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

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.

The global burden of sexually transmitted infections

Understanding the global burden of sexually transmitted infections (STIs) is fundamental to being able to address and control these infections and the health harms they cause. The World Health Organization has renewed its global health sector strategy for the prevention and control of STIs. Reducing STIs remains an integral part of HIV prevention and of sexual and reproductive health programs. Data to measure and describe the global burden continue to improve, with systematic reviews and modeling providing global and regional data for the major STIs. Although substantial gaps remain, as many countries have limited data, the measures available demonstrate the scale of the problem for the main curable STIs, gonorrhea, chlamydia, syphilis, and trichomoniasis; the most common viral STIs, human papillomavirus and genital herpes; the interrelation between STIs and HIV; and the substantially unequal burden of these infections globally and among key populations. Regional and global trends in these infections are affected by population changes; the impact and availability of interventions, such as vaccination; changing behaviors that alter the dynamics of STI transmission; and the role of international travel in promulgating STIs in an increasingly interconnected world.

Resilience model for a destination support: Pattaya, Thailand

This research focuses on resilience and sustainable development in the tourism sector during the Covid-19 pandemic, using Pattaya - a renowned beach destination in Thailand - as the studied context. Since 2020, the pandemic has significantly impacted the tourism sector and its supply chain. The consequences include the stagnation of tourism and hospitality services and other economic activities due to lockdown measures and other restrictions. To investigate Pattaya's resilience in the face of these challenges, and post-pandemic recovery, this research adopted the conceptual framework on economic resilience and tourism recovery proposed by McCartney et al. (2021), as a theoretical lens to analyse events in Pattaya. The qualitative research method was employed, using in-depth interviews with public and private stakeholders, such as local authorities, large and small hotels, tourism business agencies and relevant organisations. The results show that the tourism industry, similarly to other sectors, was adversely affected by the Covid-19 pandemic, and the slow implementation of strategies proved inadequate in coping with the uncertainty. Local entrepreneurs require clearer and more supportive measures to reopen their businesses and resume economic activities.

Injuries and medical emergencies among international travellers

BACKGROUND

Tropical infectious diseases and vaccine-preventable emergencies are the mainstay of pre-travel consultations. However, non-communicable diseases, injuries and accidents that occur during travel are not emphasized enough in these settings.

METHODS

We performed a narrative review based on a literature search of PubMed, Google Scholar, UpToDate, DynaMed and LiSSa and on reference textbooks and medical journals dedicated to travel, emergency and wilderness medicine. Relevant secondary references were extracted. We also aimed to discuss newer or neglected issues, such as medical tourism, Coronavirus Disease 2019, exacerbations of co-morbidities associated with international travel, insurance coverage, health care seeking abroad, medical evacuation or repatriation and tips for different types of travellers' emergency medical kits (personal, group, physician handled).

RESULTS

All sources reviewed led to the selection of >170 references. Among epidemiological data on morbidity and deaths while abroad, only retrospective data are available. Deaths are estimated to occur in 1 in 100 000 travellers, with 40% caused by trauma and 60% by diseases, and <3% linked to infectious diseases. Trauma and other injuries acquired during travel, such as traffic accidents and drowning, can be reduced by up to 85% with simple preventive recommendations such as avoiding simultaneous alcohol intake. In-flight emergencies occur on 1 in 604 flights on average. Thrombosis risk is two to three times greater for travellers than for non-travellers. Fever during or after travel can occur in 2-4% of travellers, but in up to 25-30% in tertiary centres. Traveller's diarrhoea, although rarely severe, is the most common disease associated with travel. Autochthonous emergencies (acute appendicitis, ectopic pregnancy, dental abscess) can also occur.

CONCLUSIONS

Pre-travel medicine encounters must include the topic of injuries and medical emergencies, such as the risk-taking behaviours and foster better planning in a comprehensive approach along with vaccines and infectious diseases advices.

