The purpose of this paper is to first discuss the public health impact of STIs, followed by the approaches to their control/prevention in the UK. Unfortunately the public health impact of STIs is negative as it causes or contributes to ill-health. In the UK and other parts of the world, STIs pose enormous challenges for the public health which may be individual well-being, mental health or the burden on health costs. Focus of this paper will be mainly on genital Chlamydia, gonorrhoea, syphilis, HIV/AIDS, and Human Papilloma Virus (HPV – [genital warts]) amongst other STIs due to the reported high rates of infection.
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Sexually transmitted infections affect people of all ages with the greatest occurrence amongst those under the age of 25 years (Nicoll, 1999; Johnson, 2001). In the UK, certain groups of populations are affected more than others thus creating sexual health inequalities. Primary and secondary syphilis occurs more often in the African community than it does in the White community. Gonorrhoea is reported more commonly among some ethnic minorities while Chlamydia infection rates are disproportionately high in the under 25s. Data on ethnic differences in behaviour and infection susceptibility are meagre and the observed differences are not accounted for. Poverty could be attributable to the high incidence rates in the ethnic minorities as STIs are more common in ethnic minorities than among the white majority which might also be a link between an increased risk and belonging to a minority population. In 2004, women aged 16-24 accounted for 74% of all Chlamydia diagnoses in the UK (anonymous). Chlamydia rate of infectivity at national level for young people aged 15-24 is one in nine supporting the level of sexual activity in that group (NHS, n.d).
The conquest of the majority of communicable disease has been one of the main successes of modern medicine. The diseases have presented the highest causes of mortality and morbidity prior the twentieth century. Until the mid twentieth century in Britain, particularly for women, the pleasures of sex were tempered by the dangers of poor health and social outcomes. However, with the development of modern antibiotics and effective vaccines, communicable diseases menace has mostly been contained and remarkably sex became safer.
Although sex became safer, STIs rates have significantly increased in recent years in the UK predominantly from unsafe sex practices arising from various factors like sexual risk behaviours and poor infection control. They have become a major public health concern as highlighted in the National Strategy for Sexual Health and HIV (Department of Health, 2001). The 16-24 year age group comprising of only 25% of the sexually active population but with the largest diagnosis of STI cases of almost 50% of newly acquired infections. Control of STIs is complicated since many of them are asymptomatic. The economic impact caused by STIs is huge on health services with high costs mostly experienced in the management of infection complications in women. However, older women and men are also at risk especially those entering into new relationships after breaking up from a long-standing relationship. Hence there is ample requirement for protecting, supporting and restoring sexual health in people.
Public Health Impact of Sexually Transmitted infections in the UK
Syphilis and gonorrhoea records have been collected for more than 80 years. In England, Wales and Scotland, diagnosis of syphilis and gonorrhoea was recorded highest in 1946, which coincided with the coming back of the armed forces after World War II (Figure 1). A sharp drop was subsequently detected and was linked to the use of penicillin and the re-establishment of social stability.
Figure 1: Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*, 1931 – 2003.
*Corresponding Scotland and Ireland data are excluded as they are not complete from 1925 to 2003.
Source: KC60 statutory returns and ISD(D) 5 data.
During the sixties and seventies, there was a stable rise in STIs diagnosis owing to more relaxed mind-sets to sexual behaviour. There was an upsurge in cases of Syphilis in males, while in women the number of cases continued to be stable. This implied sex among men during that time turned out to be the main route of transmission (CDC, 1999). Yet an increase in diagnosis was recorded in both males and females for gonorrhoea, genital warts and genital herpes signifying that these infections were acquired during heterosexual sex. Probably the rise in a small number of the STIs could have resulted from enhanced diagnostic sensitivity or public awareness, adding to higher rates of infectivity.
However, in the early eighties, HIV and AIDS were first reported which supposedly had considerable effect on other serious STIs. A brisk drop of syphilis and gonorrhoea diagnosis was experienced in early to mid- eighties. This happened simultaneously with the widespread AIDS coverage of embracing of safer sex behaviours, and resulted in a subsequent decline in transmission of HIV amongst male homosexuals (Bosch, 1995).
