Sexually transmitted infections and HIV among travellers: A review

Recreational substance use among international travellers

BACKGROUND

Drug tourism reflects the expanding illicit drug market, posing health risks in unfamiliar travel settings. Existing knowledge specifically addressing substance use among international travellers is sparse and has not been reviewed to date. This review aimed to describe the recreational substance abuse in international travellers.

METHODS

A literature search was conducted on PubMed, Google Scholar and Scopus using keywords related to recreational substances and international travellers. A total of 11 021 articles were reviewed, charted and summarized for the evidence on prevalence, patterns and characteristics of substance abuse and their health- and non-health-related problems on international travellers.

RESULTS

A total of 58 articles were included. Most were cross-sectional studies and review articles. In total, 20 articles addressed the prevalence of substance abuse in travellers, 33 looked at characteristics and patterns of substance abuse in travellers and 39 investigated the health- and non-health-related problems from substance abuse. Estimated prevalence of recreational substances abuse varied from 0.7% to 55.0%. Rates of substances abuse were 9.45-34.5% for cannabis, 20.4-35.9% for alcohol intoxication, 2.82-40.5% for MDMA, 2-22.2% for cocaine, 2-15% for psychedelic agents and 2% for methamphetamine. The prevalence varied according to travellers' characteristics and travel destinations. Direct health problems included neuropsychiatric problems. Indirect problems included accident and unintentional injuries, crime and violence, risky sexual behaviours and sexual violence and blood-borne infections. Non-health-related problems included air rage, deportation and violation of local laws.

CONCLUSION

Substance abuse among international travellers is an underestimated problem that requires intervention. These findings emphasize the importance of addressing this issue to mitigate both health and well-being problems among travellers whilst promoting safer and more responsible travel experiences. In the context of travel health practices, practitioners should counsel travellers whose itineraries may include substance abuse, informing them about associated risks and consequences.

A systematic review and meta-analysis of sexually transmitted infections and blood-borne viruses in travellers

BACKGROUND

Sexually transmitted infections (STIs) and blood-borne viruses (BBVs) impose a global health and economic burden. International travellers facilitate the spread of infectious diseases, including STIs. Hence, this review assessed the prevalence/proportionate morbidity of travellers with STIs and sexually transmitted BBVs and factors associated with the infection in this population.

METHODS

PubMed, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and Cochrane Library were searched from inception of the databases until November 2022. Published analytical observational studies reporting the prevalence/proportionate morbidity of travellers with STIs and factors associated with STIs by type of traveller [i.e. tourists, business travellers, students, visiting friends or relatives (VFRs), international truck drivers, backpackers, expatriates and men who have sex with men (MSM)] were included. The selection of articles, data extraction and risk of bias assessment were conducted by two independent reviewers. Meta-analyses were conducted for each STI by clinical presentation and type of traveller.

RESULTS

Thirty-two studies (n = 387 731 travellers) were included; 19 evaluated the proportionate morbidity of STIs among symptomatic travellers, while 13 examined the prevalence of STIs in asymptomatic travellers. The highest proportionate morbidity was found among VFRs (syphilis, 1.67%; 95% CI: 1.03-2.81%), backpackers (Chlamydia trachomatis, 6.58%; 95% CI: 5.96-7.25%) and MSM (HIV [2.50%;95% CI: 0.44-12.88%], gonorrhoea [4.17%; 95% CI: 1.1.5-13.98%], lymphogranuloma venereum [4.17%;95% CI: 1.1.5-13.98%] and HAV [20.0%; 95% CI: 14.99-26.17%]). The highest prevalence of STIs among asymptomatic were found in MSM (HIV [25.94%; 95% CI: 22.21-30.05%] and HBV [24.90%; 95% CI: 21.23-28.96%]) and backpackers (C. trachomatis, 3.92%; 95% CI: 2.72-5.32%). Short duration of the trip (<1 month), not having pre-travel consultation, travelling to Southeast Asia and being unvaccinated for HBV were identified as risk factors for STIs.

CONCLUSION

Strategies to prevent STIs and sexually transmitted BBVs should be discussed at pre-travel consultations, and recommendations should be prioritized in high-risk groups of travellers, such as backpackers, VFRs and MSMs. Additionally, healthcare providers should tailor recommendations for safe sex practices to individual travellers' unique needs.

Minimum inhibitory concentrations of Neisseria gonorrhoeae strains in clients of the Amsterdam sexual health clinic with a Dutch versus an international sexual network

OBJECTIVES

International travel combined with sex may contribute to dissemination of antimicrobial-resistant (AMR) Neisseria gonorrhoeae (Ng). To assess the role of travel in Ng strain susceptibility, we compared minimum inhibitory concentrations (MICs) for five antibiotics (ie, azithromycin, ceftriaxone, cefotaxime, cefixime and ciprofloxacin) in strains from clients with an exclusively Dutch sexual network and clients with an additional international sexual network.

METHODS

From 2013 to 2019, we recorded recent residence of sexual partners of clients (and of their partners) with Ng at the Center for Sexual Health of Amsterdam. We categorised clients as having: (1) exclusively sexual partners residing in the Netherlands ('Dutch only') or (2) at least one partner residing outside the Netherlands. We categorised the country of residence of sexual partners by World Bank/EuroVoc regions. We analysed the difference of log-transformed MIC of Ng strains between categories using linear or hurdle regression for each antibiotic.