Associations of social media and health content use with sexual risk behaviours among adolescents in South Africa

Increasing rates of mobile phone access present potential new opportunities and risks for adolescents' sexual and reproductive health in resource-poor settings. We investigated associations between mobile phone access/use and sexual risks in a cohort of 10-24-year-olds in South Africa. 1563 adolescents (69% living with HIV) were interviewed in three waves between 2014 and 2018. We assessed mobile phone access and use to search for health content and social media. Self-reported sexual risks included: sex after substance use, unprotected sex, multiple sexual partnerships and inequitable sexual partnerships in the past 12 months. We examined associations between mobile phone access/use and sexual risks using covariate-adjusted mixed-effects logistic regression models. Mobile phone access alone was not associated with any sexual risks. Social media use alone (vs. no mobile phone access) was associated with a significantly increased probability of unprotected sex (adjusted average marginal effects [AMEs] + 4.7 percentage points [ppts], 95% CI 1.6-7.8). However, health content use (vs. no mobile phone access) was associated with significantly decreased probabilities of sex after substance use (AMEs -5.3 ppts, 95% CI -7.4 to -3.2) and unprotected sex (AMEs -7.5 ppts, 95% CI -10.6 to -4.4). Moreover, mobile phone access and health content use were associated with increased risks of multiple sexual partnerships in boys. Health content use was associated with increased risks of inequitable sexual partnerships in adolescents not living with HIV. Results suggest an urgent need for strategies to harness mobile phone use for protection from growing risks due to social media exposure.

Effect of COVID-19 pandemic restrictions on chlamydia and gonorrhoea notifications and testing in Queensland, Australia: an interrupted time series analysis

OBJECTIVE

To investigate trends in testing and notifications of chlamydia and gonorrhoea during the COVID-19 pandemic in Queensland, Australia.

METHODS

Statewide disease notification and testing data between 1 January 2015 and 31 December 2021 were modelled using interrupted time series. A segmented regression model estimated the pre-pandemic trend and observed effect of the COVID-19 pandemic response on weekly chlamydia notifications, monthly gonorrhoea notifications and monthly testing figures. The intervention time point was 29 March 2020, when key COVID-19 public health restrictions were introduced.

RESULTS

There were 158 064 chlamydia and 33 404 gonorrhoea notifications and 2 107 057 combined chlamydia and gonorrhoea tests across the 72-month study period. All three studied outcomes were increasing prior to the COVID-19 pandemic. Immediate declines were observed for all studied outcomes. Directly after COVID-19 restrictions were introduced, declines were observed for all chlamydia notifications (mean decrease 48.4 notifications/week, 95% CI -77.1 to -19.6), gonorrhoea notifications among males (mean decrease 39.1 notifications/month, 95% CI -73.9 to -4.3) and combined testing (mean decrease 4262 tests/month, 95% CI -6646 to -1877). The immediate decline was more pronounced among males for both conditions. By the end of the study period, only monthly gonorrhoea notifications showed a continuing decline (mean decrease 3.3 notifications/month, p<0.001).

CONCLUSION

There is a difference between the immediate and sustained impact of the COVID-19 pandemic on reported chlamydia and gonorrhoea notifications and testing in Queensland, Australia. This prompts considerations for disease surveillance and management in future pandemics. Possible explanations for our findings are an interruption or change to healthcare services during the pandemic, reduced or changed sexual practices or changed disease transmission patterns due to international travel restrictions. As pandemic priorities shift, STIs remain an important public health priority to be addressed.

Burden of Disease of Gonorrhoea in Latin America: Systematic Review and Meta-analysis

INTRODUCTION

Neisseria gonorrhoeae causes gonorrhoea, a globally neglected but increasing disease. This systematic review and meta-analysis reviewed the epidemiology and economic burden of gonorrhoea in Latin America and the Caribbean (LAC).

METHODS

We searched PubMed, EMBase, Cochrane Library, EconLIT, CINAHL, CRD, LILACS, Global Health, Global Dissertations and Theses, SciELO, Web of Science databases, countries' ministries of health, and the IHME's Global Burden of Disease databases. Studies published in the last 10 years (20 years for economic studies) were included if conducted in any LAC country, without language restrictions. The main outcome measures were incidence/prevalence, proportion of co-infections, case fatality rates, specific mortality/hospitalisation rates, direct/indirect costs, and impact of gonorrhoea on quality of life. To assess evidence quality, we used a checklist developed by the US National Heart, Lung, and Blood Institute for observational studies and trial control arms, the Cochrane Effective Practice Organization of Care Group tool for randomised controlled trials, and the CICERO checklist for economic studies.

RESULTS

We identified 1290 articles; 115 included epidemiological studies and one included an economic study. Ministry of health data from Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay were identified. Gonorrhoea prevalence was 1.46% (95% confidence interval [CI] 1.00-2.00%) from 48 studies and 5.68% (95% CI 4.23-7.32%) from 58 studies for non-high-risk and high-risk populations, respectively. Cumulative incidence for the high-risk population was 2.05 cases per 100 persons/year. Few published studies were rated as "good" in the risk of bias assessments. Variations in the methodology of the sources and limited information found in the countries' surveillance systems hinder the comparison of data.

