Sex, sun, sea, and STIs: sexually transmitted infections acquired on holiday
http://www.100md.com
《英国医生杂志》
1 Department of Genitourinary Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF Karen.Rogstad@sth.nhs.uk
Introduction
I searched Medline in November 2003, using the key words "sexually transmitted infection", "abroad", "tourist", "holiday". I reviewed websites of the Health Protection Agency, the World Health Organization, the Department of Health, the Foreign Office, and the Association of British Travel Agents as these could be expected to provide information on travel abroad. Clinical information is from Sexually Transmitted Diseases.2
Sexual behaviour abroad and acquisition of STIs
As with "indigenous" STIs vaginal or urethral discharge or dysuria may occur. A genital ulcer is a common presentation for chancroid, particularly in men, and in 40% it will be associated with painful inguinal lymphadenopathy. Women may have pain on defecation or dyspareunia. Donovonosis can result in ulcerative, granulomatous, or hypertrophic lesions. Lymphogranuloma venereum can present with an ulcer, but men more usually attend when they develop inguinal lymphadenopathy. Women may present with all these symptoms, but they may have only abdominal pain or back pain. Presentation may be up to six months after exposure and may be associated with systemic illness.
Syphilis can also present with a genital ulcer up to three months after exposure. Several months later, secondary syphilis may occur with systemic illness, skin rashes, alopecia, lymphadenopathy, hepatitis, and nephropathy. HIV may manifest as a glandular fever-like illness with seroconversion. HTLV-I may cause spastic paraparesis or leukaemia up to 20 years later.
Management of patients who have had new sexual partners on holiday
More widespread education is necessary for holiday-makers. Patients often visit their general practitioners or travel clinics for advice before travelling to exotic locations. This travel advice should include information on safer sex and the risks of sex abroad. Men travelling alone to Thailand and the Philippines on holiday are likely to be sex tourists and require advice on condom use and provision of hepatitis B vaccination. Others holidaying for longer periods, such as gap year students, should also be considered for vaccination. Information should be given that STIs are transmitted not only by vaginal and anal sexual intercourse but also by oral sex. If travelling to countries with a high HIV prevalence then both men and women should be informed of the need to consider post-exposure HIV prophylaxis if they have been sexually assaulted.18 Contraceptive needs should also be discussed.
Health advice in travel brochures was shown to be in a prominent position in only 11%, and only 3% were found to contain advice on safe sex.20 More worrying is tour operators' encouragement of sex with new partners by presenting prizes.10 As more holidays are booked through the internet, telephone, and teletext, providers of such services must look at ways of supplying advice on the risks of holiday sex (box 2). A need exists for more detailed data collection on STI acquisition while on holiday and assessment of interventions to reduce acquisition (box 3), particularly for people travelling to areas with a high prevalence of STI/HIV. Studies have shown that, although travellers are becoming more knowledgeable about STIs, this has little relation to their behaviour.21 Some evidence shows that men who do not use condoms at home do not use them abroad either.9 Publicity about the risk of sexual assault abroad is needed, combined with advice on how to reduce such a risk. Currently no single source is collecting or publishing such data, but information is available from various organisations, as shown in box 4. Articles in the popular press may be helpful in highlighting issues such as STI risk from sex abroad.22 Research needs to be multidisciplinary, considering the social context in which sex abroad occurs, and interventions require international cooperation.23
Box 1: Management of people who have had new sexual partners on holiday
Asymptomatic patients
Testing for gonorrhoea and chlamydia
Syphilis, HIV, and hepatitis B serology testing at baseline, with repeats at six weeks, 12 weeks, and six months
Hepatitis B vaccination for people at risk if they present soon after last sexual intercourse, and for sex tourists
Consideration of post-exposure HIV prophylaxis within 48 hours of high risk sexual exposure
Prevention advice for future trips
Advice on sexual intercourse with regular or new partners while waiting for results
Symptomatic patients
Urgent referral to specialised STI services
Investigations for tropical STIs according to symptoms
HIV testing by polymerase chain reaction if an HIV seroconversion illness is suspected
Contact tracing for partners on holiday and in the United Kingdom
Box 2: Advice to travellers
Prevalence of STIs/HIV in area to be visited
Safer sex including condom use with any new partner
Risk of sexual assault
Dangers of "date rape" drug
Alcohol consumption advice
Information on post-exposure prophylaxis for HIV
Hepatitis B vaccination for sex tourists or those taking a prolonged holiday to high risk areas—for example, gap year students
Attendance at STI clinics if unprotected sexual intercourse occurs
Travel packs including condoms, drugs for HIV post-exposure prophylaxis
Box 3: Areas for research
Sexual behaviour of tourists
Interventions to promote safer sex for travellers
Value of routine screening for STIs after foreign travel
Database on sexual assault abroad
Box 4: Further sources of help and information
British Association for Sexual Health and HIV (BASHH, www.bashh.org)—List of STI clinics in the United Kingdom; guidelines on testing and treatment
Foreign and Commonwealth Office (www.fco.gov.uk)—Information on how to avoid sexual assault and what to do if it occurs
Suzy Lamplugh Trust (www.suzylamplugh.org)—Handbook and video "Worldwise" on safety abroad
Department of Health (www.archive.official-documents.co.uk)—Health information for overseas travellers 2001 edition
Health Protection Agency (www.hpa.org.uk)—Information on STI rates in young people and international travellers
World Health Organization (www.who.int)—International STI and HIV epidemiology
Lonely Planet (www.lonelyplanet.org.uk)—Information provided by other travellers on dangers in various countries
Conclusion
O'Mahony C. Take a chance. Sex Transm Infect 2003;79: 261.
