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Sexually transmitted infections and travel

Karen Rogstad
MB BSc(Hons) FRCP

Consultant in Genitourinary Medicine and HIV
Department of Genitourinary Medicine
Royal Hallamshire Hospital
Sheffield Teaching Hospitals NHS Foundation Trust

It is well recognised that those on holiday abroad drink more alcohol than they do at home; are more likely to take recreational drugs; and are more likely to drink and drive. This change in risk behaviour also extends to sexual activity. Does this matter and - if so - why do nurses need to know about it?

Knowledge about sexually transmitted infections (STIs) was, until recently, the domain of nurses practising in genitourinary medicine (GUM) clinics. Similarly, knowledge on travel health was restricted to nurses working in specialist services or vaccinating travellers on a doctor's instructions. Those travelling to tropical areas abroad were given vaccinations and antimalarials, and tested for tropical diseases if they were ill on their return.

In the past few years, however, there have been major changes to the nursing role, and also in awareness of the association between travel, changes in sexual behaviour and STI risk. Additionally, there has been a huge increase in the number of travellers from and to the UK. Worldwide, there are more than 800 million tourists every year.

Added to this are those who travel for work or business, those visiting friends and relations (VFRs), and economic migrants or asylum seekers. In the UK, 60 million people travelled abroad in 2009.

Therefore, it is inevitable that most nurses, irrespective of their specialist area, are coming into contact with people who have travelled abroad either recently or some years ago, or whose sexual partners have done so. Travel history, and associated sexual history, may influence the management of the patient. However, if questions about travel and sexual history are not asked, appropriate care cannot be given.

Nurses are now often the primary deliverers of travel advice, either in GP surgeries or travel clinics, and need to be aware of the link between sexual behaviour, travel and STIs.

Sexual behaviour abroad
Several studies have shown that when people travel they are more likely to have new partners, and more of them, and this is true for women as well as men. This likelihood increases for those people who already indulge in risky behaviour, such as multiple sex partners, and drug and alcohol use. Younger people aged 16-24 are more likely to have new partners and 27% of UK residents have casual sex when they travel, whereas the average for other countries is 16%. Even healthcare professionals, who have more knowledge about risks, are not immune, with 32% of medical students having sex with a new partner while abroad. If sex is protected, risk of acquiring an STI, including HIV, is low. However, data suggest that among those having casual sex abroad, 50% do not use condoms.

STIs and travel
All STIs that occur in the UK may also be acquired abroad, but the risk is affected by the prevalence of specific STIs in the country visited, the person with whom the visitor has sex and condom use. For example, if John had unprotected sex in the Far East with Joanne, from a small village in rural England, his risk of an STI would be relatively low and probably the same as having sex in the UK. However, if the partner was a local sex worker in the Far East, the risk could be increased for gonorrhoea, syphilis, HIV and hepatitis B.

If John then had sex with his wife in England, his wife would also be at increased risk, although she would give no travel history to suggest this. The 2000 National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) found that half of men and women from the UK having sex with a new partner abroad chose a UK partner, and for another third the partner was from another European country.1 Fewer than 5% reported new partners from sub-Saharan Africa, the Caribbean or South America, where STIs are more prevalent. However, because so many people travel, this small percentage converts into a significant number. STIs that are more common abroad are listed in Box 1.

[[Box 1 STIs]]

Chlamydia, trichomonas, genital warts and herpes can all be acquired when abroad. Gonorrhoea is more common and also more likely to be resistant to antibiotics in non-Westernised countries, so a positive test by DNA amplification, such as strand displacement amplification (SDA) or polymerase chain reaction (PCR), requires repeat testing by culture to determine antibiotic sensitivities before treatment is commenced; although once cultures have been obtained antibiotics can be given while awaiting sensitivity results.

Lymphogranuloma venereum (LGV), chancroid and donovanosis are grouped together as tropical STIs. Symptoms include genital ulcers, which may be painful, or inguinal swellings known as buboes. They are uncommon but difficult to diagnose, and referral to specialist STI services, ie, genitourinary medicine clinics, is required. Syphilis may also present with a genital ulcer that is typically painless, but ulcers can be painful and multiple, suggestive of herpes. In fact, the two conditions may co-exist.

It is important that serology for syphilis is performed not only immediately but also after six weeks in someone with genital ulcer(s) who has had sexual intercourse in a high prevalence area. Syphilis can also cause other genital or non-genital problems up to three months after exposure. There can be a generalised rash, but particularly on the trunk, palms of the hands and soles of the feet. Wart-like lesions on the genital or peri-anal area are known as condyloma lata, and in the mouth there may be snail-track ulcers.