CONCLUSION

The burden of gonorrhoea in LAC is not negligible. Our results provide public health and clinical decision support to assess potential interventions to prevent gonorrhoea.

TRIAL REGISTRATION

The protocol is registered on PROSPERO (CRD42021253342). The study was funded by GlaxoSmithKline Biologicals SA (GSK study identifier VEO-000025).

Syndromic Treatment of STIs in Low-income Countries is Inadequate: Current Threats and Future Directions

Sexually transmitted infections (STIs) pose a serious public health threat with more than 1 million curable infections diagnosed every day. While these infections are prevalent globally, the approach to evaluation and treatment varies greatly based on the capacity to make an accurate diagnosis. In low-resource settings, a syndromic approach is often used over an etiologic-based evaluation and management. Syndromic treatment of STIs recognizes groups of symptoms and recommends a multidrug empiric treatment that will cover the most likely causative organisms. By definition, syndromic treatment cannot be used as a screening tool, leaving a large portion of asymptomatic infections untreated. This will lead to the persistence of infection and associated sequelae including pelvic inflammatory disease and infertility. Syndromic treatment also leads to the overtreatment of many infections, which contributes to antimicrobial resistance. The rising threat of Neisseria gonorrhoeae resistance to last-line antibiotics is of global concern. Rapid, accurate, affordable, and easy-to-use point-of-care testing needs to be made readily available to all corners of the world to provide better care to patients and address the growing threat of multidrug resistant organisms. An urgent and collaborative global effort is needed to address the looming threat of a dangerous STI that is resistant to last-line antibiotics.

Sexual and reproductive health during international travel: Expectations and experiences among female university students

ObjectiveTo evaluate female students' expectations and experiences related to their sexual and reproductive health (SRH) during international travel. Participants: Female students from a US university with a history of sex with men completed a cross-sectional survey about their upcoming (Pre-travelers; n = 170) or recent (Travelers; n = 340) international travel. Methods: Descriptive statistics were used to characterize pre-travel SRH expectations (for Pre-travelers) and to determine the prevalence of 15 SRH experiences during both recent and lifetime travel (for Travelers). Results: Pre-travelers overwhelmingly expected to be abstinent and many were unsure of whether SRH supplies would be accessible in their destination. During Travelers' recent trip, SRH experiences included getting off schedule with contraception (30%), unwanted sexual touching (18%), new male sex partners (17%), and unexpected sex (15%); lifetime prevalence estimates were higher. Conclusions: International travel poses risks to female students' SRH that can be addressed by pre-travel counseling from study-abroad programs and clinicians.

HIV knowledge, sexual practices, condom use and its associated factors among international students in one province of China: a cross-sectional study

OBJECTIVE

China has seen an increasing number of international students in recent years, mostly from Africa and Asia. However, little is known about these students' HIV knowledge, sexual practices and potential HIV risk. This study aimed to describe HIV-related risk among international students.

DESIGN

An online cross-sectional survey.

SETTING

10 universities situated in one province of China.

PARTICIPANTS

617 international students filled out the questionnaire and 607 international students were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Socio-demographic and programme-related characteristics, HIV-related knowledge, sexual practices and other HIV/sexually transmitted infection-related variables. Logistic regression analyses were performed to examine factors associated with inconsistent condom use among international students.

RESULT

The results showed that in total, only 51.6% (313/607) of international students had adequate HIV-related knowledge, and 64.9% (394/607) reported not receiving any HIV related education or training while studying in China. Moreover, 32.3% (196/607) reported having penetrative sex including oral, vaginal and anal sex during the period in which they studied in China and among them. The proportions of inconsistent condom use in vaginal and oral intercourse while studying in China were 52.6% (50/95) and 79.5% (35/44), respectively, with casual partners, and 60% (80/129) and 91.2% (52/57) with regular partners, respectively. Female gender, being married and having multiple sexual partners were associated with inconsistent condom use.

CONCLUSION

The present study indicated that international students in one province of China have suboptimal HIV-related knowledge, significant unprotected sex, less HIV testing and less safe sex education, which highlights an urgent need to provide HIV education and related health services to international students in China.

