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Sexually transmitted infections in young adults

Sexually transmitted infection (STI) rates are collected by the Health Protection Agency (HPA) from data provided by genitourinary medicine (GUM) clinics. The annual publication of data by the HPA highlights an overall increase in the number of STIs.1 Young people aged 16–24 account for nearly half of the diagnoses made in GUM clinics, despite forming only 12% of the population.2 This age group is more likely to engage in risk-taking behaviour, with a strong link between social deprivation and poor sexual health.3

The media seem to delight in the figures, and often attribute increases in STIs to declining morals and increasing promiscuity. However, the rates could conceivably be due to greater awareness and willingness to attend for testing, improvements to GUM access and increased efforts by the National Chlamydia Screening Programme (NCSP). Conversely, these rates may be the tip of the iceberg, as the data do not include diagnoses made in general practice or undiagnosed infections due to absence of symptoms or difficulty in/fear of accessing GUM services.

Public health priority
The Department of Health considers sexual health a significant public health priority; consequences of poor sexual health are costly to the NHS and can cause longlasting morbidity and distress.3 National Institute for Health and Clinical Excellence (NICE) guidelines state that professionals (including those in general practice) should identify individuals at risk of STIs.4

Identification should inform shared decision-making on testing and discussion about risk reduction. Risk factors for STIs include being under the age of 25, low self-esteem, lack of negotiation skills, new sexual partners and more than one sexual partner in the past year.4 There are many STIs with potential for coinfection. Young people commonly acquire one or more of four infections: chlamydia, gonorrhoea, genital warts and herpes. All infections may be transmitted male to male, male to female, female to male and female to female.

General practice has the potential to promote testing, increase access and improve sexual health. For this to become a reality, nurses must have up-to-date knowledge about identification of risk, common STIs (including signs, symptoms and treatment options) and when and where to refer patients. Some STIs can be diagnosed and managed in general practice; however, patients will not be afforded the anonymity assured by GUM services. This factor may or may not concern patients, but alternatives should always be explained. The need for partner notification must also be considered to prevent onward transmission. Relationships with local GUM services should be developed and observation visits encouraged, enabling nurses to accurately describe procedures and the nature of consultations.

Chlamydia
Chlamydia is the most common STI in young adults. In 2007, 79,557 young adults were diagnosed with chlamydia,5 accounting for 65% of all chlamydia diagnoses.6 Chlamydia is a bacterial infection and asymptomatic in approximately 70% of women and 50% of men.7 Signs of infection include (but are not restricted to) urethral discharge, dysuria and epididymitis in males, and dysuria, cervicitis, vaginal discharge and intermenstrual bleeding in women.8,9 Chlamydia is a public health concern, as consequences of untreated infection include pelvic inflammatory disease, tubal damage, acute and chronic pelvic pain, ectopic pregnancy and infertility in women.8 More recently, research suggests that males may also experience infertility as a result of untreated infection.10

Concern at increasing infection rates led to the formation of the NCSP, which now offers nationwide screening. The programme has completed over 387,000 screens with continued average positivity of 10%; rates vary according to ethnic groups.11 Screening is noninvasive and self-collected, either by first pass urine or a vulvovaginal swab. Results, treatment and partner notification are coordinated by local chlamydia screening teams. Teams are keen to work with general practice to increase uptake and will provide free specimen collection kits and resources. In some areas, payment is made by the primary care trust for each test; however, the effect of this on uptake is not yet known.

Chlamydia screening is not appropriate for symptomatic patients. The screening process is typically longer than standard testing processes, which may delay treatment with the potential for complications to arise.

The preferred treatments for chlamydia are azithromycin 1 g in a single dose or doxycycline 100 mg twice daily for seven days (contraindicated in pregnancy). Both are estimated to be over 95% effective.12 Azithromycin has the advantage of being single dose, thus maximising completion of treatment. Young adults should be advised to abstain from sexual activity until partner(s) have been tested and treated. Annual chlamydia screens and with each change of sexual partner are also recommended.