RESULTS

We included 3367 gay and bisexual men who had sex with men (GBMSM), 516 women and 525 men who exclusively had sex with women (MSW) with Ng. Compared with GBMSM with a 'Dutch only' network, GBMSM with: (1) a Western European network had higher MICs for ceftriaxone (β=0.19, 95% CI=0.08 to 0.29), cefotaxime (β=0.19, 95% CI=0.08 to 0.31) and cefixime (β=0.06, 95% CI=0.001 to 0.11); (2) a Southern European network had a higher MIC for cefixime (β=0.10, 95% CI=0.02 to 0.17); and (3) a sub-Saharan African network had a lower MIC for ciprofloxacin (β=-1.79, 95% CI=-2.84 to -0.74). In women and MSW, higher MICs were found for ceftriaxone in clients with a Latin American and Caribbean network (β=0.26, 95% CI=0.02 to 0.51).

CONCLUSIONS

For three cephalosporin antibiotics, we found Ng strains with slightly higher MICs in clients with partner(s) from Europe or Latin America and the Caribbean. International travel might contribute to the spread of Ng with lower susceptibility. More understanding of the emergence of AMR Ng is needed.

Analysing the impact of migration on HIV/AIDS cases using epidemiological modelling to guide policy makers

In this paper, we present the impact of migration on the spread of HIV and AIDS cases. A simple model for HIV and AIDS that incorporates migration and addresses its contributions to the spread of HIV and AIDS cases was constructed. The model was calibrated to HIV and AIDS incidence data from Malaysia. We explore the use of Markov chain Monte Carlo (MCMC) simulation method to estimate uncertainty in all the unknown parameters incorporated in our proposed model. Among the migrant population, 1.5572e-01 were susceptible to HIV transmission, which constituted 67,801 migrants. A proportion of migrants, 6.3773e-04, were estimated to be HIV infected, constituting 278 migrants. There were 72 (per 10,000) migrants estimated to have had AIDS, representing a proportion of 1.6611e-08. The result suggests that the disease-free steady state was unstable since the estimated basic reproduction number R0 was 2.0906 and 2.3322 for the models without and with migration, respectively. This is not a good indicator from the public health point of view, as the aim is to stabilize the epidemic at the disease-free equilibrium. The advantage of introduction of migration to the simple model validated the true R0 and the transmission rate β associated with HIV and AIDS epidemic disease in Malaysia. It also indicates an approximately 12 percentage points increase in the rate of HIV infection with migration.

Investigation of the Proportion of Diagnosed People Living with HIV/AIDS among Foreign Residents in Japan

Foreign residents represent an increasing proportion of newly diagnosed human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) cases in Japan, though scant research has addressed this. This study aimed to estimate the diagnosed proportion of people living with HIV/AIDS (PLWHA) among foreign residents in Japan, covering 1990–2017 and stratifying by geographic region of the country of origin. A balance equation model was employed to statistically estimate the diagnosed proportion as a single parameter. This used published estimates of HIV incidence and prevalence, population size, visit duration, travel volume, as well as surveillance data on HIV/AIDS in Japan. The proportion varied widely by region: People from Western Europe, East Asia and the Pacific, Australia and New Zealand, and North America were underdiagnosed, while those from sub-Saharan Africa, South and South-East Asia, and Latin America were more frequently diagnosed. Overall, the diagnosed proportion of PLWHA among foreign residents in Japan has increased, but the latest estimate in 2017 was as low as 55.3%; lower than the estimate among Japanese on the order of 80% and far below the quoted goal of 90%. This finding indicates a critical need to investigate the underlying mechanisms, including disparate access to HIV testing.

Clinicoepidemiological characteristics of viral hepatitis in migrants and travellers of the +Redivi network

BACKGROUND

Continuous growth of mobile populations has influenced the global epidemiology of infectious diseases, including chronic and acute viral hepatitis.

METHOD

A prospective observational multicentre study was performed in a Spanish network of imported infections. Viral hepatitis cases from January 2009 to September 2017 were included.

RESULTS

Of 14,546 records, 723 (4.97%) had imported viral hepatitis, including 48 (6.64%) acute cases and 675 (93.36%) chronic cases. Of the 48 acute cases, 31 were travellers and immigrants returning from visiting friends or relatives (VFR), while 19 (61%) were acute Hepatitis A or Hepatitis B. Only 18.2% of VFR immigrants and 35% of travellers received pre-travel advice. Acute hepatitis was more frequent in VFR immigrants (AOR 2.59, CI95% 1.20-5.60) and travellers (AOR 2.83, CI95% 1.46-5.50) than immigrants. Of the 675 Chronic cases, 570 were immigrants, and 439 (77%) had chronic Hepatitis B. Chronic hepatitis was more frequent in immigrants (AOR 20.22, CI95% 11.64-35.13) and VFR immigrants (AOR 11.12, CI95% 6.20-19.94) than travellers.

CONCLUSIONS

Chronic viral hepatitis was typical of immigrants, acute viral hepatitis was common among travellers, and VFR immigrants had mixed risk. Improving pre-travel consultation and screening of immigrants may contribute to preventing new cases of viral hepatitis and avoiding community transmission.

A research and evaluation capacity building model in Western Australia

Evaluation of public health programs, services and policies is increasingly required to demonstrate effectiveness. Funding constraints necessitate that existing programs, services and policies be evaluated and their findings disseminated. Evidence-informed practice and policy is also desirable to maximise investments in public health. Partnerships between public health researchers, service providers and policymakers can help address evaluation knowledge and skills gaps. The Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN) aims to build research and evaluation capacity in the sexual health and blood-borne virus sector in Western Australia (WA). Partners' perspectives of the SiREN model after 2 years were explored. Qualitative written responses from service providers, policymakers and researchers about the SiREN model were analysed thematically. Service providers reported that participation in SiREN prompted them to consider evaluation earlier in the planning process and increased their appreciation of the value of evaluation. Policymakers noted benefits of the model in generating local evidence and highlighting local issues of importance for consideration at a national level. Researchers identified challenges communicating the services available through SiREN and the time investment needed to develop effective collaborative partnerships. Stronger engagement between public health researchers, service providers and policymakers through collaborative partnerships has the potential to improve evidence generation and evidence translation. These outcomes require long-term funding and commitment from all partners to develop and maintain partnerships. Ongoing monitoring and evaluation can ensure the partnership remains responsive to the needs of key stakeholders. The findings are applicable to many sectors.