International travels and transmission of multidrug resistant Neisseria gonorrhoeae in Europe: A systematic review

BACKGROUND

The increase of gonococcal infection cases in Europe and rises in Neisseria gonorrhoeae antibiotic resistance (AMR) have become an urgent concern globally. In the last few years international tourism has increased, which might contribute to the spread of different strains of multiresistant gonococcal infections. This study aimed at assessing the effect of international travel on the transmission of multidrug resistant N. gonorrhoeae in the European Union and associated European countries.

METHOD

We conducted a systematic review and searched PubMed, Scopus, Embase and CENTRAL between January 1, 2010 and June 30, 2021 for gonococcal infection, antibiotic resistance and international travel. Articles were screened in title, abstract and keywords. The quality of the articles was assessed using a pre-designed tool. Individual, travel related and susceptibility to antimicrobials data were collected.

RESULTS

A total of 18 studies met our criteria, of which 88.9% concluded that international travel directly influences the transmission of multidrug resistant N. gonorrhoeae from the country of travel to the country of return. Travelers mainly visited South East Asian countries (66.7%) and returned to the UK (38.9%). Half of the included studies reported ciprofloxacin resistant strains and the most frequently prescribed drug used for treatment was ceftriaxone.

CONCLUSIONS

International travels might be an important factor in the spread of multi-resistant sexually transmitted infections (STIs). There is a need to strengthen AMR surveillance in international travelers for prompt investigation and notification of drug resistance in STIs.

Sexual behaviors at home and abroad: an online survey of Canadian young adult travelers

BACKGROUND

For young adults, travel- an accessible and aspirational experience- may be accompanied by high-risk lifestyle behaviors abroad, which in turn, increases the risk of sexually transmitted and blood-borne infections (STBBI). This study aimed to examine sexual and risk behaviors of young Canadian adults both at-home and during international travel.

METHODS

Sexually-active Canadians, aged 18-25 years (N = 646) who travelled abroad in 2016, completed an online, cross-sectional survey analyzed by descriptive statistics. Outcome measures included young Canadian adults' lifestyle risk and sexual behaviors at-home and abroad.

RESULTS

Sexual behaviors, both penetrative and non-penetrative activities, decreased significantly (p < 0.001; McNemar test) abroad compared to at-home. International travel elicited a statistically significant increase in alcohol consumption compared to at-home (Wilcoxon, z = - 11.341, p < 0.001). Partner type (new trip-acquired partner) abroad was associated with a greater number of travel-acquired sexual partners (Mann-Whitney, U = 4901, p < 0.001), inconsistent condom use during penetrative sex (U = 7215, p = 0.009), and sex under the influence of alcohol (Test of Two Proportions, p < 0.001).

CONCLUSIONS

Although many young Canadian respondents practiced abstinence in their 2016 travel, for sexually-active travelers, new partner-type was related to high risk sexual behaviors. Young Canadians exhibited sexual risk behaviors both at-home and while travelling; suggesting the need for both domestic and pre-travel sexual health interventions.

Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: A cross-sectional study at a hospital-based family pre-travel clinic

BACKGROUND

Travellers' perception of their risk for acquiring travel-related conditions is an important contributor to decisions and behaviors during travel. In this study, we aimed to assess the differences between traveller-perceived and expert-assessed risk of travel-related conditions in children and adults travelling internationally and describe factors that influence travellers' perception of risk.

METHODS

Children and adults were recruited at the Hospital for Sick Children's Family Travel Clinic between October 2014 and July 2015. A questionnaire was administered to participants to assess their perceived risk of acquiring 32 travel-related conditions using a 7-point Likert scale. Conditions were categorized as vector-borne diseases, vaccine-preventable diseases, food and water borne diseases, sexually transmitted infections and other conditions. Two certified travel medicine experts reviewed each patient's chart and assigned a risk score based on the same 7-point Likert scale. Traveller and expert risk scores were compared using paired t-tests.

RESULTS

In total, 207 participants were enrolled to participate in this study, 97 children (self-reported, n = 8; parent-reported, n = 89), and 110 adults. Travel-related risk for adults and parents answering for their children were significantly underestimated when compared to expert-assessed risk for 26 of the 32 assessed conditions. The underestimated conditions were the same for both adults and parents answering for children. Travel-related risk was not over-estimated for any condition.

CONCLUSIONS

Adults underestimated their children's and their own risk for most travel-related conditions. Strategies to improve the accuracy of risk perception of travel-related conditions by travellers are needed to optimize healthy travel for children and their families.

