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The Holy Grail of prevention of sexually transmitted infections in travellers
  1. Alberto Matteelli,
  2. Susanna Capone
  1. Clinic of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
  1. Correspondence to Dr Alberto Matteelli, Clinic of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia, Piazza Spedali Civili, 1 Brescia 25123, Italy; alberto.matteelli{at}unibs.it

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In this issue of the journal, two articles1 ,2 provide new evidence on sexual behaviours among travellers.

Tanton et al report the rate of new sexual relationships of British residents during travel abroad. They used the Britain's third National Survey of Sexual Attitudes and Lifestyles, a probability survey undertaken in the UK between 2010 and 2012, and analysed data from 12 530 men and women aged 16–74 years reporting ≥1 sexual partner(s) in the previous 5 years. They found that 9.2% of men and 5.3% of women reported new sexual partner(s) while overseas. Among those who reported new partners while overseas, 72% of men and 58% of women reported partner(s) who were not UK residents.

In another article in this issue of the journal, Lewis and de Wildt report high proportions of backpackers, a younger, mobile population of travellers known to exhibit high risk-taking behaviour, engaging in unsafe sex while travelling through Thailand. By using a cross-sectional convenience sampling design and an anonymous self-administered questionnaire, they showed that over one-third of backpackers travelling without a long-term partner or spouse had vaginal and/or anal intercourse with a new partner; one-third of these did not use condoms consistently. The limitation of the study is the very limited geographical coverage of the survey, but its strength is the higher response rate compared with similar previous studies.

The findings from Tanton et al, consistent with those of Lewis and de Wildt, demonstrate high levels of disassortative sexual mixing (ie, with partners from countries other than the participant's own) and provide evidence for a mechanism of international transfer of sexually transmitted infection (STI).

The association between travel and sex is well known. In one systematic review, the pooled prevalence of travellers reporting casual sex during travel was over 20%.3 There are logical theoretical bases for the association between travel and sex: physical separation of partners, anonymity of travel, removal of social taboos that prevail at home and the desire for unique experiences may encourage sexual activity during travel. Although sex does not need to be unsafe, in terms of unwanted pregnancies or the risk of acquisition or transmission of STIs, it frequently happens to be. In the systematic review mentioned above, the 20% travellers reporting casual sexual intercourse had a pooled prevalence of unprotected sex of 49%.3

The potential of travel to create sexual mixing is huge. Moreover, travel-associated infections allow for the spread of resistant strains as exemplified by Neisseria gonorrhoeae. In the past decades, population mobility has increased dramatically. More than one billion people crossed international borders for work, study or pleasure. The consequences on STIs could be substantial: STIs have uneven geographical distribution, and travellers may act as bridges between high-burden and low burden countries. Syphilis is thought to have been introduced into Europe from the Americas by Columbus and the conquistadors. Much later, the HIV epidemic spread all over the five continents via the sexual route: compared with syphilis, the process was much quicker due to improvements in the means of human mobility.

Remarkably, prospective data on the incidence of STI among travellers are unavailable, and there is sparse information on the extent of travel-related STI morbidity.4 Studies on the direct relation between STIs and travel are rare because it is difficult to establish a link between diagnosis and travel, for infections often have long incubation periods and are often asymptomatic. In addition, travellers who have sexual exposures abroad might also have unsafe contacts at home, making it difficult to relate diagnosis to travel. Thus, published reports on travel-associated STIs focusing on risky behaviours and demonstrating increased exposure to STIs—as those appearing in this issue of the journal—are taken as the closest surrogate marker of the risk of STIs acquired abroad.

Tanton et al1 state that the prevalence of risk-taking behaviours in terms of sexual relationship during travel is high enough to call for action in travel clinics. Indeed, the call is timely as there is a paucity of information related to strategies to prevent STI acquisition or transmission during foreign travel. As a matter of fact, STI prevention activities have a low profile among current travel clinic practices: low perception of the consequences and the difficulties of prevention and care of travel-associated STIs likely concur to justify this scenario. Prevention tools for STIs in travellers unfortunately cannot rely on vaccine shots (excluding hepatitis A and B) or prescription of pills. Primary prevention interventions would be needed based on education, condom promotion and counselling for promotion of safer behaviours.

By recognising that it is impossible to identify a small group of travellers for targeted intensified educational interventions, Tanton et al propose that travel advice should include, as standard, sexual health as part of holistic health advice for all travellers, regardless of age, destination or motivation for travel. However, this suggestion remains speculative in the absence of feasibility studies.

On the other side, the findings from Lewis and de Wildt2 suggest that backpackers represent a small proportion of easily identifiable travellers and targeted in-depth risk-reduction intervention are conceivable and could be cost-effective. By noting that unprotected sex is less frequent in backpackers who reported bringing condoms from home, Lewis and de Wildt speculate that encouraging more single backpackers to travel with condoms may increase consistency of use.

Unfortunately, we do not have any patented intervention, of any kind, with proven efficacy in changing human behaviours towards lower risk sexual practices while travelling. The only clinical trial about the effect of specific STI interventions so far showed that neither a motivational brief intervention nor the provision of free condoms (or a combination of the two) modified risky sexual behaviour in young travellers compared with a control group of travellers who got standard pretravel information.5

Research in the field of effective interventions to decrease risk-taking behaviours in new sexual partnership acquired during travel is urgent. This research would have the highest probability of being transformational.

References

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Footnotes

  • Contributors AM and SC contributed equally to the writing of the editorial.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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