A meta-analysis and systematic literature review of factors associated with sexual risk-taking during international travel

BACKGROUND

International travel facilitates global spread of sexually transmitted infections (STI). Travellers could contribute to onward transmission of pathogens rarely encountered at home and export new strains to the destination. The aim was to systematically examine evidence regarding determinants of travel-related sexual risk-taking and identify knowledge gaps and areas for targeted interventions.

METHOD

Articles published in peer-reviewed journals from 2000 to 2017 were screened in 6 databases and assessed for relevance against criteria. Data was extracted for factors associated with travel-related STI or proxies. Meta-analyses estimated pooled prevalence of casual sex and non-condom use. Adjusted odds ratios of predictors were pooled to generate a combined estimate.

RESULT

Forty-nine articles qualified for inclusion. A heterogeneity test indicated variation across studies. The pooled prevalence of casual travel sex was 35% and prevalence of non-condom use 17%. Expectations of casual sex strongly predicted sex with a new partner when travelling abroad. Planning to have sex indicated condom use.

CONCLUSION

The studies largely represented sub-groups of risk-taking populations from a European context, indicating substantial knowledge gaps. Studies investigating migrants travelling to visit friends and relatives, older travellers, and female travelers are needed. Post-travel harm reduction activities may serve as a focus for future interventions.

Sex tourism among Chinese men who have sex with men: a cross-sectional observational study

BACKGROUND

Sex tourism among men who have sex with men (MSM) may exacerbate transmission of HIV and other sexually transmitted infections (STIs). Sex tourism is defined as purchasing sex with gifts or money outside of one's hometown. Our objective was to characterize the frequency, socio-demographic characteristics, and sexual risk behaviors among Chinese MSM sex tourists.

METHODS

An online, cross-sectional survey for high-risk MSM throughout China was conducted in November 2015 covering sociodemographic characteristics, sexual risk behaviors, and sex tourism. Univariate and multivariable logistic regressions were performed to identify correlates of sex tourism. The mean MSM HIV prevalence of sex tourism journey origins and destinations were compared.

RESULTS

Of 1189 MSM who completed the survey, 62 (5%) men identified as sex tourists; among these sex tourists, twenty (32%) traveled primarily to purchase sex and the remainder purchased sex while traveling for another purpose. There was minimal socio-demographic and behavioral difference between the two groups. In multivariable analyses, adjusting for age and income, sex tourism was correlated with high-risk sexual behaviors, higher income (aOR 4.44, 95%CI 1.77-11.18) and living with HIV (aOR 2.79, 95%CI 1.03-7.55). Sex tourism was more often from locations with lower to higher MSM HIV prevalence (mean = 4.47, SD = 2.01 versus mean = 6.86, SD = 5.24).

CONCLUSION

MSM sex tourists were more likely to have risky sexual behaviors and travel to locations with a higher HIV prevalence. MSM sex tourists may be part of core groups that are disproportionately responsible for MSM HIV transmission. Enhanced surveillance and interventions tailored to MSM sex tourists should be considered.

Global travel and HIV/STI epidemics among MSM: what does the future hold?

Infectious disease epidemics occur within dynamic systems and environments that shape risk and, ultimately, the spread of infectious diseases. Gay men and other men who have sex with men (MSM) are disproportionately impacted by HIV everywhere in the world. Several emerging trends present risks for sustained or increased HIV acquisition and transmission, and the growth of global travel in the context of emerging online platforms for social/sexual networking is discussed here. Four factors associated with travel that could potentiate HIV transmission are highlighted: different patterns of sexual risk behaviours during travel; the growth of online tools to meet sex partners more efficiently; the global heterogeneity of HIV strains; and the potential for diassortative mixing of men from high- and low-HIV prevalence areas. Prevention tools and services must rise to these challenges, and innovative mobile applications and programs have played, and will continue to play, an important role in supporting MSM at risk for or living with HIV during their periods of travel.

HIV, Other Blood-Borne Viruses and Sexually Transmitted Infections amongst Expatriates and Travellers to Low- and Middle-Income Countries: A Systematic Review

In some high-income countries, a proportion of human immunodeficiency virus (HIV), other blood-borne virus (BBV) or sexually transmitted infection (STI) diagnoses have been reported as acquired overseas in low- and middle-income countries. A review was conducted to explore HIV, other BBV or STI related knowledge, risk behavior and acquisition amongst expatriates and travelers, particularly males, travelling from high to low- and middle-income countries. Seven academic databases were searched for 26 peer reviewed articles that met inclusion criteria. Significant variability in the studies was noted, in age, travel duration and frequency and outcomes/risk factors measured and reported on. Risk factors described included longer duration of stay; being single; travel for romance or sex; alcohol and other drug use; lack of travel advice; being male; higher number of sexual partners; and inconsistent condom use. Vaccination, pre-travel health advice, and having fewer sexual partners were described as protective. Studies are needed focusing on the social context in which risk-taking occurs. Better collaboration is essential to deliver comprehensive health promotion interventions alongside more consistent pre- and post- travel testing and advice. Policy measures are crucial, including consistent evaluation indicators to assess impacts of HIV, other BBVs or STIs in the context of mobility. Risks and responses for these epidemics are shared globally.

Do travel clinic visitors read information on sexual risk abroad in travel health brochures?

