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ARCHIVED - Statement on Travellers and Sexually Transmitted Infections

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Canada Communicable Disease Report

Canada Communicable Disease Report
Volume 32 • ACS-5 1 May 2006

An Advisory Committee Statement (ACS)

Committee to Advise on Tropical Medicine and Travel (CATMAT)*†

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24 Pages - 476 KB


Preamble

The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides the Public Health Agency of Canada (PHAC) with ongoing and timely medical, scientific, and public health advice relating to tropical infectious disease and health risks associated with international travel. PHAC acknowledges that the advice and recommendations set out in this statement are based upon the best current available scientific knowledge and medical practices, and is disseminating this document for information purposes to both travellers and the medical community caring for travellers.

Persons administering or using drugs, vaccines, or other products should also be aware of the contents of the product monograph(s) or other similarly approved standards or instructions for use. Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) or other similarly approved standards or instructions for use by the licensed manufacturer(s). Manufacturers have sought approval and provided evidence as to the safety and efficacy of their products only when used in accordance with the product monographs or other similarly approved standards or instructions for use.

Introduction

Sexually transmitted infections - global overview In the last 20 to 30 years, population mobility both within and across national boundaries has increased dramatically. Approximately 1 billion people crossed international borders for work, study, or pleasure in 2003 to 20041. All mobile populations that are sexually active are at increased risk of acquiring sexually transmitted infections (STIs)2-4. The anonymity of travel, the sense of isolation brought on by unfamiliar surroundings, and the desire for unique experiences can encourage sexual activity. The risk of acquiring an STI may be enhanced by poor understanding of the global epidemiology of these infections5 and the means available to mitigate risk. Rates of STIs may be elevated among migrant and marginalized populations (e.g. refugees, internally displaced, street youth), and these populations may be overrepresented among commercial sex workers (CSW) in many countries3,6-10.

STIs are among the most common notifiable infections worldwide, and rates are particularly high in developing countries11. In 1990, theWorld Health Organization estimated the global burden of curable STIs at > 250 million cases (syphilis, gonorrhoea [GC], chlamydia, and trichomonas). Estimates rose to 333 and 340 million new cases of these infections in 1995 and 1999 respectively5,11. The 1999 estimate includes 151 million cases in South/Southeast Asia, 38 million in Latin America, and 69 million in Africa12,13. In many countries, these increasing numbers have been fuelled by the economic and societal disruption of the HIV pandemic. In sub-Saharan Africa, in particular, there has been an explosive growth in the number of children who have lost one or both parents (~14 to 20 million in 2000)14. Many of these children have been driven to trade sex for food in order to survive15.

More than 20 different infectious agents can be acquired and/or spread by various types of sexual contact5,16 (e.g. vaginal sex, anal sex, oral-genital/oral-anal contact) (Table 1). Chlamydia trachomatis is the most prevalent bacterial STI worldwide. Although prevalence rates for many of these infectious agents still vary widely by geographic region (e.g. human T lymphotropic virus type 1 [HTLV-1], chancroid), changes in migration, immigration, and travel patterns during the last 50 years have ensured that almost any STI can be acquired anywhere in the world. As a result, the risk of acquiring a given STI in any particular setting is best considered in quantitative rather than qualitative terms.

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Table 1. Sexually transmitted infections

Viral diseases

Hepatitis A virus (oral-anal contact)

HIV-1/2

HSV II Cytomegalovirus

Hepatitis B virus

HTLV-1

Epstein Barr virus

Hepatitis C virus (low risk of sexual transmission)

Human papillomavirus Moluscum contagiosum

 

Delta agent

HSV* I

 

Bacterial diseases

Syphilis (Treponema pallidum)

Neisseria gonorrhoeae

Chlamydia trachomatis (NGU‡)

Haemophilus ducreyi (chancroid)

Chlamydia trachomatis L1-3 (LGV†)

 

Mycobacterium tuberculosis

Calymmatoba- cterium granulomatosis (granuloma inguinale, donovanosis)

 

Fungal diseases

Candida albicans (not usually considered sexually transmitted)

   

Parasitic diseases

Trichomonas vaginalis

Entamoeba histolytica

 

Ectoparasitic diseases

Scabies

Lice

 

* Herpes simplex virus
† Lymphogranuloma venereum
‡ Non-gonococcal urethritis

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Many STIs are hyperendemic in developing countries of the world5. Prevalence data for most of these countries are derived largely from ad hoc surveys. Such surveys provide useful estimates but must be interpreted with caution because they may not be representative of the total population17 (Table 2). On the other hand, surveys that focus on CSW may accurately reflect the risk to travellers, since these individuals may be the most likely to engage in sex acts with foreigners. Not surprisingly, surveys of CSW in the developing world reveal high rates of the curable STIs: 13% to 32% for chlamydia, 11% to 45% for GC, and 5% to 55% for syphilis5,27,28. When prevalence rates for the major non-curable viral infections are included (e.g. HIV29, hepatitis B virus [HBV]30, hepatitis C virus [HCV]31,32, HTLV-133), (Table 3), the risk of exposure to an STI through sexual contact with a CSW is high. It is certainly worth noting that the presence of one or more STIs can increase the risk of HIV transmission by a factor of three to 10 or more5.