Key informant perspectives on sexual health services for travelling young adults: a qualitative study

Background

International travel has become increasingly popular among young adults. Young adults often engage in casual sexual relationships abroad, exhibit sexual risk behaviours and may thus be at risk of contracting sexually transmitted and blood-borne infections. Pre-travel interventions and consultations may mitigate this risk. At present, we know little about sexual health-related pre-travel interventions. The aim of this study was therefore to document key informants’ experiences, perceptions and recommendations in the context of sexual health of young adult travellers.

Methods

Key informants were professionals working in Ottawa, Canada travel clinics, travel organizations or sexual health clinics with a young adult clientele. This study used a qualitative approach and consisted of 13 in-person or Skype semi-structured interviews with key informants. Thematic content analysis was informed by a sexual health framework, with themes emerging both inductively and deductively.

Results

Sexual health was not common in pre-travel interventions described by key informants. Risk-assessment, and practical or purpose-driven pre-travel interventions were identified, resulting in risk mitigation strategies tailored to the destination region and/or mission/culture of the travel organization. Dissemination (e.g. limited time, lack of training) and uptake (e.g. young adults’ embarrassment, provider discomfort, financial constraints) barriers limited in-depth discussions of pre-travel interventions related to sexual health. Key informants acknowledged the importance of early sexual health education, and recommended ongoing, comprehensive sexual education for both youth and young adults.

Conclusion

The findings of this study suggest that more time and resources should be allocated to the topic of sexual health during pre-travel interventions with young adults. Professionals who guide and prepare young adults for travel must develop concomitant skills in sexual health promotion. Early, comprehensive sexual education is recommended to improve overall sexual health in young adults and mitigate risk behaviours during travel.

Critical illness in the returning traveller

A 70 year old man, who had recently travelled in rural Iraq, presented with fevers, rigors, and developed multiorgan failure. An extensive range of diagnostic tests was undertaken in an attempt to identify the cause. He was treated with multi-organ support and a number of antibiotics. Critical illness in the returning traveller presents a number of challenges on the ICU: obtaining adequate history, the potentially broad differential diagnosis, the requirement for numerous and sometimes specialised investigations and risks of infection transmission to staff and other patients. Travellers are more often elderly, more likely to have comorbidities and immunosuppression whilst global disease patterns are changing. Particular consideration should be given to unusual infections and venous thromboembolic disease from prolonged immobility whilst in transit, alongside more commonly encountered diseases. Antimicrobial resistance may be encountered and appropriate infection control is essential for the protection of patients, staff and others. Specialist support is available in the UK via the Imported Fever Service, especially for High Consequence Infectious Diseases. Consideration of non-infectious causes of fever and critical illness in returning travellers is also warranted. Crucially, a multidisciplinary team approach with thorough information gathering, repeated clinical review and judicious use of investigations are essential for optimal patient care.

"We Are Young, We Run Free": Predicting Factors of Life Satisfaction among Young Backpackers

Although research from a positive psychology perspective is conducted among different populations, few studies have examined the predictors of life satisfaction among young backpackers. The current study focused on young adults (ages 21–30), an age group for whom backpacking treks are a growing phenomenon, during their treks in the Far East and South America. Direct and indirect models were used to identify personal factors and environmental resources contributing to life satisfaction. After at least one month abroad, 318 young adults (M = 23.76) answered a self-report quantitative questionnaire. The findings show that personal resources, social support, and community participation were positively associated with life satisfaction, and risk-taking behaviors were negatively associated with life satisfaction. Social support and community participation partially mediated the association between risk-taking behaviors and life satisfaction and between personal resources and life satisfaction. The implications of the findings for the subjective well-being of young backpackers during their transition to adulthood include, among others, the need to help young backpackers maintain their personal and social resources as valuable assets for coping with challenges during their trips. It is also important to increase awareness of the possible wide-ranging negative effects of risk-taking behaviors during backpacking trips.

Sun, sea and sex: a review of the sex tourism literature

Background

Sex tourism is defined as travel planned specifically for the purpose of sex, generally to a country where prostitution is legal. While much of the literature on sex tourism relates to the commercial sex worker industry, sex tourism also finds expression in non-transactional sexual encounters. This narrative review explores current concepts related to travel and sex, with a focus on trans-national sex tourism.

Methods

The PubMed database was accessed to source relevant literature, using combinations of pertinent search terms. Only articles published in the English language were selected. Reference lists of published articles were also examined for relevant articles.