BACKGROUND

A substantial proportion of travel clinic visitors have sexual encounters while abroad. Hence, guidelines on travel health recommend discussing sexual risk in a pre-travel consultation. However, previous studies showed that it often is not discussed. Although travel clinic visitors usually do receive written information on sexual risk abroad, few data are available on whether this information is read. Therefore, this prospective cohort study in travel clinic visitors was performed.

METHODS

Travel clinic visitors were invited to complete a questionnaire after return from their journey.

RESULTS

A total of 130 travellers (55%) responded. Half of them recorded they read the information on sexual risk. Male gender (OR 9.94 95% CI 3.12 - 31.63) and 'travelling with others' (OR 2.7 95% CI 1.29 - 5.78) were significant independent predictors of reading the information on sexual risk. High risk travellers, i.e. those travelling without a steady partner, were less likely to have read it. Although websites and apps were mentioned as better methods of providing information, none of the participants visited the websites on sexual behaviour and sexually transmitted infections recommended in the travel health brochure.

CONCLUSION

Only half of travel clinic visitors read information on sexual risk in the health brochure received in the clinic and none of them visited the related websites mentioned in the brochure. Further research to identify the most effective way to inform travellers about sexual risk is needed.

Health and sexual behaviour among exchange students

AIM

The objective was to describe the exchange students' health and sexual behaviour associated with their exchange studies, and examine the extent to which they had received preventive efforts against human immunodeficiency virus (HIV)/sexually transmitted infection (STI) and safer sex before departure.

METHODS

A cross-sectional study was conducted based on a web survey with questions about sexual behaviour, self-esteem and psychological well-being. Data were analysed using descriptive and analytical statistics.

RESULTS

A total of 136 outgoing exchange students from a Swedish University participated. Most of the exchange students rated their health as good, had psychological well-being and rated their self-esteem as being high. Approximately half of the exchange students had sex with a new partner during the exchange semester, and 87% of them had sexually risky behaviour. More than half (61%) of the exchange students had received preventive efforts before departure. No statistically significant difference regarding preventive information was found between those who reported sexually risky behaviour and those who did not. The group that had sexually risky behaviour desired free condoms and access to clinics for sexual health.

CONCLUSIONS

Exchange students rated their health as good, and the majority of them participated in information sessions that addressed preventive efforts on HIV/STI and safer sex before departure. Sexually risky behaviour during exchange studies was reported and highlights the need for more effective preventive measures; for example, a recollection of reading STI information.

Forming new sex partnerships while overseas: findings from the third British National Survey of Sexual Attitudes & Lifestyles (Natsal-3)

OBJECTIVES

Travelling away from home presents opportunities for new sexual partnerships, which may be associated with sexually transmitted infection (STI) risk. We examined the prevalence of, and factors associated with, reporting new sexual partner(s) while overseas, and whether this differed by partners' region of residence.

METHODS

We analysed data from 12 530 men and women aged 16-74 years reporting ≥1 sexual partner(s) in the past 5 years in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability survey undertaken 2010-2012.

RESULTS

9.2% (95% CI 8.3% to 10.1%) of men and 5.3% (4.8% to 5.8%) of women reported new sexual partner(s) while overseas in the past 5 years. This was strongly associated with higher partner numbers and other sexual and health risk behaviours. Among those with new partners while overseas, 72% of men and 58% of women reported partner(s) who were not UK residents. Compared with those having only UK partners while abroad, these people were more likely to identify as 'White Other' or 'Non-White' (vs White British ethnicity), report higher partner numbers, new partners from outside the UK while in the UK and paying for sex (men only) all in the past 5 years. There was no difference in reporting STI diagnosis/es during this time period.

CONCLUSIONS

Reporting new partners while overseas was associated with a range of sexual risk behaviours. Advice on sexual health should be included as part of holistic health advice for all travellers, regardless of age, destination or reason for travel.

Restricted access to antiretroviral treatment for undocumented migrants: a bottle neck to control the HIV epidemic in the EU/EEA

Background

In the European Union/European Economic Area (EU/EEA), migrants from high-endemic countries are disproportionately affected by HIV. Between 2007 and 2012, migrants represented 39 % of reported HIV cases. There is growing evidence that a significant proportion of HIV acquisition among migrant populations occurs after their arrival in Europe.

Discussion

Migrants are confronted with multiple risk factors that shape patterns of population HIV susceptibility and vulnerability, which simultaneously affect HIV transmission. Undocumented migrants incur additional risks for contracting HIV due to limited access to adequate health care services, protection and justice, alongside insecure housing and employment conditions.

All EU/EEA countries have ratified a number of international and regional human rights instruments that enshrine access to health care as a human right that should be available to everyone without discrimination.

From a clinical and public health perspective, early HIV care and treatment is associated with viral suppression, improved health outcomes and reductions in transmission risks. A current challenge of the HIV epidemic is to reach the highest proportion of overall viral suppression among people living with HIV in order to impact on HIV transmission.

Although the majority of EU/EEA countries regard migrants as an important sub-population for their national responses to HIV, and despite the overwhelming evidence of the individual and public health benefits associated with HIV care and treatment, a significant number of EU/EEA countries do not provide antiretroviral treatment to undocumented migrants.

Summary

HIV transmission dynamics in migrant populations depend on the respective weight of all risk and vulnerability factors to which they are exposed, which act together in a synergistic way. People who are not linked to HIV care will continue to unwillingly contribute to the on-going transmission of HIV. Following the recommendations of the European Union Agency for Fundamental Rights, ensuring access to HIV-care for all sub-populations, including undocumented migrants, would fulfil the human rights of those populations and also strengthen the control of HIV incidence among those not currently able to access HIV care.