Table 2. Examples of STI prevalence rates in healthy populations in the developing world (percentage of clinic visits)

Country n Source of sub-jects GC Syph-ilis Chla- mydia Trich-omo-nas Chan-
croid
Gard-ner-ella HIV HBV HSV-2 Geni-tal warts

Nige-ria18

230

Ante-natal

1.3

1.7

-

7.4

-

3.9

-

-

-

-

Zimb-abwe19

175

Pre-natal /STI

17.8

-

5.9

25.5

17.8

-

-

-

-

13.7

Ethio-pia20

1,907

Family plan-ning & others

56-66

35-39

61-64

-

-

-

 

-

-

19-20

South Africa21

lit rev/ rev. litt.

Various clinics

8.0

5-15

16.0

-

-

20-49

-

38-40

38-4

-

Ctr Afr Rep22

481

Ante-natal

3.1

6.7

6.2

9.9

-

29

12.2

-

-

-

Thai-land23

1,021

Ante-natal

0.2

0.5

5.7

-

-

-

3-7

-

-

-

India24

1,981

Various clinics

-

-

-

-

-

-

1.8

5.3

-

-

Mongo-lia25

pop/ pop.

Various

1.4

0.3

-

1.6

-

-

< 0.001

-

-

-

Brazil26

13,986

Ante-natal & various

-

-

-

-

-

-

-

-

43

-

Table 3. Examples of STI prevalence rates in commercial sex workers (CSW) in the developing world (percentage of clinic visits)

Country n Sour-ce of sub-jects GC Syph-ilis Chla-my-dia Trich-omo-nas Chan-croid Gard-ne- rella HIV HBV HSV-2 Gen-ital war-ts

Sen-egal34

374

Fem-ale CSW

24.9

29.4

-

46

-

-

-

-

-

-

South Africa35

145

Fem-ale CSW

14.3

42.1

16.3

41.3

-

71

50.3

-

-

-

China36

966

Fem-ale CSW

24.9*

29.4

24.9

46

-

-

 

-

-

-

Indon-esia37-39

1,340

Fem-ale CSW

10-60

7-30

9-18

4-8

-

-

0.5

-

37.7

-

Bang-ladesh40

286

Fem-ale CSW

28*

57.1

28*

-

-

-

0

-

-

-

Indo-nesia41

296

Male CSW

04-13

43.6

2.4-3.8

-

-

-

-

-

-

-

Vene-zuela42

212

Fem-ale CSW

-

2-4

-

-

-

-

0

13.8

-

-

Brazil43

-

Fem-ale CSW

-

-

-

1.6

-

-

-

10.9

-

-

Peru44

966

Fem-ale CSW

-

-

-

-

-

-

0.3

59.8

-

0.7

Urug-uay45

200

Male CSW

-

-

-

-

 

-

21.5

50.5

-

6.5

DRC†46

1,144

Fem-ale CSW

-

-

-

-

-

-

34.1

-

 

6.6

* Clinical evidence of cervicitis (either GC or chlamydia)
Democratic Republic of Congo

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Drug resistance in STIs

A steadily increasing proportion of STIs acquired abroad are resistant to standard antibiotics47. Beta lactamase-producing strains of Neisseria gonorrhoeae (NG) are prevalent in Africa, the Caribbean, and Asia48-55. In Canada, the rate of penicillinresistant NG rose from 8.7% in 1992 to 15% to 22% in 200356. Similarly, resistance to other antibiotics has been reported for NG in many other countries of the industrialized world56-58. Chromosomally mediated tetracycline resistance is also common among NG isolates in developing world settings59, and spectinomycin resistance has begun to appear in some industrialized regions as well56,60. Fluoroquinolone-resistant NG, which first appeared in 1992, is most prevalent in the Far East but occurs throughout the world, including the UK, US, and Canada61. Antibiotic resistance in Haemophilus ducreyi, the causative agent of chancroid, continues to spread globally52: resistance to trimethoprim/ sulphonamide combination drugs is now widespread in Southeast Asia (e.g. Thailand, Viet Nam, Laos, Cambodia)47, 62. The development of highly resistant HIV strains is an emerging issue63-65.

Sexual behaviour of travellers

The sexual attitudes and behaviours of travellers to the developed world have been extensively studied in the last 10 to 15 years(3,29,53,54,66-78). Rates of reported casual sexual exposures (CSE) during travel vary between 5% and 51%70,73. Since all of these studies have used questionnaires, and no study has achieved a 100% response rate (some as low as 30%), the reported figures are therefore likely to be underestimates. In an “intention-tohave- sex” study of young Australian males travelling to Thailand, only 34% reported a definite intention not to have sex77. Although early studies demonstrated that men were far more likely than women to have CSE while travelling, more recent studies suggest that male and female travellers are quite similar in their willingness to acquire new partners while abroad73-81. However, both quantitative and qualitative behavioural differences persist between the sexes (e.g. number of partners, willingness to pay for sex, consistent condom use, and partner choice)75,82-86. Factors that increase the chances of a given individual engaging in sex while travelling include youth, male sex, travelling alone or with a same-sex group, a history of casual sex or multiple partners at home, repeated visits to the same region, history of previous STIs higher social status longer duration of stay, travelling on business, being a smoker, and using alcohol or illicit drugs83,87,88. As with other high-risk behaviours, there is considerable evidence that alcohol and drugs contribute to CSE in both men and women8,75,80,88-94. The syndrome of sun, stimulants, and sex has been described as “situational disinhibition”95,96.