Gonorrhoea
Gonorrhoea is caused by Neisseria gonorrhoeae, a bacteria that infects mucosal surfaces such as the genital tract, urethra and rectum.8,13 Although overall numbers of diagnoses have declined in recent years, rates are increasing in young adults; specifically, black and ethnic minorities and men who have sex with men (MSM). Figures show 9,410 infections in 2007 (50% of all gonorrhoea infections).5 Females are more likely to acquire gonorrhoea from infected males than vice versa.8

Men will typically develop symptoms of urethral discharge or dysuria within two to 10 days.8,9 Gonorrhoea can be asymptomatic in up to 50% of women8 and symptoms include vaginal discharge, dysuria, intermenstrual bleeding and lower abdominal pain.8,9,13 Complications of untreated infection can involve the epididymis and prostate in males, and the endometrium and pelvic organs in females.13

Diagnosis is made using cultured urethral, rectal, endocervical and oropharyngeal specimens, which provide information on antibiotic sensitivities. Antibiotic resistance is increasing, and treatment will depend on where the infection was acquired. Guidelines suggest that treatment should be given in the GUM clinic, either by a single dose of antibiotics given intramuscularly or orally.13 All current sexual partners will need assessment and testing even if asymptomatic.

Genital warts
In 2007, 49,250 new cases of genital warts were diagnosed. Genital warts are the second most common STI in young adults, representing 50% of all genital wart diagnoses.5 Approximately 30 types of human papillomavirus (HPV) cause genital infection, types 6 and 11 being the most common.8 Of particular concern are types 16, 18, 31 and 33, which have been identified as increasing the risk of cervical cancer.8

The incubation period varies from two weeks to eight months;9 so infection may not be from the current partner. Diagnosis is on the basis of clinical features, but women may be unaware of warts due to difficulties in self-examination and the asymptomatic nature of infection. Bleeding from the urethra or anus may indicate internal lesions.14 Warts may be hard, soft, solitary or multiple. Not all infected patients will display clinical features due to subclinical infection.

Psychological distress may be apparent, perhaps due to the physical reminder of infection or a regretted sexual encounter. Although treatment is possible, it is not always successful and often uncomfortable. Options include caustic agents, cryotherapy and excision, which may need to be repeated frequently.14 Treatment choice depends on site of infection and clinical features. Women with genital warts should be advised to attend for cervical screening according to the national schedule, and earlier recall is not considered necessary. HPV testing to determine presence of infection is available; however, it is not part of any screening programme. Nurses may be asked about testing and should be aware of local private healthcare facilities offering testing.

Genital herpes
Genital herpes is a particularly interesting STI as the majority of people with the condition do not develop symptoms. As many as 80% will continue to be asymptomatic for months or even years after contact with the virus.15 Infected individuals can, however, continue to transmit the virus through viral shedding during sexual contact.8,9 Condoms will not always prevent transmission as the virus can be shed anywhere on the genitals, including the scrotum and labia majora. In 2007, 11,252 new cases of genital herpes were reported.5 It can be assumed that there may be significantly higher numbers unaware of infection with the potential to transmit infection to others.

Genital herpes is caused by one of two types of herpes simplex virus – HSV1 or HSV2. HSV1 is associated with genital and oropharyngeal infection (the typical "cold sore"); however, HSV2 is largely responsible for genital infections. HSV1 genital infection has become prevalent because childhood infection with orolabial herpes has declined.9 Following infection, the virus will become latent in the local sensory ganglia and reactivates from time to time causing symptoms or viral shedding.

The first attack may be a primary episode indicating recent infection or a first clinical episode which may occur months or years after infection.8 It is not always possible to determine the type of episode. The uncertainty can cause distress and accusations of infidelity if a patient has been with a partner for some time. Symptoms of primary infection include fever, dysuria, bilateral inguinal lymphadenopathy, tingling and bilateral genital blisters.15

Treatment is possible but will provide symptomatic relief only. Antiviral therapy of aciclovir, famciclovir or valciclovir should be started within five days of lesions developing, reducing duration and severity of symptoms.15 Additionally, patients should be advised to try warm saline baths and analgesia to alleviate symptoms. Recurrent episodes are less likely with HSV1; however, those experiencing more than six episodes per year or lengthy episodes may find relief from a period of suppressive therapy.8,15

The threat of future episodes and the stigma attached to the lifelong nature of herpes can cause psychological pain, especially when disclosing infection to current/future partners. Patients should be given a thorough explanation of the natural history and advised that any recurrences are often milder than the first episode, becoming less frequent over time.9 Recurrence is more likely with HSV2, with lesions appearing anywhere in the distribution of the dermatome (such as buttocks). The Herpes Virus Association has a very useful and clinically sound website that patients may find helpful (see Resources).

