table 6. Number of diagnoses of the 5 main STIs in London by STI, data source and data subset 2022

Five main STIs	GUMCAD: Specialist SHSs	GUMCAD: Non-specialist SHSs (note 11)	CTAD (note 12)	Total
Chlamydia	22,453	554	28,725	51,732
Gonorrhoea	23,605	10,123		33,728
Genital warts	6,760	276		7,036
Genital herpes	6,117	249		6,366
Syphilis	3,939	8		3,947

Data sources: GUMCAD, CTAD

Note 11: Diagnoses from enhanced GPs reporting to GUMCAD are included in the ‘Non-specialist sexual health services (SHSs)’ total.

Note 12: Including site type 12 chlamydia from GUMCAD.

Table 6 summarises diagnoses of the 5 main STIs for London residents in 2022 by the surveillance system through which they were reported and, for GUMCAD, whether they were reported by specialist or non-specialist SHSs. CTAD only collects information on chlamydia diagnoses so the only entry in that column is for that STI. It accounted for 56% of chlamydia diagnoses with 43% being reported by specialist SHSs through GUMCAD and just 1% by non-specialist SHSs through GUMCAD. The only STI where more than 4% of diagnoses were reported via non-specialist SHSs was gonorrhoea (30%). The STI with the highest proportion reported via specialist SHSs was syphilis, where close to 100% of diagnoses were in this group.

Figure 20. Shigella diagnoses in London residents presumed GBMSM by year and quarter: 2017 to Q2 of 2023

Data source: SGSS

Figure 20 is a line chart which shows shigella diagnoses in London residents presumed to be GBMSM between the beginning of 2017 and the end of the second calendar quarter (June) of 2023. Years are subdivided into quarters. Unlike the preceding charts, the data is drawn from the laboratory reporting system, SGSS. This data is more timely than GUMCAD but not as accurate.

The chart shows a steep fall of Shigella diagnoses in London residents presumed GBMSM in 2020, the main pandemic year, following by a renewed rising trend beginning in the second quarter of 2021. By the end of 2022 the number of shigella diagnoses in this group was already higher than seen before the pandemic and in quarter 2 of 2023, the most recent quarter for which we have data, reached 278, the highest number reported over the trend period.

Figure 21. LGV diagnoses in London adult male residents aged 16 years or over by year and quarter: 2019 to quarter 2 of 2023

Data source: SGSS

Figure 21 is a line chart showing LGV diagnoses in London adult male residents aged 16 years or over by year and calendar quarter from the beginning of 2019 to the end of the second quarter (June) of 2023. As with the previous chart, it uses data from the laboratory reporting system, SGSS. Only data for men is included as LGV is very rare in women and investigations of cases reported to be female have suggested that these are mostly due to reporting errors.

The trend for LGV is more difficult to interpret. The number of LGV diagnoses peaked in the third quarter of 2019 with 194 diagnoses and then fell. As with other STIs, there was a steep drop in the second quarter of 2020, the main lockdown period. However, the number of LGV diagnoses then rose in the next quarter before falling again in 2021. This pattern of peaks and troughs has continued. The number of diagnoses for quarter 4 of 2022 was 195, just above the previous highest peak. The trend for 2023 so far has been a decline but with numbers still at higher levels than in most of the pandemic period. For quarter 2 of 2023, the most recent quarter for which we have data, 131 LGV diagnoses were reported.

Figure 22. Confirmed and highly probable mpox cases: London residents, 2022 to June 2023

Data sources: SGSS and Rare and Imported Pathogens Laboratory, UKHSA

For 2022 date is by specimen date. For 2023 date is by specimen reception added date.

Mpox is a zoonotic infection, caused by the mpox virus, that previously occurred mostly in West and Central Africa and is transmitted through close contact (including through sexual contact). Previous cases in the UK had been either imported from countries where mpox is endemic or contacts with documented epidemiological links to imported cases.

In 2022, there was a very large outbreak of mpox with community transmission in the UK, mainly in GBMSM. London was most affected, with 2,439 cases reported in 2022 (69% of the England total), with 98% being adult males. In response to the rise in mpox cases, over 50,000 mpox vaccinations were given in 2022 in London, mainly to GBMSM, with vaccination persisting into 2023.

Figure 22 is a bar chart showing the number of confirmed and highly probable mpox cases in London residents by month from 2022 to June 2023. The figure shows a rapid increase in cases in May 2022, to a peak of more than 800 cases being reported in July 2022 and a subsequent decline to low numbers by November 2022. Very low numbers of cases were reported in the first few months of 2023, with a slight increase to 10 cases in June 2023.

Figure 23. Consultations by service medium: London residents, 2018 to 2022

Data sources: GUMCAD

Figure 23 is a column chart. It shows the number of sexual health consultations for London residents for the 5 years from 2018 to 2022 by consultation medium. Consultations is a term used here to describe contacts with SHSs, which may vary from a face-to-face clinic appointment, to online triage or asymptomatic screening.

The rise in online consultations can be seen throughout the 5-year period, but it accelerated rapidly in 2020, the main pandemic year, due to the need to create access to services during the first lockdown when face to face consultations had to be tightly restricted. Compared to 2018, the number of online consultations was 553% higher in 2022. They rose by 17% when 2022 is compared to 2021. As a proportion of all consultations, online consultations increased from 11% in 2018 to 53%, the majority, by 2022.