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Groups at particular risk

Expatriates: Long-term overseas workers or expatriates are more likely than other types of traveller to engage in sexual activity while abroad. In studies of Peace Corps volunteers and European expatriates, 13% to 60% reported at least one CSE while living overseas82-85,97,98. Many contacts are with local residents (31% to 41%), and condoms are inconsistently used (usually 30% to 50%). Although both male and female expatriates have CSE while abroad, men are much more likely to pay for sex85. These figures help to explain why expatriates can have STI prevalence “profiles” intermediate between those of their countries of origin and their host countries84-86.

VFR travellers: Travellers returning to their countries of origin to visit family and relatives (so-called “VFR travellers”) are at high risk of acquiring a number of travel-related illnesses99,100. VFR travellers may be at particularly high risk of acquiring STIs through their choice of setting in which to solicit sex101,102, more intimate contact with the local population, and a willingness to use substandard, locally purchased condoms73,103.

Military personnel and seamen: Seamen and military personnel are reported to have high rates of sexual contact with overseas nationals, ranging from 45% to 56%104-112. These numbers are only slightly higher than in other expatriate groups. Again, both male and female military personnel are at risk113, and reported condom use is, at best, erratic107. However, a 2004 representative survey of the Regular component of the Canadian Forces indicated that only 7% of Canadian Forces members who were deployed in the previous 12 months had had a sexual encounter outside of a committed relationship while deployed; of those, 58% had always used a condom during these encounters and15% had never used a condom (Dr. Martin Tepper, Department of National Defence: personal communication, 2006).

Men who have sex with men: Men who have sex with men are at least as likely to engage in CSE while travelling as heterosexual men45,114,115. In a Norwegian study, homosexual/bisexual travellers were twice as likely to have paid for sex while overseas as heterosexuals (64% vs 32% respectively)90.

Condom use

At least one-third to over one-half of travellers do not consistently use condoms116,117. Limited and/or inconsistent condom use in travellers appears to be independent of country of origin, travel “style” (e.g. business, back-packer) and country of destination69,70,78,83,85,86,90,97,98,114,118-120. Although many travellers carry condoms, they often “forget” to use them in the heat of the moment88,89. Even when they use condoms, there may be greater risks of failure because of the poor quality of locally purchased products103, improper storage (i.e. at the bottom of the knapsack for 2 months at 40° C), and improper application or sexual practices that may lead to higher likelihood of condom failure (e.g. anal penetration)109,121,122.

Profile of the traveller who will have sex overseas

There is no single profile of the traveller likely to have CSE while travelling83,87. With few exceptions, questions related to anticipated or actual sexual activity are appropriate for almost every pre-travel interview and every post-travel review of systems. In this context, it is worth pointing out that the teenage peak in new sexual partner acquisition can be followed by a second peak among men and women 35 to 55 years of age: the “just-divorced” group123. Finally, an ever-greater number of elderly Canadians are travelling to exotic locations124, and STIs among the elderly are easily overlooked125. On the basis of their studies of Dutch travellers, der Graaf and colleagues divided travellers into four groups with regard to CSE overseas82:

  1. the “unprepared” (who are surprised when sex happens)
  2. the “fanatical” (who must have sex to have a successful vacation)
  3. the “unaffected” (who feel that sex abroad is the same as sex at home), and
  4. the “slightly accessible” (who feel that sex abroad is different and come prepared).

Sexual tourism

Sexual tourism is defined as travel expressly for the purpose of engaging in sexual activity29,126. Such travel is highly risky with respect to STIs, and prevention/harm reduction measures should be encouraged (i.e. consistent and correct use of condoms, reduction in number of partners). In some instances, sexual tourism can be exploitative or illegal (i.e. seeking sex with minors), in which case such travel should be strongly discouraged126.

Sexual tourism by another name: The subtlety of sexual predation in the developing world needs to be explained to travellers. Many people in developing countries engage in sexual acts simply to survive15,126. In many settings, the fact that a traveller is not paying cash for sex does not mean that he/she is not buying sex. Effective “currencies” in many poor countries include food, gifts, and even hope (i.e. the chance to emigrate). The commercial nature of such transactions is often not appreciated or acknowledged by the Western traveller. After travel, more females than males make longer-term commitments with sexual contacts89,120.

