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Sexually transmitted infection - an update

• some STIs have potentially serious outcomes for physical and psychological health and may have an adverse impact upon relationships
• some favour the spread of HIV infection
• some cause serious ill health in mothers and babies, and may cause infertility [7].

• The problem of HIV infection in the United Kingdom (UK) intensified during 2002. The estimated overall prevalence of HIV infection in adults increased over 12 months by 20%. By the end of 2002 there were an estimated 49,500 people living with HIV in the country. The key factors driving this increase were a possible expansion of HIV transmission in homo/bisexual men and continued migration of HIV-infected heterosexual men and women from sub-Saharan Africa.
• Despite the large increase in the use of combination anti-retroviral therapy (ARV) in individuals with diagnosed HIV infection, and the various targeted health promotion campaigns, the surveillance data suggest that HIV transmission may be increasing in homo/bisexual men. In 2002, 5.4% of homo/bisexual men in London attending seven genitourinary medicine (GUM) clinics were infected with HIV and were unaware of their infection, as were 4% of those aged under 25; a clear indication of continuing HIV transmission at relatively high levels.
• Monitoring recent HIV seroconversions, using a serological test algorithm, has shown that the incidence of HIV infection in homo/bisexual men attending 15 GUM clinics throughout England, Wales and Northern Ireland has risen in 2002 to over 3% per annum. Against the background of a sustained increase in homosexually acquired gonorrhoea over three years, 12% of homo/bisexual men who were aware of their HIV infection prior to their GUM clinic attendance and 38% of those who were previously unaware of their HIV infection, were also infected with an acute STI. While the uptake of voluntary confidential testing (VCT) for HIV in homo/bisexual men increased from 45% in 1997 to 62% in 2002, of those who could potentially have had their HIV infection diagnosed, 59% remained undiagnosed after leaving the clinic.
• The HIV situation in heterosexual men and women born in sub-Saharan Africa deteriorated in 2002. The annual number of infections newly diagnosed increased still further to over 2,300 cases, the prevalence of previously undiagnosed infection in heterosexual GUM clinic attendees increased to 4.9%; and overall HIV prevalence in pregnant sub-Saharan African women increased to 2.5%. The vast majority of heterosexuals born in sub-Saharan Africa, however, are not infected with HIV: 90% of GUM clinic attendees and 98% of pregnant women surveyed in 2002.
• Over the past five years there has been a steady increase in the number of diagnoses of HIV infection in people who are thought to have acquired their infection heterosexually within the UK, from 147 in 1998 to 275 reported so far for 2002. In heterosexual GUM clinic attendees born in the UK, prevalence of previously undiagnosed HIV infection increased three-fold in men since 1997 to 0.3% in 2002, while in women there has been no change.
• Overall, HIV prevalence in injecting drug users (IDUs) attending specialist agencies remained low, at less than 1%. Equipment sharing rates continued to be high. In those who had begun injecting in the previous three years, the prevalence of hepatitis C antibody was 14%.
• In 2002, increases in the major acute bacterial and viral STIs continued unabated. In England, Wales and Northern Ireland, 82,206 new diagnoses of genital Chlamydia trachomatis infections were reported, representing a 141% increase since 1996 and a 14% increase over the previous year. Increases of a similar magnitude were observed for gonorrhoea with 24,958 new infections being diagnosed in 2002, a 9% increase over the previous year. In Scotland, laboratory reports of chlamydial infection rose by 290% between 1996 and 2002. The most marked increases in the UK were however seen in new reports of infectious syphilis. In England, Wales and Northern Ireland, the 1,232 reported cases in 2002 represented a 902% increase since 1996 and a 68% rise over the previous year. Rises in viral STIs such as genital warts and genital herpes infections were also seen, however these have continued to increase at a much lower rate than the bacterial STIs.
• The available surveillance data confirm the substantial variations in the distribution of HIV and STIs in the general population. High infection rates continue to be found amongst those with high rates of sexual partner change, in particular homo/bisexual men and young heterosexuals. As the likelihood of STI transmission is dependent on the average duration of infectiousness, disease rates are also high among those with poor access to curative health services. This is particularly relevant in a context of recent increases in waiting times for GUM clinic appointments [10]. It is also highly relevant to population sub-groups for whom stigma or discrimination prevent access to and uptake of treatment and care services [11].
• Marked geographic variations in disease occurrence exist, with a concentration of the HIV and STI epidemics in Greater London. However, other parts of the country are not exempt from the burden of sexual ill health as demonstrated by the recent outbreaks of infectious syphilis [12] and ciprofloxacin resistant gonorrhoea [13].