HIV
Although HIV rates in young adults (15–24) are low compared to other STIs, 846 young adults were diagnosed with HIV in 2007.16 Three-hundred and seventy-one infections were acquired heterosexually and 336 infections in MSM. Young adults may not consider themselves to be at risk of HIV, yet rates of heterosexually-acquired infection are increasing. Recent government sexual health campaigns have concentrated on the more common STIs with little to increase awareness of HIV among young adults. Nurses should ensure that young adults are aware of the risk and include HIV in any discussion about sexual health.

HIV rates are thought to be underestimated with many remaining undiagnosed due to the asymptomatic nature of early infection.16 General practice can help improve detection rates and nurses must be aware of signs and symptoms of undiagnosed infection. The Medical Foundation for Aids and Sexual Health (Medfash) produced a useful guide for primary care professionals. The booklet should be available to all members of the primary care team and could be used as the basis for discussion at practice meetings.

Signs and symptoms of HIV may resemble other illnesses, including fever, sore throat, malaise, lymphadenopathy, chronic skin problems, diarrhoea and oral candidiasis. Clearly, the indication for testing may be missed if symptoms are attributed to another, perhaps more benign problem. The Medfash booklet contains useful information and tips on broaching the possibility of HIV with patients.

Promoting sexual health
Many practices provide dedicated young person's or sexual health clinics. Although such services will not replace the need for GUM clinics, it is important that nurses actively promote sexual health to young adults. Nurses should be able to advise young adults about types of infections and discuss strategies to reduce risk. NICE guidance stresses that intervention should focus on behaviour change theories.4

Many young adults enjoy their lifestyles and may feel patronised if told not to have unsafe sex. It is preferable to engage in discussion which allows time for questions and chance to challenge myths than a one-sided lecture on the dangers of sex. Stigmas about sexual health and STIs prevail in British society. Even if practices do not perform testing much can be done to reduce the stigma felt by young people in accessing sexual health services. Sexuality should be normalised and young people empowered to make positive decisions. Central to this is the provision of nonjudgmental and factually correct information. Sexual diversity must be respected at all times and heterosexuality should never be assumed. Key messages from the HPA should be used when working with young adults:

  • Have fewer sexual partners and avoid overlapping sexual relationships.
  • Use a condom when having sex with a new partner and continue to do so until both have been screened.
  • Get screened for chlamydia every year and whenever you have a new partner.
  • If you are a man who has sex with men, then always use a condom and have an annual sexual health screen including an HIV test.6

Such intervention may not always be feasible, perhaps due to lack of knowledge or skills, and referral to other professionals such as sexual outreach or school nurses should be considered.
Proficient and sustained use of condoms is essential for safer sex with free condom availability significantly affecting use. Many practices do not provide free condoms despite World Health Organization recommendations.17 It is vitally important that young adults know when and where to obtain free supplies and how to use them correctly. Many areas operate "condom card" schemes where young people will show a card to a health professional, pharmacist or receptionist and be given a supply of free condoms. Local sexual health leads will be able to provide details about schemes which are at no cost to the distributor. Where such schemes are not available, nurses should be able to direct young adults to the nearest free supplier which may be a contraceptive clinic or local outreach worker.

[[Tab 1 infect]]

Conclusion
Sexual health in the UK is often referred to as being "in crisis", and there is no simple solution to solving the rising rates of infection. Many initiatives, such as the NCSP and the increasing numbers of sexual health outreach nurses, are improving access to sexual health care. Practices should capitalise on their role as a source of health information, and provide a variety of posters and leaflets to raise awareness and explicit directions to the nearest free condom supplier (preferably at the practice).