Experiences of and attitudes towards HIV/STI prevention among holidaymaking men who have sex with men living in Sweden: a cross-sectional Internet survey

AIM

Foreign travellers and men who have sex with men (MSM) are prioritised groups for human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention efforts in Sweden because of high prevalence of sexual risk-taking. This study aims to describe experiences of and attitudes towards HIV/STI prevention efforts, prior to travelling abroad, among MSM, and to investigate the kinds of prevention efforts that are desirable.

METHODS

The study is based on survey responses from 656 MSM who had travelled abroad. Recruitment took place through a Nordic website, and had a cross-sectional design. The analysis has mainly been descriptive, but bivariate analyses were performed using the chi-square test. The level of significance was p <.05.

RESULTS

Only a few of the participants had encountered HIV/STI prevention efforts in Sweden (5%) and abroad (23%), and a majority (58%) felt that it should be more prevalent. Having free access to condoms and lubricants was preferred among 68% of the men. Furthermore, having written information, as opposed to oral, was also preferred (68% vs. 26%). MSM felt that it was easy to find out information (79%) and claimed they would use the Internet to do so (87%).

CONCLUSIONS

Service providers who offer their services to travellers are encouraged to provide helpful links to information about sexual health. Information that is geared towards risk groups such as young adults should be presented with awareness that MSM are also part of that group. It is important for information to be conveyed respectfully to everyone, but perhaps MSM in particular, since they may have experienced feelings of being stigmatised or discriminated against previously.

The potential role of circuit parties in the spread of HIV among men who have sex with men in Asia: a call for targeted prevention

We postulated that the growing popularity of circuit parties may play a role in the escalating HIV prevalence among men who have sex with men (MSM) in Asia. The present study is the first to characterize the sociodemographic and HIV-related behavioral factors of circuit party attendees living in Asia. We analyzed a subset of data from the Asia Internet MSM Sex Survey conducted from January 1 to February 28, 2010. Inclusion criteria included: being biologically male, aged 18 years or above, self-reported sex with another man, and reported international travel in the past 6 months (N = 6,094). From our multivariable logistic regression model, participants' resident country with low HIV prevalence (among MSM) (AOR 1.59, 95 % CI 1.27-2.00) and country of destination with high HIV prevalence were independently associated with higher odds of circuit party attendance (AOR 1.32, 95 % CI 1.14-1.53) during international travel. Statistical interaction indicated circuit party attendees were likely to have traveled from low HIV prevalence (among MSM) countries to high HIV prevalence countries (AOR 1.40, 95 % CI 1.20-1.64). Other independent correlates included unprotected anal sex with a male casual sex partner and recreational drug use during travel. HIV and STI prevention focusing on circuit party attendees may have a pivotal role on the spread of the HIV epidemics among MSM in Asia.

Sexually transmitted infections in men who have sex with men

Homosexuality is a global human phenomenon. Although the American Psychiatric Association removed homosexuality from its list of disorders more than 35years ago, homophobia among physicians is still widely prevalent. Men who have sex with men (MSM) form a relatively new epidemiological risk group for STI. To perform correct management, clinicians evaluating men with male-male sex contacts for STI related complaints or STI screening must obtain a thorough sexual history. Emerging STI like lymphogranuloma venereum, hepatitis C, and multidrug resistant N. gonorrhea strains have been described first in MSM. STI related proctitis often occur in MSM. Within the MSM population, HIV positive patients form a special group affected by STI related diseases, such as anal carcinoma and neurosyphilis. The final part of this review concludes with recommendations to reduce the STI burden in MSM.

Perceptions of HIV/STI prevention among young adults in Sweden who travel abroad: a qualitative study with focus group and individual interviews

BACKGROUND

Young adults are at risk for HIV/STIs because they generally have an active sex life with multiple sexual partners; moreover, they use condoms to a lesser extent. Travelling increases sexually risky behaviour, and among both women and men, sexual contacts abroad are common. Better knowledge of how young adults experience prevention efforts prior to travelling, and what they prefer, is important when planning prevention efforts to this group. Experiences of and attitudes towards prevention efforts against HIV/STI among young adults in Sweden who have travelled abroad were investigated.

METHOD

We conducted 12 focus-group interviews and four individual interviews with young adults (20-29 years) who had travelled abroad within the last 12 months. The interviews were recorded, transcribed verbatim, and analysed using thematic content analysis. Results were discussed from a salutogenic perspective.

RESULTS

Only a few had any experience of prevention efforts against HIV/STIs. The majority welcomed the idea of prevention efforts prior to travelling and would have welcomed more, preferably short reminders or links to reliable websites, or someone professional to discuss the issue with. Most of the young adults would use the Internet to search for information. They proposed the possibility of reaching young adults through social media, and the importance of better basic knowledge in school.

CONCLUSION

It is difficult to reach young adults before their trips abroad. Prevention efforts on HIV/STI must therefore focus on the use of established forums. Setting the foundation for a positive attitude towards condom use is needed during school years. Even social media, where there is the possibility for dialogue, should be used as an information source.

The effect of pre-travel advice on sexual risk behavior abroad: a systematic review

BACKGROUND

Travelers often have casual sex abroad and the risk of acquiring a sexually transmitted infection (STI) associated with casual travel sex is considered to be threefold higher compared to the risk of casual sex in the home country. Consequently, international guidelines recommend including STI advice in the pre-travel consultation. We performed a systematic review on the effect of a pre-travel STI intervention on sexual risk behavior abroad.

METHODS

In September 2012, a systematic analysis and meta-analysis of peer reviewed literature were performed on the relation between pre-travel STI advice for travelers and sexual risk behavior abroad. Primary outcome measure consisted of the number of travelers with a new sexual partner abroad; secondary outcome measure entailed the proportion of consistent condom use.