• Reviewing and strengthening primary prevention efforts directed at homo/bisexual men
• Offering and recommending annual HIV testing to homo/bisexual men attending GUM clinics
• Promoting further voluntary confidential HIV testing of migrants from sub-Saharan Africa presenting at GUM clinics
• Developing further studies of the sexual behaviour within the UK of migrants from sub-Saharan Africa and HIV positive individuals in order to better inform primary and secondary prevention efforts
• As the numbers of HIV infections due to heterosexual transmission within the UK rises, surveillance resources devoted to risk factor follow-up of newly diagnosed HIV-infected heterosexuals should increase to ensure there is no loss of timeliness in monitoring this evolving situation
• Reducing the current lengthy waiting times to GUM clinics
• Stepping up the implementation of the National Chlamydia Screening Programme (by increasing the number of locally funded programmes) to reduce the prevalence of genital chlamydial infection and its sequalae
• Extending routine screening for infectious syphilis to sexually active HIV positive homo/bisexual men attending all centres providing treatment and care. Research is also needed to determine the impact of syphilis outbreaks on HIV transmission amongst homo/bisexual men
• In view of increases in gonococcal antimicrobial resistance, reviewing and disseminating updated national guidelines for the treatment of gonococcal infections which should encourage regular local audit of therapeutic efficacy
• Finally, as the public debate continues over the proposed Human Tissue Act [14] [15], continued emphasis of the public health value of large scale Unlinked Anonymous testing of clinical specimens that would otherwise be discarded is required

• An independent advisory group to report on the strategy's progress
• A sexual health and HIV commissioning toolkit to support PCT and local authority plans from April 2003
• In autumn 2002, a national campaign to explain the risks of unprotected sex
• A review of the evidence base for local HIV and STI prevention by the HDA
• A set of service standards for treating HIV and STIs to be in place by 2003
• National roll-out of a £1.5m chlamydia screening programme from this summer
• Target groups at special risk through partnerships with the voluntary sector. (www.doh.gov.uk/sexualhealthandhiv/)

• Between 1999 and 2000 the number of reported diagnoses of chlamydia in the UK (except Scotland) increased by 20% in males and 17% in females
• During 2000, 3,723 new cases of HIV infection were diagnosed in the UK. Since records began, a cumulative total of 49,715 cases have been reported
• The monetary value of preventing a single onward transmission of HIV is estimated to be £0.5-£1 million in terms of individual health benefits and treatment costs http://www.hda-online.org.uk/hdt/0802/evidence.html

• Re-asserting the recommendations made in the BMA’s 2002 STI report. In particular:
  • Campaigning for education strategies that increase young people’s knowledge of the full spectrum of STIs are essential [18]. In particular developing skills, such as negotiating in relationships and accessing/using sexual health services [19]. Well-designed sex education programmes have been shown to be effective [20] and education tailored for adolescents, which supports and promotes healthy behaviour and attitudes regarding sexual health.
  • Promote positive health behaviours among individuals who are infected with STIs – to seek treatment and to practice safer sex.
  • Renew ‘safer sex’ campaigns/messages: educating individuals about the importance of using condoms and signs of such diseases as summarised above. Given the rise in the number of STIs recorded, the need for renewed health promotion efforts cannot be over-emphasised.
  • Promote openness in discussing sexual matters and practice.
• Campaigning for improved access to contraceptive [21] and GUM services across the UK.
• Campaigning for effective implementation of the National Strategy for Sexual Health and HIV in England.
• Contribute to the development of the Sexual Health Strategy for Scotland.
• Continue to keep a watching brief on forthcoming research and policy and ensure that the voice of sexual health is strong