HIV seroconversion illness
Travellers with a fever returning from tropical areas are usually screened for tropical infections such as malaria. They are often not asked their sexual history or tested for HIV, particularly if they are not perceived to be at risk, such as older men or women. HIV seroconversion illness may present with a glandular fever-like illness and also mimic malaria or meningitis (Box 2). There can be a fever, sore throat, generalised rash, lymphadenopathy, muscle and joint pain, and pneumonia. Symptoms and signs of meningitis or other neurological conditions can occur.

[[Box 2 STIs]]
 
Testing for HIV may be negative initially. Ideally, a fourth-generation antibody test should be performed immediately, which will detect most cases of HIV if exposure was four to six weeks previously. However, HIV cannot be ruled out until a test is performed at 12 weeks post-last exposure. Failure to consider HIV in returning travellers who are unwell has resulted in missed diagnosis of HIV, with patients presenting years later with advanced HIV infection, associated serious morbidity and death.

Management of travellers
Someone attending for health advice before travel expects information on vaccinations and malaria prevention. They may not expect advice on sexual health issues and it can be difficult to raise this. The best approach is to have it as a routine part of the travel consultation and to introduce it as such, so that patients do not feel they are being judged.

Basic information can be given on the HIV risk in the area they are travelling to, advice on taking condoms (as they may not be readily available or of poor quality where they are going to), and the need for a sexual health check on their return if they have sex with a new partner while abroad. Hepatitis B vaccination can be offered for those more likely to have sex abroad, eg, those travelling for longer periods such as gap-year students, expatriates and those in the military deployed overseas. Sex tourists, usually men, often do not disclose spontaneously their reason for travel, but it can be suggested if a male is travelling without a partner to particular countries such as Thailand or the Philippines.

Returning travellers who present for a STI screen, or who disclose sex abroad, should be tested for gonorrhoea, chlamydia, syphilis, hepatitis B and HIV. Examination needs to take into account any same-sex experience that would require additional tests in men. Women may need emergency contraception, ideally within 72 hours of unprotected sex, but it can be given up to a week afterwards using one the newer drugs, or by inserting an intra-uterine contraceptive device.

If genital or systemic symptoms are present then referral to a GUM clinic is advised. It is essential that repeat tests for syphilis, HIV and hepatitis B are performed 12 weeks after their last sexual encounter. If they have had sex in a high-risk area for hepatitis B and present within six weeks of risky behaviour an accelerated vaccination schedule for hepatitis B should be given as there is some evidence of a protective effect in those already exposed. Returning sex tourists should be offered vaccination even after this period as they may well return for another visit.

Post-exposure prophylaxis for HIV (PEP/PEPSE) is an option for those who may have been exposed to HIV, but is only recommended within 72 hours of unprotected sex. Treatment consists of three drugs for four weeks and they have side-effects that can be unpleasant and, in some cases life-threatening; therefore, they should only be offered according to risk. The British Association for Sexual Health and HIV (BASHH) guidelines on assessing risk and the need for treatment should be referred to and are available from the website (www.bashh.org).

References
Rogstad KE. Sex, sun, sea and STIs: sexually transmitted infections acquired on holiday. BMJ 2004;329(7459):214-17.
Fisher M, Benn P, Evans B et al. UK Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Int J STD AIDS 2006;17(2):81-92.
Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. Int J Infect Dis 2010;14(10):e842-51.

Resources
The UK “Yellow Book” is an excellent resource for travel health professionals and travellers themselves. It is published by the National Travel Health Network and Centre (NaTHNaC) and has a section on STI and HIV risks.
W: www.nathnac.org/yellow_book/YBmainpage.htm

Information on specific STIs, testing for them, and the use of post-exposure prophylaxis for HIV is available from the British Association of Sexual Health and HIV (BASHH).
W: www.bashh.org

A new programme of e-learning on STIs has been developed by the Department of Health, the Royal College of Physicians and BASHH.
W: www.e-lfh.org.uk/projects/hiv-sti/index.html

Training courses on sexual health, STIs and HIV can be accessed by nurses through the STI Foundation (STIF) which provides Level 1 1-2 day courses with certification. This can be followed by a competency based training and assessment programme, which will result in a five-year BASHH accreditation.
W: www.bashh.org/education_training_and_careers/stif www.bashh.org/stif_ic_