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Risk of acquiring an STI during international travel

The risk of acquiring one or more STIs while travelling depends entirely on the behaviour of the traveller. There is no such thing as the “standardized sexual act”. As a result, accurate estimates for rates of STI transmission per exposure are very hard to generate. However, the following general rules apply to all situations:

  • Most STIs are more readily transmitted from males to females than the reverse.
  • Individuals with obvious lesions (e.g. sores, ulcers, vesicles) are more likely to transmit the agents that caused the lesions as well as co-pathogens (e.g. HIV, HBV) than individuals without any evident genital pathology.
  • Decisions about sexual partners and/or sexual activities made under the influence of alcohol or drugs will increase the risk of acquiring STIs.
  • Sex acts that result in bleeding or that occur during menses significantly enhance the risk of transmitting and/or acquiring sexually transmitted, blood-borne viruses (e.g. HIV, HBV, and HCV).

Because so many factors can influence risk, there have been relatively few attempts to quantify the risk of transmitting any given STI through individual sex acts. However, the risk of acquiring HIV, HBV, or HCV from a percutaneous injury are relatively well defined (0.5%, 4% to 30%, and 3% to 10% respectively)127)-. The risks following a single, unprotected, heterosexual and consensual sex act are thought to be much lower: ~ 0.001% for HIV128 and 0% to 0.6% forHCV129. However, the presence of genital lesions can dramatically increase the risk of acquiring HIV and possibly other sexually transmitted viruses130. The transmission of gonorrhea and chlamydia is highly efficient during both heterosexual and homosexual sex. A single episode of vaginal intercourse incurs a 20% to 50% risk of acquiring gonorrhea131. The transmission efficiencies for open syphilis and chancroid lesions are probably at least as high. C. trachomatis is transmitted heterosexually with only slightly lower efficiency than gonorrhea (0.8% to 8%/episode)132. In a large study of Swiss travellers, Steffen et al. estimated that HBV, GC, and syphilis were acquired at rates of 4, 3, and ~1 per 1,000 traveller-months133. Prior to HBV vaccination, the reported rates of HBV acquisition by unvaccinated, long-term travellers were as high as 4% to 7% per year134,135.

The consequences of acquiring an STI while travelling

STIs can result in both short-term problems (e.g. genital ulcers, urethritis, cervicitis) and long-term or chronic complications (e.g. infertility and ectopic pregnancy, pelvic inflammatory disease or chronic pelvic pain, liver disease secondary to HBV, cervical dysplasia secondary to human papillomavirus [HPV], immunodeficiency due to HIV). Several of these chronic infections can significantly shorten life (e.g. cancers secondary to hepatitis viruses or HPV infections, liver cirrhosis due to HBV, progression of HIV infection). Infections that are manifest during travel can expose travellers to products (e.g. antibiotics) that are not used in the developed world and to suboptimal medical practices and environments (e.g. unsterilized, reusable needles/instruments). Some drugs and products (e.g. antiretrovirals) may not be available in some areas of the world or may be of unpredictable or unacceptably low potency. Infections that are manifest only upon the traveller’s return can also be problematic. Several STIs remain rare in North America and may go undiagnosed or be treated inappropriately by physicians unfamiliar with them (e.g. chancroid, lymphogranuloma venereum). Finally, travellers who bring one or more STIs “home” to previous partners must also consider the enormous emotional price, including lost trust and broken relationships.

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Public health perspective

Travellers who have CSE overseas may be more likely to engage in CSE back in their home country. As a result, there are both small and large public health issues with CSE among travellers. At the micro level, transmission of rare and/or resistant STIs to the non-travelling partner(s) must always be considered in the presence of a confusing clinical presentation. At the macro level, the potential to import exotic and/or resistant STIs is very real3,57,58,79,136,137. Because so many people are currently travelling, the risk-taking behaviour of individuals can add up to epidemic spread rather quickly66,68,71,138. Many of these imported STIs exhibit unusual or broad spectrum antibiotic resistance138,139.

Management of STI

The treatment of STIs has recently been reviewed in both the general population140-142 and specifically in travellers28,70. The following general statements apply to all STIs:

  • the only way to avoid the risk of STIs altogether is abstinence,
  • monogamous sex with a stable, uninfected partner is another way to avoid STIs,
  • condoms reduce the risk of almost all STIs to some degree,
  • prevention of STIs is preferred over treatment,
  • partner notification is essential to prevent STI spread,
  • prompt diagnosis and therapy can reduce both complications and spread,
  • therapy should be guided by culture and sensitivity tests when possible,
  • the presence of one STI should trigger a search for others,
  • global resistance patterns should be considered when choosing antimicrobials.

It is also worth pointing out that the treatment options for some of the most serious STIs remain very limited (e.g. HBV)142. For an overview of screening and diagnosis, see Table 4; for general treatment recommendations of the most common STIs see Table 5. These recommendations have been abstracted largely from the guidelines of the Public Health Agency of Canada140 and Center for Disease Control and Prevention141. The reader is encouraged to visit these sites to obtain more complete information:<http://www.phac-aspc.gc.ca/std-mts/sti_2006/sti_intro2006_e. html> and <http://www.cdc.gov/STD/treatment/default.htm>.