Holmes KK, et al, eds. Sexually transmitted diseases. 3rd ed. New York: McGraw-Hill, 1999.
Department of Transport. Transport statistics: Great Britain, 1994. London: HMSO, 1994.
Wellings K, Macdowall W, Catchpole M, Goodrich J. Seasonal variations in sexual activity and their implications for sexual health promotion. J R Soc Med 1999;92: 60-4.
Department of Transport. Transport statistics: Great Britain, 2003. London: HMSO, 2003.
Hawkes S, Hart GJ, Johnson AM, Shergold C, Ross E, Herbert KM, et al. Risk behaviour and HIV prevalence in international travellers. AIDS 1994;8: 247-52.
Gillies P. HIV related risk behaviour in UK holiday makers. AIDS 1992;6: 339-40.
Finney H. Contraceptive use by medical students whilst on holiday. Fam Pract 2003;20: 93.
Carter S, Horn K, Hart G, Dunbar M, Scoular A, MacIntyre S. The sexual behaviour of international travellers at two Glasgow GUM clinics. Int J STD AIDS 1997;8: 336-8.
Batalla-Duran E, Oakeshott P, Hay P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract 2003;20: 493-4.
Health Protection Agency. Renewing the focus. HIV and other sexually transmitted infections in the United Kingdom in 2002. London: HPA, November 2003.
Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization. AIDS epidemic update: December 2003. Geneva: UNAIDS, WHO, 2003
Gonococcal Resistance to Antimicrobials Surveillance Programme Steering Group. The gonococcal resistance to antimicrobials surveillance programme (GRASP) year 2002 report. London: Health Protection Agency 2003.
Hawkes S, Hart GJ, Bletsoe E, Shergold C, Johnson AM. Risk behaviour and STD acquisition in genitourinary medicine clinic attenders who have travelled. Genitour Med 1995;71: 351-4.
Schmid GP, Sanders LL Jr, Blount JH, Alexander ER. Chancroid in the USA: re-establishment of an old disease ref. JAMA 1987;258: 3265-8.
Kleiber D, Wilke M. AIDS-bezogenes Risikoverhalten von (Sex-)Touristen in Thailand, in Zeiten von AIDS . In: Heckmann W, Koch MA, eds. Berlin: Sigma Rainer Bohn Verlag, 1994.
Rogstad K E, Bramham L, Lowbury R, Kinghorn GR. Use of a leaflet to replace verbal pre-test discussion for HIV: effects and acceptability. Sex Transm Infect 2003;79: 243-5.
Stephenson J. PEP talk: treating non-occupational HIV exposure. JAMA 2003;289: 287-8.
Ison C A, Woodford P J, Madders H, Claydon L. Drift in susceptibility of Neisseria gonorrhoeae to Ciprofloxacin and emergence of therapeutic failure. Antimicrob Agents Chemother 1998;42: 2919-22.
Shickle D, Nolan-Farrell MZ, Evans MR. Travel brochures need to carry better health advice. Comm Dis Public Health 1998;1: 41-3.
Mulhall B. Sex and travel: studies of sexual behaviour, disease and health promotion in international travellers—a global review. Int J STD AIDS 1996;7: 455-65.
When are you most likely to catch an STI? Company 2003, November.