Results

With regard to preferred destinations, South/Central America and the Caribbean were more likely to receive tourists looking for casual sex. Longer duration of travel, travelling alone or with friends, alcohol or drug use, being younger and being single were factors associated with higher levels of casual sex overseas. The majority of literature retrieved on sex workers focused on risk behaviours, sexually transmitted infections (STI), mobility of sex workers and how these factors affected their lives. Sex tourists require better access to effective methods of preventing HIV, such as pre-exposure prophylaxis, and better education on HIV prevention. Drugs and alcohol play a major role as risk factors for and cofactors in casual sexual behaviour while abroad.

Conclusions

Travellers need to be informed of the increased risks of STI before travel. They should be aware of the local prevalence of STIs and the risks associated with their sexual practices when they travel, including engaging with commercial sex workers, having unprotected sexual intercourse and becoming victims of sexual violence.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

International travel as risk factor for Chlamydia trachomatis infections among young heterosexuals attending a sexual health clinic in Melbourne, Australia, 2007 to 2017

BackgroundInternational travel is considered a risk factor for acquiring Chlamydia trachomatis; however, there are little empirical data to support this.AimTo examine the prevalence and risk factors for Chlamydia trachomatis infections among heterosexual international travellers (n = 28,786) attending the Melbourne Sexual Health Centre (MSHC), Australia, compared to Australian residents (n = 20,614).MethodsWe conducted a repeated cross-sectional study and analysed sexual behaviours and chlamydia positivity among heterosexual males and females aged ≤ 30 attending MSHC for the first time between January 2007 and February 2017. 'Travellers' were defined as individuals born outside of Australia who had resided in the country < 2 years. Associations between patient characteristics and chlamydia positivity were examined.ResultsChlamydia positivity was higher among travellers (11.2%) compared with Australian residents (8.5%; p < 0.001). Male travellers had higher chlamydia positivity (12.1%) than Australian males (9.3%; p < 0.001), as did female travellers (10.4%) compared with Australian females (7.7%; p < 0.001). Travellers had a higher mean number of sexual partners than Australian residents among males (5.7 vs 4.7; p < 0.001) and females (3.6 vs 3.2; p < 0.001). Travellers from the United Kingdom, Europe, Ireland and New Zealand accounted for 29.6%, 21%, 8.5% and 5.8% of C. trachomatis infections, respectively. Chlamydia in males and females was associated with younger age (≤ 25), inconsistent condom use, a higher number of sexual partners (≥ 4 partners) and being a traveller (p < 0.001).ConclusionsWe found that international travel is an independent risk factor for chlamydia among young heterosexual travellers in Australia, who should therefore be a target group for chlamydia prevention.

Antimicrobial resistance in sexually transmitted infections

RATIONALE FOR REVIEW

International travel facilitates the spread of drug-resistant infections, including sexually transmitted infections (STIs). In 2016, the World Health Organization highlighted the global burden of 'curable' STIs, estimating 376 million new infections of gonorrhoea, chlamydia, syphilis and trichomoniasis annually, with considerable geographic variation in both the burden of disease and prevalence of resistance. Travelers' risk of contracting and transmitting drug-resistant STIs depends in part on their geographic exposure. In this review, we describe the epidemiology of antimicrobial resistance (AMR) and the management of these four common STIs and Mycoplasma genitalium, an increasingly recognized cause of non-gonococcal urethritis.

KEY FINDINGS

Multi-drug and extensively drug resistant gonorrhoea strains have been associated with international spread, particularly in travelers returning from Southeast Asia. Chlamydia is the most common bacterial STI worldwide. Although in vitro resistance has been reported, surveillance data suggest that clinically significant resistance to macrolides and tetracyclines is rare. Macrolide resistance in syphilis is now endemic in much of the world but there is no documented penicillin resistance, which remains first-line therapy. Trichomoniasis is the most common non-viral STI worldwide. Although clinical failure after treatment occurs, resistance to metronidazole is thought to be uncommon. Mycoplasma genitalium exhibits intrinsic resistance to many antibiotics, and the prevalence of resistance to both first- and second-line regimens (macrolides and fluoroquinolones) is increasing worldwide, with limited alternative therapeutic options.

RECOMMENDATIONS

International travelers are at risk for acquiring resistant STIs with limited therapeutic options. Improved diagnostics are urgently needed to improve AMR surveillance and the management of infected patients. As no vaccinations are currently available for these STIs, and pre-exposure prophylaxis is an area of active study with limited data, condom use is critical for prevention. Travel medicine providers should incorporate STI risk reduction counselling, with an emphasis on condom use, into the routine pre-travel consultation.