RESULTS

Six studies were identified for inclusion in the review, of which three clinical trials on the effect of a motivational intervention compared to standard pre-travel STI advice qualified for the meta-analysis. Two of these trials were performed in US marines deployed abroad and one in visitors of a travel clinic. The extensive motivational training program of the marines led to a reduction in sexual risk behavior, while the brief motivational intervention in the travel clinic was not superior to standard advice. The meta-analysis established no overall effect on risk behavior abroad. No clinical trials on the effect of a standard pre-travel STI discussion were found, but a cohort study reported that no relation was found between the recall of a nonstructured pre-travel STI discussion and sexual risk behavior, while the recall of reading the STI information appeared to be related to more consistent condom use.

CONCLUSIONS

Motivational pre-travel STI intervention was not found to be superior to standard STI advice, while no clinical trials on the effect of standard pre-travel STI advice were found.

Sexual risk taking in a community sample of international backpackers visiting Brisbane, Australia

We sought to examine correlations between international backpackers' alcohol consumption and sexual behaviors and determine the prevalence of Chlamydia trachomatis and Neisseria gonorrhoea in this population. A cross-sectional study design consisting of a convenience sample (N = 168) of non-treatment-seeking international backpackers visiting Brisbane, Australia was recruited. Participants were asked to self-complete a questionnaire on sexual behavior and to undertake a urine-based polymerase chain reaction test for C trachomatis and N gonorrhoea. Since arriving in Australia, 73.2% reported having had sex, with a median number of 2 different sex partners (range = 0-21). Most participants had consumed alcohol (53.7%) and used condoms (46.3%) the last time they had sex. In our sample, there was a 4.3% prevalence of C trachomatis and a 0% prevalence of N gonorrhoea. This study identified a variable pattern of risk among backpackers, with those spending longer periods in the country more likely to have sex with Australians.

International travel among HIV-positive and HIV-negative men who have sex with men, San Francisco, USA

We measured the prevalence of international travel, the demographic and risk profile of international travellers and risk and preventive behaviours of travellers among HIV-negative and HIV-positive men who have sex with men (MSM), based in San Francisco, CA, USA, through the addition of questions to the local implementation of the National HIV Behavioral Surveillance survey in 2008. Of 270 MSM participating in the survey, slightly more than one-quarter (26.3%) had travelled internationally in the last year. Those with a history of international travel were more likely to be foreign born, of a higher socioeconomic status and HIV uninfected. Of eight HIV-positive MSM who travelled internationally (11.3% of HIV-positive MSM), all were on antiretroviral therapy and only three recalled being vaccinated for hepatitis A and B. Human papillomavirus infection was also higher among international travellers. Travel health services must be improved to address special needs of this population of international travellers.

Safe travels? HIV transmission among Britons travelling abroad

OBJECTIVES

The aim of the study was to identify and describe the characteristics of persons born in the UK who acquire HIV infection abroad.

METHODS

Analyses using case reports and follow-up data from the national HIV database held at the Health Protection Agency were performed.

RESULTS

Fifteen per cent (2066 of 13 891) of UK-born adults diagnosed in England, Wales and Northern Ireland between 2002 and 2010 acquired HIV infection abroad. Thailand (534), the USA (117) and South Africa (108) were the countries most commonly reported. As compared with UK-born adults acquiring HIV infection in the UK, those acquiring HIV infection abroad were significantly (P < 0.01) more likely to have acquired it heterosexually (70% vs. 22%, respectively), to be of older age at diagnosis (median 42 years vs. 36 years, respectively), and to have reported sex with a commercial sex worker (5.6% vs. 1%, respectively). Among men infected in Thailand, 11% reported sex with a commercial sex worker.

CONCLUSIONS

A substantial number of UK-born adults are acquiring HIV infection in countries with generalized HIV epidemics, and in common holiday destinations. Of particular concern is the high proportion of men infected reporting sex with a commercial sex worker. We recommend HIV prevention and testing efforts be extended to include travellers abroad, and that sexual health advice be provided routinely in travel health consultations and in occupational health travel advice packs, particularly to those travelling to high HIV prevalence areas and destinations for sex tourism. Safer sex messages should include an awareness of the potential detrimental health and social impacts of the sex industry.

Motivational brief intervention for the prevention of sexually transmitted infections in travelers: a randomized controlled trial

Background

Sexually transmitted infections (STIs) are among the frequent risks encountered by travelers. Efficient interventions are needed to improve the understanding of the risks of STIs. We investigated the potential benefits of a motivational brief intervention (BI) and the provision of condoms on the engagement in unprotected casual sex.

Methods

3-arm randomized controlled trial performed among single travelers aged 18-44 years visiting a travel clinic in Switzerland. The main outcomes were the prevalence of casual unprotected sexual intercourse and their predictors.

Results

5148 eligible travelers were seen from 2006 to 2008. 1681 agreed to participate and 1115 subjects (66%) completed the study. 184/1115 (17%) had a casual sexual relationship abroad and overall 46/1115 (4.1%) had inconsistently protected sexual relations. Women (adjusted OR 2.7 [95%CI 1.4-5.6]) and travelers with a history of past STI (adjusted OR 2.8 [95%CI 1.1-7.4]) had more frequent casual sexual relationships without consistent protection. Regarding the effect of our intervention, the prevalence of subjects using condoms inconsistently was 28% (95%CI16-40) in the motivational BI group, 24% (95%CI10-37) in the condoms group and 24% (95%CI14-33) in the control group (p = 0.7).