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Prevention of STIs

Health care professionals who see international travellers should make advice about STIs a routine part of the pre-travel visit. Among the microbiological risks associated with travel, the STIs are probably second only to malaria in terms of their potential for serious morbidity and mortality. Safer sex and harm reduction counselling should be emphasized. Sexual activity within a stable, monogamous relationship and avoidance of high-risk encounters are the best ways to prevent STIs during travel. Barrier contraceptive devices, specifically male and (possibly) female condoms140,143-145, provide the best alternatives by preventing direct contact with infective genital lesions.

Condoms : Although male and female condoms are likely to have similar efficacy for many STIs when used appropriately, almost all of the available data come from studies of male condom use. Condoms made from latex provide a more effective barrier than “natural” condoms made from animal membranes143. If possible, latex condoms should be purchased in a developed country, since the quality of condoms produced in many regions of the world is inconsistent103. Only water-based lubricants should be used with condoms, since oil-based products (e.g. petroleum jelly, mineral oil, massage oil) can significantly weaken latex condoms and lead to breakage143. High-quality polyurethane condoms are available in most developing world countries for travellers with latex allergies146. The reported efficacy of latex condoms against STIs ranges from 40% to 70%147. The most serious limitation of condoms is behavioural (i.e. failure to use them). The most common factors involved in condom breakage include inappropriate application, repeated or prolonged use, and anal intercourse. Although early studies suggested that spermicides, such as nonoxynol-9, could reduce STI risk148, a recent Cochrane Database review suggests that nonoxynol-9 has no protective effect against a range of pathogens149,150. Too frequent vaginal use of nonoxynol-9 or use in anal receptive intercourse can disrupt epithelial integrity and lead to increased transmission of HIV and other STIs142,149,150.

Table 4. Overview* of STI screening and diagnosis

Clinical presentation (differential diagnosis)

Appropriate investigations and follow-up

Asymptomatic but at risk (i.e. unprotected sexual activity while travelling where STI status of contact(s) is not known)

  • Culture or nucleic acid amplification testing (NAAT) for N. gonorrhoeae from all points of sexual contact (culture only, not NAAT for rectal and pharyngeal specimens), and/or urine for NAAT

  • NAAT or culture for C. trachomatis (urethral, cervical), culture for rectal and pharyngeal specimens (if the only point of sexual contact), and/or urine for NAAT

  • Serology for syphilis to include a non-treponemal test (e.g. RPR, VDRL) or treponemal-specific ELISA (or both)

  • Advise or consider HIV testing

  • HBV serology and offer HBV vaccination if not immune

  • Consider wet mount and/or culture for Trichomonas vaginalis

  • Consider HAV serology especially in the case of oral-anal contact

  • Consider HCV serology especially in the case of IDU history

Genital ulcer(s) (syphilis, HSV-II, HSV-I, chancroid, LGV, granuloma inguinale (donovanosis))

  • Dark field microscopy or immunofluorescence for Treponema pallidum (if available)

  • Serology for syphilis to include a non-treponemal test (e.g. RPR, VDRL) or treponemal-specific ELISA (or both)

  • Culture or NAAT (where available) or antigen test for HSV

  • Consider serology for HSV (if lesions not present or not suitable for above tests)

  • Culture or NAAT for C. trachomatis (which if positive can be sent for DNA sequencing or RFLP to confirm LGV)

  • Culture or NAAT (where available) for H. ducreyi (alert laboratory to suspicion of chancroid diagnosis - not available in most laboratories)

  • Advise or consider HIV testing

  • Follow-up in 3 to 7 days

Purulent urethritis/cervicitis (N. gonorrhoeae, C. trachomatis, rarely HSVI/II)

  • Urethral or cervical swab; or urine specimen for NAAT

  • Gram stain of discharge (looking for > 5 WBCs per oil-immersion field and GC)

  • Culture or NAAT for N. gonorrhoeae (special culture medium required)

  • Culture or NAAT for C. trachomatis

Sexual assault

  • Culture or NAAT for C. trachomatis and N. gonorrhoeae from all partially or fully penetrated orifices (culture only for rectal and pharyngeal specimens)

  • Cultures should be repeated 1 to 2 weeks after exposure in the absence of prophylaxis

  • Urine for NAAT for C. trachomatis and N. gonorrhoeae should also be collected

  • Wet mount and/or culture for T. vaginalis

  • A non-treponemal (e.g. RPR, VDRL) and a treponemal test (e.g. TPPA) for syphilis (repeat at 12 and 24 weeks after exposure and possibly at 2 to 4 weeks after assault if high risk)

  • If patient known to be immune to HBV no testing is required, if not, serum sample for baseline antibodies to hepatitis B surface antigen

  • Baseline HIV antibody (repeat HIV serology at 6, 12, and 24 weeks)

  • Baseline HCV antibody is optional (consider HCV risk of perpetrator and associated trauma during the assault - if performed should be repeated at 12 and 24 weeks)

*This table is designed as a quick reference and is not meant to replace more comprehensive guidelines (e.g. those from the Public Health Agency of Canada140 or CDC141).
RPR = rapid plasma reagin; VDRL = venereal disease research laboratory test; ELISA = enzyme-linked immunoassay; IDU = intravenous drug use; RFLP = restriction fragment length polymorphism; LGV = lymphogranuloma venereum; WBC = white blood cells; TTPA = Treponoma pallidum particle agglutination

