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Tickets, passport, condoms: travel and sexual health

Justin Gaffney
RN BSc(Hons) Nursing (Sexual health)
Nurse Consultant for STI Control
St Mary's Hospital, London
Chairperson
Genito Urinary Nurses Association
E:justin.gaffney@st-marys.nhs.uk

International travel for business and tourism has increased significantly with the expansion of low-cost airlines in recent years. Yet the evidence would suggest that a suntan is not all that many travellers bring home with them. Surveys show that, globally, 15% of people have sex with a new partner when they first meet, and 44% of these do not use a condom.(1) Sexually transmitted infections (STIs) in the UK continue to rise, especially among the young. Resistance strains of one bacterial STI, imported by those that travel, and then spread among the indigenous population, led to a change in first-line treatment of gonorrhoea in 2003 within the UK. This article will highlight some of the issues related to the acquisition of sexually transmitted infections and travel, and suggest some risk factors that nurses working in primary care may be able to identify when undertaking health assessments with patients attending travel or vaccination clinics. Opportunities for health promotion will be identified and guidance given as to how nurses can empower patients to consider condoms as an essential travel item.

Global trends
Statistics from the International Civil Aviation Organisation show that 1,562 million travelled by air in 1999, increasing to 1,647 million in 2000, with 188,880 passengers embarking on international air travel in 2002 from UK airports alone, according to the National Office of Statistics.(2) The world is more easily traversed, and consumer demand for affordable air travel has recently seen the development of a plethora of low-cost budget airlines. This has facilitated easy access to the continent and further afield for an increasing number of our patients, and more so for the young or those on a low income or benefits, who previously were not presented with such opportunities.
Further, for many, the broadcasting of docu-soaps focusing on the hedonistic exploits of 18-30s holidaying on Mediterranean islands has established a mindset of cheap package holidays equating to sun, sand, booze and sex. This is alarming when compared with the recently published findings of the Durex Global Sex Survey 2003,(1) conducted across 34 countries, including the UK, which showed that as many as one in four of those surveyed had unprotected sex with a new sexual partner in the 12 months before the survey. Further, one in six (15%) would have sex on a first night, of which a third (36%) would still have sex with a new partner if they refused to wear a condom.
A number of travel health resources identify the human immunodeficiency virus (HIV) and STIs as potential health hazards for travellers.(3,4) Studies also find that being male has a higher associated risk for travel away from home and the acquisition of an STI, including HIV. Lydie et al found an association between overnight travel and being HIV- positive.(5) Their study looked at risky sexual behaviour of men in Cameroon, and found that travel away from home was associated with a higher number of one-off sexual encounters and a greater number of sexual partners, for men, but not so with women.
A further study, conducted in Latin America,(6) found that 12.2% of respondents had new sex partners during their stay in Peru, and that sex with a local partner was more frequent than with fellow travellers or a sex worker. Risk factors for engaging in sex with a new partner included being male, being single, a duration of stay greater than 30 days, travelling alone or with friends, and having a bisexual orientation.
In the UK, rates of all STIs across all populations are increasing, and according to the Health Protection Agency,(7) particularly in the 16-24 age group. This is the very age range that many of the low-cost budget holiday companies target with hard-hitting marketing campaigns.

Clinical governance
Those who travel overseas and acquire sexual infections can transmit those infections within the indigenous population upon their return to the UK. This can have a marked impact on the management of STIs within clinical practice. GRASP 2002 data recommended a change to first-line treatment for gonorrhoea, due to increasing levels of ciprofloxacin (quinolone) resistance, thought to originate from disease acquired overseas (see Figure 1).(8)

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Health promotion
The national strategy for sexual health and HIV - implementation action plan clearly sets out two of the strategies key aims:(9)

  • To reduce the transmission of HIV and STIs.
  • To reduce the prevalence of undiagnosed HIV and STIs.

The action plan further identifies local resources and additional strands of Department of Health funding to help meet the targets within the strategy and ways to achieve these aims on a local level.
In addition, a toolkit for "Effective sexual health promotion" has been launched,(10) with a focus on primary care. This toolkit will be particularly useful for practice nurses who wish to develop and utilise health promotion opportunities with their patients in regard to travel and safer sex advice.

Travel and safer sex resources
A number of health promotion resources and materials are readily available to assist practitioners who may want to develop initiatives. For gay, bisexual and men who have sex with men (MSM), the Terrace Higgins Trust have a range of travel related leaflets and information packs, which provide sexual health information for such travellers.

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References

  1. Durex Global Sex Survey 2003. Cambridge: SSL International; 2003.
  2. HMSO (2004) National Statistics website. Accessed at http://www.statistics.gov.uk/STATBASE/Expodata/Spreadsheets/D7819.xls
  3. Burger ET. Preparing adult patients for international travel. Nurse Pract 2001;26(5):13-23.
  4. Travel health Information Services - Health Advice & Resources for Travellers - Sexual Health. Posted  4 December 2003. Accessed at http://www.travelhealth.co.uk/advice/sexualhealth.htm
  5. Lydie N et al. Mobility, sexual behavior, and HIV infection in an urban population in Cameroon. J Acquir Immune Defic Syndr 2004;35:67-74.
  6. Cabada MM, et al. Sexual behavior of international travellers visiting Peru. Sex Transm Dis 2002;29(9):510-3.
  7. Ellis S, Grey A. Prevention of ­sexually transmitted infections (STIs): a review of reviews into the effectiveness of non-clinical interventions - evidence briefing - Part three: population sub-groups requiring targeted prevention interventions. Health Protection Agency, January 2004 - 1st Edition.
  8. GRASP Steering Group. The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) Year 2002 report. London: Health Protection Agency; 2003.
  9. Department of Health. The national strategy for sexual health and HIV - implementation action plan. London: DH; 2002.
  10. Department of Health. Effective sexual health promotion: a toolkit for PCTs and others working in the field of promoting good sexual health and HIV prevention. London: DH; 2003.