Women Who Trade Sexual Services from Men: A Systematic Mapping Review

Most research on transactional sex frame men as buyers and females as sellers of sex. We conducted a systematic mapping review of the empirical research on transactional sex where women form the demand (buyer) and men the supply (seller). We included 46 studies, of which 25 explicitly researched women as buyers of sex from male sellers, and 21 studies where this topic was a subset of larger topics. The majority of research on women who trade sexual services from men is published in the last 15 years, by female researchers, using cross-sectional or qualitative/ethnographic design, and from the perspective of males as sellers. While the women appear to be mature and financially independent, the men are young and socioeconomically vulnerable. Men's main motivation for the sexual-economic exchanges with women is financial, whereas women's motivations are largely satisfaction of sexual needs and a stereotyped erotic fantasy of black male hypersexuality. Condoms are often not used. Our review shows that there is a - possibly growing and diversifying - female consumer demand for male sexual services, and transactional sex where women trade sex from men is a complex social phenomenon firmly grounded in social, economic, political, and sexual relations.

Travel-associated STI amongst HIV and non-HIV infected travellers

BACKGROUND

The incidence of sexually transmitted infections (STI) is increasing in Western countries whilst travel plays a major role in STI dissemination worldwide. However, there is no study distinguishing HIV-positive and HIV-negative travellers.

METHODS

We retrospectively evaluated the epidemiological, clinical and biological characteristics of the patients diagnosed with a travel-related STI between 2008 and 2016. We describe and compare the spectrum of STI diagnosed amongst HIV-positive and negative travellers.

METHODS

Overall, 163 travel-related STI were identified in 140 patients (89% male, 54% men having sex with men, 40% HIV-positive). Symptoms occurred during travel in 39% of them, otherwise the median time between return and symptoms' onset was 13 days. Amongst the 84 HIV-negative travellers, the main STI were primary HIV infections (n = 36, 38%), Neisseria gonorrhoeae (NG) infections (17%) and primary herpes infection (14, vs 1.5% amongst HIV-positive travellers, P = 0.01). The regions of exposure to HIV were concordant with the known geographical distribution of HIV subtypes. Amongst the 56 HIV-positive travellers, the main STI were syphilis (43, vs 6% amongst HIV-negative travellers, P = 0.01), Chlamydia trachomatis (CT) infections (22, vs 13% amongst HIV-negative travellers, P = 0.08), NG infections (13%) and acute hepatitis C (12, vs 1% amongst HIV-negative travellers, P = 0.01), with a predominance of anal forms for both CT and NG infections.

CONCLUSIONS

The spectrum of STI diagnosed in returning travellers is broad with important differences according to HIV status. In our setting, primary HIV infection was the leading STI in non-HIV infected patients, which suggests that pre-exposure prophylaxis may have a role in HIV prevention in at-risk travellers.

Contraception in female travellers: challenges and solutions

Contraception is an important issue for female travelers, but one that is often neglected in the pre-travel consult. Options have expanded in the 21st century. Travel medicine practitioners should have a basic understanding of the choices available to their female patients, as well as the advantages and disadvantages of each. This paper will review the contraceptive methods available to female travelers, including newer methods, and discuss emergency contraception options.

Pathogens without borders

Purpose

Drawing insights from the ecological theory, the purpose of this paper is to explore social determinants related to pathways to high-risk sexual behaviors of international travelers across their life span.

Design/methodology/approach

Data were collected from 45 international travelers in Houston, a critical transit point frequented by international visitors.

Findings

Overall, several ecological settings (individuals, interpersonal, institutional and contextual) related to two typologies of international travelers (risk takers vs non-risk takers) and their inclination to engage in high-risk sexual practices in an international or/and local context were identified.

Research limitations/implications

This research calls for the need to assess high-risk sexual behaviors from the ecological perspective to better understand the dynamics of disease transmission among frequent international travelers from diverse backgrounds/life styles and age cohorts.

Practical implications

Prevention and treatment programs developed for at-risk international travelers should target both distal and proximal social factors that predispose travelers to vulnerable situations. To build a reliable health surveillance network, policy makers, health practitioners and educators must focus not only on individual-level determinants but also on other ecological determinants that branch out beyond the personal level (e.g. interpersonal, institutional and contextual levels). Multi-level formal and informal social networks can be developed to promote a global social climate and environment that encourage safe sex and safety precautions.

Social implications

To raise awareness, the public must be constantly reminded that outbreaks of potentially health hazards can lead to unpredictable morbidity/mortality and security risks that place a burden on our nation’s economic growth, emergency responsiveness and homeland security infrastructure.