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Table 5. Choice of antimicrobial therapy for selected STIs (preferred regimens are listed first, followed by alternatives)

Chancroid
(Haemophilus ducreyi)

Ciprofloxacin 500 mg PO x 1 OR
Erythromycin base 500 mg PO TID x 7 days OR
Azithromycin 1 g PO x 1 OR
Ceftriaxone 250 mg IM x 1 (CAUTION: treatment failure with ceftriaxone commonly reported in HIV co-infected patients)

Bacterial vaginosis

(Characterized by an overgrowth of genital tract organisms, e.g. Gardnerella, Prevotella,Mobiluncus spp., and a depletion of lactobacilli) (not usually considered sexually transmitted)

Metronidazole 500 mg PO BID x 7 days OR Metronidazole gel (0.75%) 5 g intravaginally QD x 5 days OR
Clindamycin cream (2%) 5 g intravaginally QD x 7 days

Granuloma inguinale (Calymmatobacterium granulomatis)

Doxycycline 100 mg PO BID x 21 days (at least)* OR
Trimethoprim-sulfamethoxazole DS (800 mg/160 mg) PO BID for 21 days (at least) OR
Ciprofloxacin 750 mg PO BID for 21 days (at least) OR
Erythromycin base 500 mg PO QID for 21 days (at least) OR
Azithromycin 500 mg PO daily or 1 g PO once per week for 3 weeks (at least)

HSV-II

For severe primary disease, IV acyclovir 5 mg/per kg infused over 60 minutes every 8 hours is optimal, with conversion to oral therapy when substantial improvement has occurred. (In addition to antiviral therapy, analgesia and laxativesmay be required.)

(First episode)

Acyclovir 200 mg PO five times/day x 5 to 10 days OR
Acyclovir 400mg POTID x 7 to 10 days
Famciclovir 250 mg PO TID x 5 days OR
Valacyclovir 1 g PO BID x 10 days

HSV-II (recurrent)

Valacyclovir 500 mg PO BID x 5 days OR
Valacyclovir 1 g POQDx 3 days OR
Famciclovir 125 mg PO BID x 5 days OR
Acyclovir 200 mg PO 5x/day x 5 days OR
Acyclovir 800 mg PO TID x 2 days
(Suppressive therapy may also be considered.)

Human papillomavirus

(For external genital warts)
Patient-applied:
Imiquimod cream (5%) applied to warts QHS 3 x
per week for up to 16 weeks (should be washed
off after 6 to 8 hours)
Podofilox (0.5% solution or gel) applied QHS to
warts x 3 days then 4 days of “rest” for up to 4
cycles
A cycle can be repeated for up to 6 weeks only,
with total dose per day not to exceed 0.5 mL
(There are office-based treatment options,
including cryotherapy, podophyllin 10% to 25%,
bi- or trichloroacetic acid, electrofulguration, CO2
laser ablation, and surgical excision; please refer
to the 2006 PHAC STI guidelines140)

Lymphogranuloma
venereum
(C. trachomatis L1-3)

Doxycycline 100 mg PO BID x 21 days OR
Erythromycin base 500 mg PO QID for 21 days OR
Azithromycin 1g PO once per week for 21 days

Neisseria gonorhoeae

(All regimens should be followed by empiric treatment for chlamydial and non-gonococcal infections.)

Cefixime 400 mg PO x 1 OR
Ceftriaxone 125 mg IM x 1 OR
Ciprofloxacin 500 mg PO x 1 OR (unless not recommended because of quinolone resistance)

Ofloxacin 400 mg PO BID x 7 days OR (unless not
recommended because of quinolone resistance)

Alternative ONLY if quinolones not recommended
and cephalosporin allergy or immediate/
anaphylactic allergy to penicillin:
Azithromycin 2 g PO x 1 OR
Spectinomycin 2 g IMx 1

Chlamydia trachomatis or
non-gonococcal urethritis or
mucopurulent cervicitis

Azithromycin 1 g PO x 1 OR
Doxycycline 100 mg PO BID x 7 days OR
Erythromycin base 2 g/day PO in divided doses x
7 days OR
Erythromycin base 1 g/day PO in divided doses x
14 days OR
(Erythromycin dosages refer to erythromycin base. Equivalent dosages of other formulations may be substituted. If erythromycin has been used for treatment, test of cure should be performed 3 to 4 weeks after completion of therapy.)