Consultations by phone also rose in response to the pandemic, albeit from a much smaller base, however in 2022 the number of phone consultations fell by 40% and accounted for just 4% of all consultations. It is likely that many of those who would have received a consultation by phone are now being seen online instead.

Face to face was the only consultation medium to decline over the 5-year period. Face to face consultations fell by 30%, although they have risen since 2020. In 2018, 88% of consultations were face to face but by 2022 this had fallen by half to 44%.

When all consultation mediums are considered together, the total number of consultations increased by 40% from 1,059,728 to 1,478,616 between 2018 and 2022. GBMSM have seen a higher proportional rise in consultations in this time period (67% increase), compared to heterosexual and bisexual women who have sex with men (WSM, 43% increase), heterosexual men who have sex with women (MSW, 19% increase).

There is also variation by sexual orientation by the proportion of consultations that are online, with the highest proportion of online consultations in 2022 being among MSW (64%), compared to WSM (53%) and GBMSM (43%). This variation may reflect preferences in contact type, availability of a face-to-face consultation or clinical need for a face-to-face consultation.

Information on data sources

Find more information on local sexual health data sources in the UKHSA guide.

This report is based on data from the GUMCAD and CTAD surveillance systems published on 6 June 2023 (data to the end of calendar year 2022).

GUMCAD surveillance system

This disaggregate reporting system collects information about attendances and diagnoses at specialist (Level 3) and non-specialist (Level 2) SHSs. Information about the patient’s area of residence is collected along with demographic data and other variables. GUMCAD superseded the earlier KC60 system and can provide data from 2009 onwards. GUMCAD is the main source of data for this report.

Due to limits on how much personally identifiable information sexual health clinics can share, it is not possible to deduplicate between different clinics. There is a possibility that some patients may be counted more than once if they are diagnosed with the same infection (for infection specific analyses) or a new STI of any type (for new STI analyses) at different clinics during the same calendar year.

CTAD surveillance system

CTAD collects data on all NHS and local authority or NHS-commissioned chlamydia testing carried out in England. CTAD is comprised of all chlamydia (NAATs) tests for all ages (except for conjunctival samples), from all venues and for all reasons. CTAD enables unified, comprehensive reporting of all chlamydia data, to effectively monitor the impact of the NCSP through estimation of the coverage of population screening, proportion of all tests that are positive and detection rates.

For services which report to GUMCAD and for which CTAD does not receive data on the patient’s area of residence (for example SHSs), information about chlamydia diagnoses is sourced from GUMCAD data.

CTAD does not collect information about sexual orientation or country of birth. Reports from CTAD are excluded from figures in this report which relate to analyses by sexual orientation or world region of birth.

New STIs

New STI diagnoses comprise diagnoses of the following:

• chancroid
• LGV
• donovanosis
• chlamydia
• gonorrhoea
• genital herpes (first episode)
• HIV (acute and AIDS defining)
• Molluscum contagiosum
• non-specific genital infection (NSGI)
• non-specific pelvic inflammatory disease (PID) and epididymitis, chlamydial PID and epididymitis (presented in chlamydia total)
• gonococcal PID and epididymitis (presented in gonorrhoea total)
• scabies
• pediculosis pubis
• syphilis (primary, secondary and early latent)
• trichomoniasis and genital warts (first episode)
• Mycoplasma genitalium
• shigella

Calculations

Confidence Intervals were calculated using Byar’s method.

ONS mid-year population estimates for 2021 were used as a denominator for rates (other than by ethnic group) for 2022. ONS estimates of population by ethnic group for the year 2021 were used as a denominator for rates by ethnic group for 2022. This is the first time that new estimates of population by ethnic group have been available since 2011. This must be considered if comparing rates for 2022 in this report with rates by 2021 in last year’s report, as the rates in the last report used the 2011 estimates.

Further information

As of 2020, all analyses for this report include data from non-specialist (Level 2) SHSs and enhanced GP services as well as specialist (Level 3) SHSs.

For further information, access the online Sexual and Reproductive Health Profiles.

For more information on local sexual health data sources, see the UKHSA guide.

Local authorities have access to The Summary Profile of Local Authority Sexual Health (SPLASH) Reports (accessible from the Sexual and Reproductive Health Profiles) and the SPLASH supplement reports via the HIV and STI Data exchange.

For more information on HIV in London please access the Annual Epidemiological Spotlight on HIV in London.

About the Field Service

The Field Service was established in 2018 as a national service comprising geographically dispersed multi-disciplinary teams integrating expertise in Field Epidemiology, Real-time Syndromic Surveillance, Public Health Microbiology and Food, Water and Environmental Microbiology to strengthen the surveillance, intelligence and response functions of UKHSA.

You can contact your local Field Service team at [email protected]

If you have any comments or feedback regarding this report or the Field Service, contact [email protected]

Acknowledgements

We would like to thank:

• local SHSs for supplying the SHS data
• local laboratories for supplying the CTAD data
• UKHSA Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division for collection, analysis and distribution of data

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