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Guided learning

Raising awareness of the risk of sexually transmitted infection among overseas travellers

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A significant proportion of STIs in the UK are contracted abroad. Travel health consultations offer an ideal opportunity to advise people on how to cut their risks 

 

Author

Joanna Lowry, DTN, RN, is sexual health nurse, Winchester and Eastleigh NHS Trust, and nurse specialist and managing partner, Winchester Travel Health.

 

Abstract

Lowry J (2010) Reducing the risk of sexually transmitted infections in overseas travellers. Nursing Times; 106: 8, early online publication.

A range of factors can increase risk of sexually transmitted infections in overseas travellers. Since many people receive travel advice and vaccinations before they travel, nurses have an opportunity to offer education and advice to increase travellers’ awareness of how they can minimise their risk. Interventions should be tailored to the individual by using simple, direct questions to assess risk.

Keywords Sexually transmitted infections, STIs, Overseas travel, Sexual health

  • This article has been double-blind peer reviewed

 

 

Learning objectives

1. Understand the risks when people are sexually active with a new partner overseas.

2. Be able to identify methods of reducing the risk of contracting an STI while travelling.

 

 

Introduction

Overseas travel can offer new experiences and opportunities. However, while away from home, particularly when on holiday, people may make decisions while under the influence of alcohol and/or drugs. Even without these influences, simply being away from their usual environment and its normal social constraints may lead to overseas travellers making choices they would not normally make (Laurance, 1997).

Travel and new experiences are more likely to encourage people to have sex with a new partner while away (Rogstad, 2004), and this may put their sexual health at risk. For example, some parts of the world have a high prevalence of certain sexually transmitted infections (STIs), while others are renowned for their sex industries.

In order to protect their sexual health it is important for people planning overseas travel to recognise the risk of STIs and how this can be reduced. Travellers often visit nurses and other professionals for travel health consultations and vaccinations before their trip, so there is an opportunity to help them minimise their risk.

This one-part unit examines nurses’ role during travel health consultations in educating clients and recommending methods of STI prevention. Although any person who is sexually active while abroad is at risk, individual risk assessment is essential due to the many different reasons for travel.

Background

People travel for many different reasons. While recreation is one of the most common, business travel and visiting friends and family abroad are also increasing. In addition, sports teams tour the world for international games, opting to have elective surgery overseas is increasingly common and “gap year” travel is also becoming increasingly popular for all ages. All travellers can meet new partners while away irrespective of the reason for their trip.

Many people actively seek holiday romances - for example, a study by Bellis et al (2004) found that 22% of men who travelled to Ibiza did so for sex. “Sex tourism” is increasing and some travel companies offer trips tailored for holidaymakers hoping to meet new partners overseas or take advantage of legalised prostitution. Online guides enable tourists to choose travel destinations purely for sexual activity.

Research has found different levels of casual sex among travellers. An anonymous study of Swiss travellers found that 51% of participants had had casual sex abroad (Gagneux et al, 2006), while an earlier study found 44% of travellers visiting Hong Kong had had sex with a new partner while travelling (Abdullah et al, 1998). On the other hand, a study on international travellers visiting Peru found only 12% of those surveyed had had sex with a new partner during their stay (Cabada at al, 2002).

Although the majority of people in Abdullah et al’s (1998) study having sex with new partners were younger, as many as 40% of those aged up to 65 years admitted having done so and a slightly higher proportion of these were men. It is therefore essential that nurses appreciate that travellers of any age may be sexually active while travelling.

The need for health promotion

The number of STIs in the UK contracted abroad is significant, and in the interests of public health both in this country and in the countries where the travellers became infected, it is vital that nurses can offer advice and support to prevent infections.

Of all UK born heterosexuals diagnosed with HIV between 2000 and 2003, it is likely that nearly half contracted the virus while abroad (Health Protection Agency, 2005). This is one reason why healthcare professionals such as HIV prevention teams are so keen to reduce the level of HIV contracted abroad.

Travellers going abroad are at considerable risk of exposure to blood and body fluid borne pathogens (Correia et al, 2001).  Havingconcurrent sexual partners also increases the risk of contracting an STI (Kelley at al, 2003).

Men who have sex with men (MSM) may be at increased risk of some STIs, and since overseas travel may be seen as an opportunity to experiment sexually with members of the same sex, this group may include men who consider themselves to be heterosexual. Overseas travel may put MSM at increased risk where the incidence of particular infections is higher. Lymphogranuloma venereum (LGV) is a common infection in Africa, Asia and South America but was rarely seen in Western Europe until 2003; there have recently been frequent outbreaks among MSM in Europe. Awareness of the infection may be low among men in Britain, so it is important to educate those visiting high risk areas about the diseaseand condom use to reduce their risk. In addition, the risk of heterosexual transmission of LGV is particularly high in Africa.  

Some sexual practices can also increase the risk of STIs. Hepatitis A and B can be transmitted through the oro-anal route (Edwards and Carne, 1998) and it is advisable to highlight the risk of this practice in endemic areas.

Post exposure measures

Another consideration for travellers at risk of STIs is post exposure care and the consequences of delays in treatment. Post exposure prophylaxis (PEP) is available to reduce the risk of HIV transmission after exposure and immunoglobulin therapy can reduce hepatitis B infection risk. It is essential to advise clients that action can be taken if they have been exposed to an STI. However, PEP can have side effects and be unpleasant to take, so it should not replace condom use and hepatitis vaccination as the primary method of prevention.

Prompt diagnosis is essential as delayed treatment can lead to complications, especially in conditions such as chlamydia where delays in treatment can lead to pelvic inflammatory disease and infertility (Horner et al, 2006).