Ofloxacin 300 mg PO BID x 7 days

Sexual assault

Cefixime 400 mg PO x 1 OR

Ciprofloxacin 500 mg PO x 1 (unless not recommended because of resistance) AND

Azithromycin 1 g PO x 1 OR doxycycline 100 mg
PO BID x 7 days

(Metronidazole should only be given if positive
test for trichomonas - not for prophylaxis) PLUS
consider
HIV post-exposure prophylaxis (anti-retrovirals, i.e triple therapy such as zidovudine (AZT) + 3-TC + efavirenz)

Should be started ASAP and no later than 72
hours after exposure and continued for 28 days

Hepatitis B immune globulin (HBIG) up to 14 days after exposure and HBV vaccination (if
unvaccinated)

Syphilis (T. pallidum)
(primary)

Benzathine penicillin G 2.4 million units IM x 1 OR
Doxycycline 100 mg PO BID x 14 days OR
Azithromycin 2 g PO x 1
In light of recent reports of failure of azithromycin for the treatment of early syphilis and the rapid development of azithromycin resistance in T. pallidum, this agent should not be routinely used as a treatment option for early or incubating syphilis unless adequate and close follow-up can be ensured, and only in jurisdictions where little to no azithromycin genotypic resistance in T. pallidum has been demonstrated OR

Ceftriaxone 1 g IV or IMQD x 10 days (to be used
in exceptional circumstances)

T. vaginalis

Metronidazole 2 g PO x 1 OR
Metronidazole 500 mg PO BID x 7 days

*Note: Treat until lesions have healed completely. An aminoglycoside can be added to the regimens above if no improvement is seen in the first week of therapy (e.g. gentamicin 1mg/kg IV every 8 hours).


Screening for STIs is appropriate for many travellers who report CSE while abroad151. Such screening should be guided by the nature of the sexual contact and current or past symptoms and could include an examination of the genitals, a cervical/urethral/ anal/pharyngeal swab and/or urine testing, and serologic tests for syphilis, HIV, and possibly HBV and HCV (Table 4).

The morning after " STI pill: Although it may be tempting to “arm” travellers likely to engage in high-risk sexual activities with a morning-after course of antibiotic therapy, this practice is not recommended. Ready access to antibiotics could lead to a false sense of security and increased exposure to STIs not targeted by the therapy provided (e.g. HIV, herpes simplex virus, HPV). Such behavioural effects have recently been documented among CSW152.

Post-exposure prophylaxis for sexual assault victims: The management of sexual assault victims has recently been reviewed153,154. Women travelling for prolonged periods of time in developing world countries should be counselled with regard to risk mitigation strategies in the event of sexual assault. In all such long-term travellers (male and female), verification of hepatitis B vaccination status should be routine. Unvaccinated travellers who have been assaulted should begin active HBV immunization as well as HBIG if a trustworthy product can be found locally. Individuals with incomplete immunization schedules must be reviewed on a case-by-case basis (i.e. complete or re-initiate active immunization with or without HBIG). Although post-exposure prophylaxis (PEP) for HIV using three drugs would be appropriate in many circumstances, these combinations are expensive (e.g. ~ $1,500 for 28 days of AZT +3TC + efavirenz) and would not be appropriate to prescribe for all travellers. Such an expenditure might be reasonable for groups living or working overseas for prolonged periods (e.g. a semester abroad, large international projects). A lower cost strategy for individual travellers might be the purchase of a “starter kit” with a 3 to 5 day supply of PEP drugs ($160 to $260) to initiate PEP rapidly while risk assessment decisions are being made. Should the final risk assessment determine the need to complete a 28-day course of HIV PEP, then the exposed traveller will either need to have the remaining PEP drugs couriered to them or they will need to return home to complete the regimen (Table 4). Prophylaxis for other STIs should be offered if it is unsure whether the patient will return for follow-up, if the assailant has a known STI, if prophylaxis is requested by the patient, or if the patient has signs or symptoms of an STI.While the efficacy of antibiotic prophylaxis has not been studied in sexual assault, prophylaxis should be offered as recommended for treatment of specific infections140.

Unintended pregnancy may also result from sexual assault. The emergency contraceptive pill may be considered for prevention of pregnancy. Treatment should be taken as soon as possible, up to 72 hours after exposure (for maximum efficacy), but may be of benefit up to 120 hours after exposure. The cost is reasonable and may be appropriate to prescribe for female travellers155.

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Special groups

Pregnant women
Pregnancy is also one of the major risks of CSE in any setting. Although limited data are available, pregnancy does not appear to be a major risk factor for the acquisition or evolution of most STIs, although treatment can be complicated by the presence of the fetus. Alternative means of sexual activity during pregnancy (e.g. anal intercourse) can certainly put the pregnant woman at higher risk of STIs.

Children
As a general rule, most children who travel do so with their parents and are relatively unlikely to be at high risk of STIs. However, it is worth repeating that developing world children are common targets of the sex trade6,15.

Adolescents and young adults
Adolescents and young adults are at particularly high risk of acquiring and spreading STIs. The acquisition of new sexual partners peaks in most cultures during the teen and early adult years123.

Immunocompromised hosts
A recent survey of 133 HIV-positive Canadian travellers (93% male) suggested that these individuals are as likely as their non-infected peers to engage in casual sex while overseas (23%) and are just as likely to use condoms inconsistently (only 58%)156. STIs facilitate the transmission of HIV and, conversely, the diagnosis, clinical presentation, and treatment of STIs can be adversely influenced by HIV157-160. Most HIV-positive subjects with an STI can nonetheless be expected to respond to standard therapy (with the exception of neurosyphilis, which can be difficult to treat in those with HIV)140,142,159,161. It is worth noting that HIV testing is increasingly demanded of immigrants and refugees in many countries107,162. There has been a parallel worldwide increase in mandatory HIV testing for long-term, nonresident visas.