Hart GJ, Hawkes S. International travel and the social context of sexual risk. In: Carter S, Clift S, eds. Tourism and sex: culture, commerce and coercion. Cassell: London, 2000.(K E Rogstad, consultant1)
Introduction
I searched Medline in November 2003, using the key words "sexually transmitted infection", "abroad", "tourist", "holiday". I reviewed websites of the Health Protection Agency, the World Health Organization, the Department of Health, the Foreign Office, and the Association of British Travel Agents as these could be expected to provide information on travel abroad. Clinical information is from Sexually Transmitted Diseases.2
Sexual behaviour abroad and acquisition of STIs
As with "indigenous" STIs vaginal or urethral discharge or dysuria may occur. A genital ulcer is a common presentation for chancroid, particularly in men, and in 40% it will be associated with painful inguinal lymphadenopathy. Women may have pain on defecation or dyspareunia. Donovonosis can result in ulcerative, granulomatous, or hypertrophic lesions. Lymphogranuloma venereum can present with an ulcer, but men more usually attend when they develop inguinal lymphadenopathy. Women may present with all these symptoms, but they may have only abdominal pain or back pain. Presentation may be up to six months after exposure and may be associated with systemic illness.
Syphilis can also present with a genital ulcer up to three months after exposure. Several months later, secondary syphilis may occur with systemic illness, skin rashes, alopecia, lymphadenopathy, hepatitis, and nephropathy. HIV may manifest as a glandular fever-like illness with seroconversion. HTLV-I may cause spastic paraparesis or leukaemia up to 20 years later.
Management of patients who have had new sexual partners on holiday
More widespread education is necessary for holiday-makers. Patients often visit their general practitioners or travel clinics for advice before travelling to exotic locations. This travel advice should include information on safer sex and the risks of sex abroad. Men travelling alone to Thailand and the Philippines on holiday are likely to be sex tourists and require advice on condom use and provision of hepatitis B vaccination. Others holidaying for longer periods, such as gap year students, should also be considered for vaccination. Information should be given that STIs are transmitted not only by vaginal and anal sexual intercourse but also by oral sex. If travelling to countries with a high HIV prevalence then both men and women should be informed of the need to consider post-exposure HIV prophylaxis if they have been sexually assaulted.18 Contraceptive needs should also be discussed.
Health advice in travel brochures was shown to be in a prominent position in only 11%, and only 3% were found to contain advice on safe sex.20 More worrying is tour operators' encouragement of sex with new partners by presenting prizes.10 As more holidays are booked through the internet, telephone, and teletext, providers of such services must look at ways of supplying advice on the risks of holiday sex (box 2). A need exists for more detailed data collection on STI acquisition while on holiday and assessment of interventions to reduce acquisition (box 3), particularly for people travelling to areas with a high prevalence of STI/HIV. Studies have shown that, although travellers are becoming more knowledgeable about STIs, this has little relation to their behaviour.21 Some evidence shows that men who do not use condoms at home do not use them abroad either.9 Publicity about the risk of sexual assault abroad is needed, combined with advice on how to reduce such a risk. Currently no single source is collecting or publishing such data, but information is available from various organisations, as shown in box 4. Articles in the popular press may be helpful in highlighting issues such as STI risk from sex abroad.22 Research needs to be multidisciplinary, considering the social context in which sex abroad occurs, and interventions require international cooperation.23
Box 1: Management of people who have had new sexual partners on holiday
Asymptomatic patients
Testing for gonorrhoea and chlamydia
Syphilis, HIV, and hepatitis B serology testing at baseline, with repeats at six weeks, 12 weeks, and six months
Hepatitis B vaccination for people at risk if they present soon after last sexual intercourse, and for sex tourists
Consideration of post-exposure HIV prophylaxis within 48 hours of high risk sexual exposure
Prevention advice for future trips
Advice on sexual intercourse with regular or new partners while waiting for results
Symptomatic patients
Urgent referral to specialised STI services
Investigations for tropical STIs according to symptoms
HIV testing by polymerase chain reaction if an HIV seroconversion illness is suspected
Contact tracing for partners on holiday and in the United Kingdom
Box 2: Advice to travellers
Prevalence of STIs/HIV in area to be visited
Safer sex including condom use with any new partner
Risk of sexual assault
Dangers of "date rape" drug
Alcohol consumption advice
Information on post-exposure prophylaxis for HIV
Hepatitis B vaccination for sex tourists or those taking a prolonged holiday to high risk areas—for example, gap year students
Attendance at STI clinics if unprotected sexual intercourse occurs
Travel packs including condoms, drugs for HIV post-exposure prophylaxis
Box 3: Areas for research
Sexual behaviour of tourists
Interventions to promote safer sex for travellers
Value of routine screening for STIs after foreign travel
Database on sexual assault abroad
Box 4: Further sources of help and information
British Association for Sexual Health and HIV (BASHH, www.bashh.org)—List of STI clinics in the United Kingdom; guidelines on testing and treatment
Foreign and Commonwealth Office (www.fco.gov.uk)—Information on how to avoid sexual assault and what to do if it occurs
Suzy Lamplugh Trust (www.suzylamplugh.org)—Handbook and video "Worldwise" on safety abroad
Department of Health (www.archive.official-documents.co.uk)—Health information for overseas travellers 2001 edition
Health Protection Agency (www.hpa.org.uk)—Information on STI rates in young people and international travellers
World Health Organization (www.who.int)—International STI and HIV epidemiology
Lonely Planet (www.lonelyplanet.org.uk)—Information provided by other travellers on dangers in various countries
Conclusion
O'Mahony C. Take a chance. Sex Transm Infect 2003;79: 261.