Emergency contraception can be difficult to access, particularly in countries where religion discourages its use. Publications such as the Back Pocket Travel Guide to Sexual Health Around the World (Marie Stopes International, 2009) offer advice on where to access contraception services abroad. People who are sexually assaulted overseas often do not report these crimes as they feel there is no benefit in doing so. However, this is not the case as the Foreign and Commonwealth Office takes assaults extremely seriously and has produced advice leaflets (FCO, 2009).

Travellers should be given information about where to find help overseas and advised to have comprehensive medical insurance with an emergency contact number to help identify their closest and safest medical service.

Preventing STIs

Although the most effective method of preventing STIs is by immunisation, there are no vaccines available for most infections; to prevent these condoms are the most effective method. Vaccination is available against hepatitis A and hepatitis B as well as immunisation against HPV 6, 11, 16 + 18. Hepatitis B vaccination is available in genitourinary medicine clinics for certain risk groups such as MSM and partners of people infected with the virus.

Consistent condom use can reduce the risk of HIV transmission by 90-95%. (Varghese et al, 2002) While this clearly highlights their benefit for HIV prevention, condoms also protect against other STIs and unintended pregnancy.

Travellers may be aware of the benefits of using condoms, but may not do so due to inconvenience, such as lack of availability when needed, or they may choose not to use them due to personal preference. Cabada et al (2002) found only 24% of overseas travellers used condoms consistently, with 20% using them sometimes.

Broaching the subject

Sexual health is an intimate and personal subject that can be difficult to discuss with patients/clients, particularly in a consultation that is not obviously related, such as a travel health risk assessment. Nurses carry out the majority of pre-travel assessments and consultations in the UK, and many find it difficult to start conversations about clients’ sex lives. It is therefore essential for nursing staff to receive appropriate training and education to give them the confidence to discuss sexual risk during travel with their patients/clients. In my personal experience, clients rarely raise the subject during travel health consultations, which suggests that nurses should raise the issue.

Asking simple, direct questions is the most effective method of assessing an individual’s risk. A useful question is: “Is there any possibility you might meet a new sexual partner while you are away?”

Nurses should be cautious about discussing sexual health with patients/clients who are accompanied during their consultation, such as young people who attend with a parent. A follow up appointment, such as to complete a course of vaccination, may present an opportunity to initiate the discussion. It may be a good idea to recommend that the young person attends alone if this is possible. Giving young people written information, including the risk of contracting STIs while travelling, may also be beneficial.

Risk assessments

Having established that many travellers are likely to be sexually active while abroad and that there is a high risk of contracting an STI, what can be done to prevent them returning with an infection?

An individual risk assessment is essential in order to personalise the consultation and ensure the advice given is relevant to that individual. Since people can be sensitive about discussing their sexual health, it is worth deciding on an appropriate way to broach the subject. For example, one possible way is to mention the risk of hepatitis B transmission when recommending vaccines for the trip.

Hepatitis B is on the increase and its epidemiology is variable. Travellers’ destination should be considered when assessing their risk. For example, a traveller to Asia should be educated about the high infection rate of the disease (see Fig 1).

Hepatitis B immunisation is essential for people who frequently change sexual partners, and for those staying for long periods in an endemic country (Department of Health, 2006). Highlighting this risk and recommending vaccination can then lead into a discussion about the risk of other STIs, such as HIV awareness and recommending condom use.

Interestingly, many people who understand the advantages of using condoms also admit to not using them with new partners when abroad (Gagneux et al, 2006). In some cases this may be because they did not have access to condoms when they were needed. Offering free condoms to people attending travel clinics may therefore be useful.

This may mean that although travellers are aware of the benefits of using condoms with a new partner abroad, they may not have access to them when required. Therefore, supplying all travellers with free condoms before departure would mean they have them to hand if needed.

Implications for practice

Although sexual health is a specialist area, it extends into every area of nursing. While the Royal College of Nursing (2001) said different skills are needed for specific areas of practice, it is unrealistic to educate and train every nurse as a specialist sexual health provider. Nonetheless, it is important that all nurses realise that, with some knowledge, they can offer prevention advice such as immunisation and condom use and refer clients to an appropriate specialist service if necessary.

Ideally all travel health clinics should offer free condoms to every client. The World Health Organization (2000) demonstrated that government promotion of 100% condom use among commercial sex workers in Thailand led to an increase in use from 14% to 94% over four years.

Vaccination should be offered to travellers at risk of hepatitis A and B and education should be given about the availability of post exposure prophylaxis and emergency contraception. Giving people information about where to find these services while abroad is extremely helpful.

It would be useful for nurses to have guidelines on how to recognise professional boundaries, as advised by the Nursing and Midwifery Council (2008), while creating a supportive and caring environment to discuss clients’ sexual health. It is important to consider and protect clients’ personal life and avoid asking overly intrusive questions (RCN, 2001).

Finally, many young people travel with friends, and this presents an excellent opportunity to ask them to recommend that their friends also use condoms while abroad, especially in those clinics where they are available for free. This may encourage clients’ friends to attend not only for free condoms but also for travel advice.

Conclusion

All travellers are at risk of STIs if they develop sexual relationships while away. Since it is impossible to predict which clients might meet a new partner overseas, all those attending for travel health consultations should be given the opportunity to discuss their sexual health risk, using simple and direct questions.

Education and awareness will help reduce risk and nurses’ role is therefore to advise clients to consider social and lifestyle choices that may put their sexual health at risk, such as having concurrent partners, and the significance of their partner’s previous sexual experiences.

Immunisation and condoms are effective methods of reducing the risk of contracting STIs. All travel clinics should advise travellers to take condoms with them when planning a trip, and how to ensure they buy safe ones when abroad. Ideally all travel clinics should provide free condoms to clients if requested. If more travellers use condoms, this may lead to a lower UK rate of STIs contracted abroad.

 

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