Originality/value

The study is one of very few to address international travelers’ health risk, while abroad, from an ecological lens across the life course.

Longitudinal survey of condom use across a US Navy and Marine Corps shipboard deployment

OBJECTIVES

Condoms are highly effective in preventing sexually transmitted infections (STIs) but implementation is often inconsistent with use rarely examined across travel transition periods. We examined the prevalence of condom use among ship-assigned US military personnel across an overseas deployment cycle and identified factors associated with condom non-use.

METHODS

Longitudinal survey data were collected from ship-assigned US Navy/Marine Corps personnel on 11 ships before (T1), during (T2) and after (T3) an overseas deployment. The anonymous, self-completed survey included demographics, condom use at last sex, STI diagnosis, alcohol misuse and drug use with sex. Descriptive and generalised regression model analyses were conducted.

RESULTS

Analysis included 1900 (T1), 549 (T2) and 1168 (T3) personnel who reported age, sex and condom use/non-use at last sex. The proportion reporting condom use was significantly higher during T2 (53%, p<0.0001) than T1 (27%) or T3 (28%), with STI prevalences of 1% (T1), 7% (T2) or 2% (T3), with fewer (29%) sexually active individuals at T2. In adjusted models, condom non-use was associated with hazardous alcohol use (OR 1.44, 95% CI 1.21 to 1.71), or drug use to enhance sex (OR 1.37, 95% CI 1.06 to 1.77), but transactional sex was negatively associated (OR 0.69, 95% CI 0.50 to 0.84).

CONCLUSIONS

Condom use was highest during deployment, as was STI prevalence (among non-users), possibly reflecting concentration of high-risk sexual activities/individuals and/or sexual partners more likely to be infected. Higher condom use with transactional sex likely reflects awareness of higher STI risk. These data can be used to facilitate targeted interventions to reduce STI transmission and may extend to similarly aged cohorts travelling outside the US (eg, college students on spring break).

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.

Addressing the rising rates of gonorrhea and drug-resistant gonorrhea: There is no time like the present

Increasing rates of gonococcal (GC) infection and antimicrobial resistant (AMR) GC, are a serious public health concern for Canada and around the world. Previously recommended treatments are ineffective against many of the gonorrhea strains circulating today. The current recommendation for combination therapy is now being threatened by globally emerging and increasingly resistant strains. It is important that coordinated efforts be made now to ensure these new global strains do not become established in Canada. Otherwise, we will be faced with the possibility of persistent GC infection which can lead to pelvic inflammatory disease, infertility and chronic pelvic pain in women; and epididymitis in men. The presence of GC can also increase the risk of HIV acquisition and transmission. There are a number of reasons why we are facing this public health threat. GC infection is often asymptomatic and it is highly transmissible. People may hesitate to seek testing (or to offer testing). Treatment is complex: recommendations vary by site of infection and risk of resistance. Sexual contact during travel is an important source of imported emerging resistant global strains. The new screening and diagnostic Nucleic Acid Amplification Test (NAAT) is excellent but has decreased the number of cultures being done and therefore our capacity to track AMR-GC. There are four key actions that clinicians and front-line public health professionals can take to stem the increase in rates of GC and drug resistant GC. First, normalize and increase GC screening based on risk factors and emphasize the need for safer sex practices. NAAT is useful for screening, but culture is still needed for extra-genital sites. Second, conduct pretravel counselling and include a travel history as part of the risk assessment. Third, use culture along with NAAT to establish the diagnosis and follow up for test-of-cure. Finally, refer to the most current Canadian Guidelines on Sexually Transmitted Infections or provincial/territorial recommendations on combination therapies for patients and their contacts as recommendations may have changed in response to evolving AMR-GC trends.

Sexual safety and HIV prevention in travel medicine: Practical considerations and new approaches

Travellers who engage in sexual contact with a new sexual partner abroad may be at high risk of HIV and other sexually transmitted infections (STIs), but these risks can be reduced through appropriate planning during the pre-travel clinic visit. Here we discuss strategies available to the clinician to maximise travellers' sexual safety during travel. Strategies may include immunizations, condoms, HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), self-initiated treatment of symptomatic bacterial STIs, post-exposure prophylaxis for bacterial STIs and hormonal contraception. We discuss the role of these different strategies for travellers, and provide resources to assist clinicians in making clinical decisions and in educating travellers about sexual safety.