The mature or elderly traveller
Sexual activity is a central part of a healthy life at all ages124,125,163). It is important not to make assumptions about the actual or intended sexual activity of either male or female travellers at any age.

Conclusion

Canadians who acquire new sexual partners while travelling, especially those who pay for sex or have multiple CSEs overseas, are at risk of a wide range of STIs. Although the behaviours of some travellers put them at higher risk of contracting STIs, there is no single profile of the at-risk traveller. Condoms can provide some degree of protection against many STIs, but 100% protection cannot be achieved even with meticulous use. Only HAV and HBV can currently be prevented by licensed vaccines. Although drug resistance is more commonly encountered in STIs acquired overseas, all of the bacterial STIs can be treated successfully at the current time if appropriate antimicrobials are chosen. A series of evidence-based recommendations for managing travellers and sexually transmitted infections are presented in the next section.

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Summary and recommendations

Recommendations related to behaviours

  • A frank discussion of sex and STI risk and prevention should be a routine part of pre-travel counselling (AIII).

  • Safer sex and harm reduction counselling should be emphasized (AIII).

  • Abstinence is the only way to avoid STIs altogether (AIII).

  • Monogamous sex with a stable, uninfected travel partner is another way to avoid STIs (AIII).

  • Condoms reduce the risk of most, but not all, STIs (AII).

  • Alcohol and drugs contribute to unhealthy decisions with regard to sexual partners and condom use (AII).

  • Sexual contact with CSW is always a high-risk behaviour (EIII).

  • Men and women with multiple sexual partners at home or a history of STIs are more likely to have CSE while travelling (AIII).

  • Sexual tourism is highly risky with respect to STIs and may be exploitative (EIII).

  • Sexual tourism with minors is illegal (EIII).

  • It is not possible to make any assumptions about who will have CSE during travel (AIII).

Recommendations related to prophylaxis

  • Hepatitis B vaccination should be offered to all travellers who may have CSE (AI).

  • Hepatitis A vaccination should be offered to all travellers who may have CSE (AII).

  • Spermicides should not be used without a condom (AII).

  • Condoms should be used for all casual sexual encounters (male AI, female AII).

  • Condoms should be used that have been manufactured in the developed world and stored appropriately (AI).

  • Condoms must not be reused (AI).

  • Double or “extra strength” condoms should be used for anal intercourse (AI).

  • Natural condoms do not protect against viral STIs and should not be used if reliable latex condoms are available (although they are probably better than nothing) (DI).

  • Condoms must be applied before genital contact and removed before detumescence (AIII).

  • Reuse of condoms and use for anal intercourse will increase the risk of breakage (AII).

  • Oil-based lubricants should not be used with latex condoms (EI).

  • Advice should be provided with regard to post-exposure care if a sexual assault takes place during travel (AIII).

  • Short-course antiretroviral therapy and a course of antibiotics for common bacterial pathogens should be considered as post-exposure prophylaxis for high-risk sexual exposures (e.g. sexual assault) (AII).

Recommendations related to treatment and screening

  • During the pre-travel visit, travellers should be instructed, should one or more CSE occur, to seek STI screening. They should be advised where such screening can be obtained overseas and locally (AIII).

  • Thorough STI screening should be pursued in a returned traveller who acknowledges one or more CSE overseas (AIII).

  • Follow-up screening to rule out HIV, HBV, and HCV transmission is appropriate at 6 months (CSE) or more frequently (0, 1, 3, and 6 months) in the case of sexual assault (AI).

  • All of the possible STIs to which a traveller may have been exposed during CSE should be considered and travellers screened appropriately (AIII).

  • Testing and sensitivity testing should be obtained when appropriate for all bacterial STIs acquired while travelling (AIII).

  • Canadian guidelines for the treatment of STIs should be followed while waiting for culture results (AI).

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* Members: Dr. B.Ward (Chair); Dr. C. Beallor; M. Bodie-Collins (Executive Secretary); Dr. K. Gamble; Ms. A. Henteleff; Dr. S. Houston; Dr. S. Kuhn; Dr. A. McCarthy; Dr. K.L. McClean; Dr. P.J. Plourde; Dr. J.R. Salzman.

Liaison Representatives: Dr. R.J. Birnbaum; Dr. C. Greenaway; Dr. C. Hui; Dr. R. Saginur; Dr. P. Teitelbaum; Dr. M.Woo.

Ex-Officio Representatives: Dr. J. Given, Dr. F. Hindieh; Dr. J.P. Legault; Dr. P. McDonald; Dr. R. Paradis; Dr. C. Reed; Dr. M. Smith; Dr. M. Tepper

Member Emeritus: Dr. C.W.L. Jeanes.

This statement was prepared by Dr. B. Ward and Dr. P. Plourde and approved by CATMAT.

[Canada Communicable Disease Report]