Holmes KK, et al, eds. Sexually transmitted diseases. 3rd ed. New York: McGraw-Hill, 1999.
Department of Transport. Transport statistics: Great Britain, 1994. London: HMSO, 1994.
Wellings K, Macdowall W, Catchpole M, Goodrich J. Seasonal variations in sexual activity and their implications for sexual health promotion. J R Soc Med 1999;92: 60-4.
Department of Transport. Transport statistics: Great Britain, 2003. London: HMSO, 2003.
Hawkes S, Hart GJ, Johnson AM, Shergold C, Ross E, Herbert KM, et al. Risk behaviour and HIV prevalence in international travellers. AIDS 1994;8: 247-52.
Gillies P. HIV related risk behaviour in UK holiday makers. AIDS 1992;6: 339-40.
Finney H. Contraceptive use by medical students whilst on holiday. Fam Pract 2003;20: 93.
Carter S, Horn K, Hart G, Dunbar M, Scoular A, MacIntyre S. The sexual behaviour of international travellers at two Glasgow GUM clinics. Int J STD AIDS 1997;8: 336-8.
Batalla-Duran E, Oakeshott P, Hay P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract 2003;20: 493-4.
Health Protection Agency. Renewing the focus. HIV and other sexually transmitted infections in the United Kingdom in 2002. London: HPA, November 2003.
Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization. AIDS epidemic update: December 2003. Geneva: UNAIDS, WHO, 2003
Gonococcal Resistance to Antimicrobials Surveillance Programme Steering Group. The gonococcal resistance to antimicrobials surveillance programme (GRASP) year 2002 report. London: Health Protection Agency 2003.
Hawkes S, Hart GJ, Bletsoe E, Shergold C, Johnson AM. Risk behaviour and STD acquisition in genitourinary medicine clinic attenders who have travelled. Genitour Med 1995;71: 351-4.
Schmid GP, Sanders LL Jr, Blount JH, Alexander ER. Chancroid in the USA: re-establishment of an old disease ref. JAMA 1987;258: 3265-8.
Kleiber D, Wilke M. AIDS-bezogenes Risikoverhalten von (Sex-)Touristen in Thailand, in Zeiten von AIDS . In: Heckmann W, Koch MA, eds. Berlin: Sigma Rainer Bohn Verlag, 1994.
Rogstad K E, Bramham L, Lowbury R, Kinghorn GR. Use of a leaflet to replace verbal pre-test discussion for HIV: effects and acceptability. Sex Transm Infect 2003;79: 243-5.
Stephenson J. PEP talk: treating non-occupational HIV exposure. JAMA 2003;289: 287-8.
Ison C A, Woodford P J, Madders H, Claydon L. Drift in susceptibility of Neisseria gonorrhoeae to Ciprofloxacin and emergence of therapeutic failure. Antimicrob Agents Chemother 1998;42: 2919-22.
Shickle D, Nolan-Farrell MZ, Evans MR. Travel brochures need to carry better health advice. Comm Dis Public Health 1998;1: 41-3.
Mulhall B. Sex and travel: studies of sexual behaviour, disease and health promotion in international travellers—a global review. Int J STD AIDS 1996;7: 455-65.
When are you most likely to catch an STI? Company 2003, November.
Hart GJ, Hawkes S. International travel and the social context of sexual risk. In: Carter S, Clift S, eds. Tourism and sex: culture, commerce and coercion. Cassell: London, 2000.(K E Rogstad, consultant1)