Conclusion

This study showed that a motivational brief intervention and/or the provision of free condoms did not modify risky sexual behavior of young travelers. The rate of inconsistently protected sexual relationships during travel was however lower than expected

Trial Registration Number

ClinicalTrials.gov: NCT01056536

Travel-related cerebro-meningeal infections: the 8-year experience of a French infectious diseases unit

BACKGROUND

The etiological spectrum of cerebro-meningeal infections (CMI) in travelers has never been specifically analyzed.

OBJECTIVES

To assess the etiologies of CMI in hospitalized travelers and to propose a diagnostic approach to travel-related CMI.

METHODS

During an 8-year period, we retrospectively collected data on all travelers hospitalized in our department for a CMI occurring during travel or in the month after their return.

RESULTS

Fifty-six patients (35 men and 21 women; mean age 29 years (16-83); 44.6% tourists, 26.8% military, 16% immigrants, 12.5% expatriates) were included. The main destinations were Africa (57.2%), Europe (19.5%), and Asia (12.5%). The median duration of travel was 24 days (5-550). Symptoms occurred during travel in 20 patients (11 of which required a medical evacuation). In the remaining 36 patients, the median duration between return and clinical onset was 10 days. The median time from clinical onset to hospitalization was 4 days (0.5-96). Twenty-four patients presented with a meningeal syndrome and 20 others with encephalitic features. The remaining 12 patients had an incomplete clinical presentation (headaches or fever). The etiology was confirmed in 42 cases (75%) of which tropical diseases (n = 14) were less common than cosmopolitan ones (n = 28). Sub-Saharan Plasmodium falciparum malaria (n = 12) was the leading tropical infection, whereas viral infections (enterovirus, herpesviridae, HIV) were the main cosmopolitan etiologies. Only four bacterial infections were reported (Neisseria meningitidis, Mycoplasma pneumoniae, Brucella melitensis, Salmonella typhi). Sixteen patients were admitted to intensive care for a median time of 9.5 days (1-63). The average duration of hospitalization was 14 days (3-63). One death by herpes simplex virus 1 encephalitis was recorded. Four patients (7%) had neurological sequelae.

CONCLUSIONS

Among the diversified etiological spectrum of CMI, cosmopolitan infections are widely predominant, particularly viral infections, followed by tropical causes, of which malaria is the leading disease in returnees from endemic areas. The diagnostic approach should be driven by history and physical examination. Key investigations include: blood smear, cerebrospinal fluid polymerase chain reaction and culture as well as neuroimaging. Management should focus on curable causes.

[Sexual exposure to HIV in the French armed forces between 2005 and 2007]

BACKGROUND

Non-occupational HIV exposure in the French forces has been placed under epidemiological surveillance since 2000. This surveillance programme provides an indirect indicator of risky sexual behaviour among military personnel.

PATIENTS AND METHODS

All cases of non-occupational exposures in French military personnel that meet the notification criteria, wherever they occur, are reported by a military physician, with data being collected from 2005 to 2007.

RESULTS

Between January 2005 and December 2007, 2241 cases of sexual exposure within the French forces were filed. The annual incidence was 214.3 per 100,000 with an average patient age of 26 years. Sexual exposures concerned men in 99.2% of cases and occurred overseas in 92.9% of cases. Partners were sex-workers in 66.7% of cases. Failure to use condoms adequately during sexual intercourse was reported in 15.5% of cases. In cases where condoms were used, exposure to HIV resulted either from condom rupture or slippage. Postexposure HIV prophylaxis was prescribed in 70.5% of cases.

DISCUSSION

The majority of cases of sexual exposure reported in the French armed forces involved high risk of HIV transmission. However, since the beginning of surveillance in 2000, no cases of HIV seroconversion have been reported following postexposure antiretroviral prophylaxis. The non-occupational postexposure prophylaxis strategy is not in question.

Army women's evaluations of a self-administered intervention to prevent sexually transmitted diseases during travel

BACKGROUND

Military personnel experience seven times the sexually transmitted infections of civilians. Military women are especially vulnerable. No self-administered interventions to promote safer sexual behaviors are available for use by military personnel while on duty in austere locations. The purpose of this study was to ascertain Army women's evaluations of a new theory-based, self-administered, and portable intervention designed to promote safer sexual practices during duty abroad.

METHOD

Two focus groups were conducted at a large military installation in the Pacific Northwest. Army women (N=20) ages 18-49 years participated in the groups. Women first examined the intervention and then their reactions to the intervention were elicited with open-ended questions. The qualitative data then were content analyzed.

RESULTS

All participants would either recommend or personally use the intervention. Positive features of the intervention included the type of information, a user-friendly and self-explanatory format, and that it was an aid to decision making about safer sex. Concerns included a tendency toward too much information and fears of non-acceptance by peers or sexual partners.

CONCLUSION

Minor changes have been made based upon these results. The intervention will be reviewed again and proceed to clinical trials with female military personnel and other travelers.

An increase in overseas acquired HIV infections among heterosexual people in Western Australia

Background: There has been a recent increase in the number of heterosexually acquired HIV infections among non-Aboriginal people in Western Australia (WA), which has not been reported in other Australian jurisdictions. This report describes the epidemiological features of this increase. Methods: A descriptive analysis was conducted of newly diagnosed HIV infections among non-Aboriginal WA residents notified to the Department of Health from 2002 to 2006. Analysis outcomes included demographics, exposure categories, and place of HIV acquisition. Results: From 2002 to 2006, 258 new HIV diagnoses were notified among non-Aboriginal WA residents. Over this period, the number of notifications increased from 41 cases in 2002 (2.2 cases/100 000 population) to 66 cases in 2006 (3.4 cases/100 000 population). Overall, 107 (42%) of the cases were heterosexually acquired, and the annual number increased threefold from 2002 to 2006 (12 to 36 cases, respectively). Of these cases, 64 (60%) were male and 43 (40%) were female. The majority (89%) of male cases acquired HIV overseas, mostly in countries other than their region of birth; South-east Asia was the most common place of acquisition reported. Over half (56%) of the female cases acquired HIV overseas, mainly in their region of birth (83%), and sub-Saharan Africa was the most common place of acquisition. Conclusion: There has been a recent increase in heterosexually acquired HIV infections among male and female WA residents, many of whom reported acquiring HIV overseas. Safe sex campaigns in WA should continue to reinforce safe sex messages among people travelling overseas.