Sexual health discussion should be proactive and nonjudgmental and raised opportunistically. Nurses should not be afraid to discuss sexual health for fear of causing offence, as it may be the only encounter that the patient has with a healthcare provider and such opportunities to improve sexual health and preventing complications must not be lost. It may not seem much in the scheme of things, but nurses should not underestimate the importance of their role in promoting sexual health, and in reducing the stigma associated with STIs.

[[Pract point infect]]

References
1. Health Protection Agency. All new STI episodes made at genitourinary medicine (GUM) clinics in the United Kingdom: 1998–2007. London: HPA; 2007.
2. Health Protection Agency. Continued increase in sexually transmitted infections: an analysis of data from UK genitourinary medicine clinics up to 2007. London: HPA; 2008.
3. Department of Health. The national strategy for sexual health and HIV. London: DH; 2001.
4. National Institute for Health and Clinical Excellence. One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups. London: NICE; 2007.
5. Health Protection Agency. Selected STI diagnoses and diagnosis rates from GUM clinics in the UK: 2003–2007. London: HPA; 2008.
6. Health Protection Agency. Sexually transmitted infections and young people in the United Kingdom: 2008 report. London: HPA; 2008.
7. Department of Health. Summary and conclusions of CMO's expert advisory group on Chlamydia trachomatis. London: DH; 1998. Available from: http://www.dh.gov.uk/en/Publicationsand
statistics/Publications/PublicationsPolicyAnd
Guidance/DH_4005254
8. Edwards A, Sherrard J, Zenilman J. Fast facts: sexually transmitted infections. 2nd ed. Oxford: Health Press; 2007.
9. Adler M, Cowan F, French P, Mitchell H, Richens J. The ABC of sexually transmitted infections. 5th ed. London: BMJ Books; 2004.
10. Idahl A, Boman J, Kumlin U, Olofsson JI. Demonstration of Chlamydia trachomatis IgG antibodies in the male partner of the infertile couple is correlated with a reduced likelihood of achieving pregnancy. Hum Reprod 2004;19:1121–6.
11. National Chlamydia Screening Programme. Maintaining momentum. Annual report of the National Chlamydia Screening Programme 2006/07. London: NCSP; 2007. Available from: http://www.chlamydia
screening.nhs.uk/ps/assets/pdfs/AnnualReport0607.pdf
12. British Association for Sexual Health and HIV. 2006 UK national guideline for the management of genital tract infection with chlamydia trachomatis. London: BASHH; 2006. Available from: http://www.bashh.org/documents/61/61.pdf
13. British Association for Sexual Health and HIV. National guideline on the diagnosis and treatment of gonorrhoea in adults, 2005. London: BASHH; 2005. Available from: http://www.bashh.org/
documents/116/116.pdf
14. British Association for Sexual Health and HIV. United Kingdom national guideline on the management of anogenital warts, 2007. London: BASHH: 2007. Available from: http://www.bashh.org/documents/86/86.pdf
15. British Association for Sexual Health and HIV. 2007 national guideline for the management of genital herpes. London: BASHH: 2007. Available from: http://www.bashh.org/documents/115/115.pdf
16. Health Protection Agency. United Kingdom HIV new diagnoses to end of June 2008. London: HPA: 2008. Available from: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1219735627377
17. Evans D. Clever dicks do it in a condom. Prof Nurse 2005;30:24–9.

Resources
Medical Foundation for AIDS and Sexual Health
W: www.medfash.org.uk/publications/documents/Recommended_standards_for_sexu...
r u thinking?
W: www.ruthinking.co.uk
National Chlamydia Screening Programme 
W: www.chlamydiascreening.nhs.uk/index.htm
Royal College of Nursing Chlamydia Educational Initiative  
W: www.rcn.org.uk/__data/assets/pdf_file/0006/78648/002513.pdf
Sexual Halth Professionals (Facebook group)
W: www.facebook.com/group.php?gid= 37905583448
University of Greenwich Sexual Health Skills Course
E: sexualhealthskills@gre.ac.uk
UK Nursing.net
W: www.uknursing.net