Risk of hepatitis B for travelers: is vaccination for all travelers really necessary?

OBJECTIVES

Behavioral studies in travelers suggest that 33% to 76% of all travelers to hepatitis B virus (HBV)-endemic countries are at risk for HBV infection. We study the incidence and risk factors for HBV infection in travelers.

METHODS

Retrospective analysis of the characteristics and risk factors of all reported acute HBV patients in Amsterdam, the Netherlands, from January 1, 1992, until December 31, 2003.

RESULTS

The estimated incidence in travelers from Amsterdam to HBV-endemic countries is 4.5/100,000 travelers. Two thirds of these patients were immigrants who lived in Amsterdam and who had visited their friends and relatives in their country of origin. In 12 years, only three Dutch short-term tourists contracted HBV while traveling, all by heterosexual contacts.

CONCLUSIONS

Dutch tourists who travel to HBV-endemic countries run a very low risk of contracting HBV. Vaccination of short-term Dutch tourists is not necessary. Immigrants run a higher risk irrespective of travel or duration of travel. This group should be advised vaccination.

Frequent international travel by men who have sex with men recently diagnosed with HIV-1: potential for transmission of primary HIV-1 drug resistance

We assessed the potential for international transmission of primary drug resistance among men who have sex with men newly diagnosed with human immunodeficiency virus (HIV) (n = 64) during the period in which they were unaware of their infection. During their exposure period, 55% of participants lived or traveled outside of the United States, and 59% had foreign-born sexual partners. Eighteen participants (28%) were classified as recently infected with HIV. Primary HIV-1 drug resistance was detected in eight participants (13%), four of whom were recently infected. Given the high frequency of international travel and prevalence of primary HIV-1 drug resistance among study participants, prevention strategies should incorporate specific counseling on risk of cross-border transmission.

Preventing women's sexual risk behaviors during travel

Sexually transmitted infections (STIs) are a global concern. Although several countries have tracked the incidence of STIs acquired during travel to foreign countries, the United States lags behind in this practice. Nevertheless, there is evidence from the US and several countries that women engage in sexual risk behaviors during travel whether domestic or foreign, thereby placing themselves at risk for contracting STIs. Guidelines for assessment, prevention, and travel-related supplies and resources are discussed.

Sexual behaviour in young people

PURPOSE OF REVIEW

The purpose of this review was to synthesize major research findings in relation to young people and sexual behaviour from the period 2006-2007.

RECENT FINDINGS

We found several key reviews that advance knowledge in the field of young people and sexual behaviour, including observational studies, both qualitative and quantitative, and intervention studies designed to reduce sexual transmission of HIV in both developed and developing countries. Other reviews focused on same-sex behaviours, victimization within relationships, HIV infection/sexually transmitted infection in travellers, prevention of HIV/sexually transmitted infection and the determinants of sexual behaviour in young people.

SUMMARY

Powerful and consistent forces sustain gender differences in sexual behaviour. The design of interventions to reduce sexual risk behaviour should take account of these forces that help explain young people's sexual behaviour. Knowledge about the kind of interventions that reduce risk behaviour and should be implemented has improved, although the impact on health outcomes such as pregnancy and HIV/sexually transmitted infection is often uncertain. Effective school sex education needs to be part of much broader strategies to improve sexual health, and there is an urgent need for better evaluation of interventions, especially community interventions. Further longitudinal studies are needed to provide insight into the development of relationships and sexual behaviour as well as the course of acculturation.

Sex partner acquisition while overseas: results from a British national probability survey

BACKGROUND

Over the past 20 years, there has been a huge increase in the number of overseas trips made by UK residents. Although a number of studies have examined the frequency of overseas partner acquisition, they have used convenience samples and thus are not generalisable to the British general population.

METHODS

A national probability sample survey was carried out in 1999-2001 of 12,110 men and women aged 16-44 years resident in Britain. Sociodemographic, health-related, travel, sexual behaviour and attitudinal data were collected by computer-assisted interviewing. The main outcomes were the proportion of British residents who reported new sexual partners overseas in the past 5 years, the country of origin of these new sex partners, and the association between reporting a new partner while overseas with a range of demographic, behavioural and attitudinal variables.

RESULTS

13.9% of men and 7.1% of women reported having new sexual partner(s) while overseas in the past 5 years. Among respondents who were aged 16-24 and never married, the proportions were significantly higher (23.0% of men and 17.0% of women). Half of those with new sex partners overseas reported their partner's origin as the UK, and over a third as another European country. In addition to age and marital status, reporting new partners overseas was associated with a higher number of partners, paying for sex (among men), reporting a diagnosis of sexually transmitted infection, and HIV testing. Adjustment for sociodemographic factors attenuated the magnitude of, but did not remove, these associations.

CONCLUSIONS

A substantial minority of young, unmarried people form new sexual partnerships abroad, but these are typically with residents from the UK or other European countries. Those who have new partners abroad are likely to have higher-risk sexual lifestyles more generally, and to be at higher risk of sexually transmitted infections. Greater attention should be paid to sexual health promotion for travellers abroad, especially young travellers, emphasising the risks of new sexual relationships with compatriots as well as those from other countries in terms of STI/HIV acquisition and onwards transmission.