Sexually Transmitted Infections Trends
Since 1999 to mid 2004, cases of Chlamydia infection rose by 108%, gonorrhoea by 87% and infectious syphilis by 486%. Still the young people bear the greatest burden. In 2001, women under 20 years of age had reported cases of 42% from gonorrhoea and 36% of Chlamydia. As reported by the Department of Health (DH), diagnosis of new STIs and other STI diagnosed cases in the UK such as re-infections made in genitourinary medicine clinics (GUM) showed a gradual rise in 1999-2008. The introduction of the National Chlamydia Screening Programme (NCSP) in 2003 and other health screens in England, Wales and Northern Ireland and in 2005 in Scotland resulted in an increase of sexual health screens from 759,770 to 1,219,308. For the same period, there was an increase of HIV tests recorded from 520,278 to 951,148. In 2008, uncomplicated infections from Chlamydia, syphilis, genital warts, and genital herpes rose considerably from 1999. Yet for the same year, cases of new diagnosis of gonorrhoea and syphilis were reported to have dropped.
The National Survey of Sexual Attitudes and Lifestyles (NATSSAL) identified sexual behaviour as the risk of acquiring an STI in the young age groups. The factors included lower age at time of having sexual intercourse for the first time, partners frequently changed, increased likelihood of being involved with concurrent partnerships, irregular use of condoms and the increased chances of being involved with a partner from a high-risk area of the world other than UK (Hughes, 2000; Johnson, 2001, Mueller, 2008; Skinner, 2010). However, the young people act as a core group for the risk of onward transmission to other groups. Thus prevention should be mostly targeted at this core group which would result in economic benefits.
Sexually transmitted infections still exert a major toll on the human population in the UK and other nations worldwide. Bacterial and protozoan infections are curable with antimicrobial therapy, while viral infections are treatable but not curable in the classic sense. STIs can cause immediate pain and suffering, profound psychosocial stress, and serious, long-term health consequences. Many STIs are asymptomatic, and surveillance systems to track STIs are incomplete in developed and developing countries. STIs have been shown to be important cofactors in HIV transmission (Fleming, 1999). New approaches to STI control and prevention are needed to reduce the spread of infection and minimize associated suffering.
Chlamydia trachomatis is the most widespread bacterial pathogen transmitted through infected secretions and mucous membranes of urethra, cervix, rectum, conjunctivae and throat following unprotected sexual contact with an infected partner. In addition, an infected mother can infect her baby during vaginal delivery. It is the most commonly diagnosed STI in individuals under 25 years in the UK (Fenton, et al, 2001; Creighton, et al, 2003). Most people infected with Chlamydia show no symptoms until a diagnostic test is performed and in most cases they do not seek medical care. Thus, in those individuals affected by the disease, if efficient and effective health measures are not administered, the STI has the potential of causing a significant amount of health complications to women’s well-being including infertility and pelvic inflammatory disease (Golden, et al, 2000; Garnett, 2008). There is also greater risk in those with recurring infection and untreated infections to spread to other reproductive organs resulting in chronic pelvic pains (La Montagne, et al, 2007). The number of diagnosed episodes of Chlamydia infection has been rising over the past 10 years (Figure 1). Furthermore, the economic impact of Chlamydia infections on the health service is enormous with high cost in the management of female health complications arising from Chlamydia infection (Garside, 2001). Because of the impact of Chlamydia infection on the health of young people, it is important to identify and treat infected patients and their partners and as a result reduce the burden of the disease on the people and health systems.
Figure 1: Rates of genital Chlamydia infection by sex and age group (1995 – 2004).
Source: Health Protection Agency, London
In men Chlamydia infection causes epididymo-orchitis and urethritis. Also rectal pain, discharge and bleeding occur from proctitis which is from infection of the rectal mucosa. Additionally, since the incubation phase of gonorrhoea is less than that of Chlamydia, individuals can develop dysuria after their treatment for gonorrhoea causing postgonococcal urethritis.
In nearly three decades, ever since HIV was first identified, HIV infection has turned out to be a deadly disease and has caused a disturbing adversity to humans, in almost all areas of life. In the early eighties, when the first few cases of AIDS were reported, few might have realised its propensity to become a global public health problem. The UK is facing a sexual health crisis. Between 1999 and 2002, HIV prevalence rose by about 20% annually, and almost a third of HIV-positive individuals did not know their HIV status (HPA, n.d.). Furthermore, the increase in rates of HIV infections could be brought about by the rise in STI incidences in the public as already highlighted in this paper. The number of newly diagnosed cases of HIV increased by 55% from 2000 to 2002 (DH, n.d.). In 2004, a minimum of 49 000 individuals had HIV in England. In the late 1980s and early 1990s in the UK there was a significant drop in STIs figures in reaction to the awareness campaigns on HIV.
The disturbing extent of its increase, infection, very long incubation phase, secondary susceptibility of spread and the absence of a vaccine to prevent it calls for the attainment of comprehensive information about the disease. Currently AIDS prevention mainly relies on health education and behavioural modifications based on AIDS awareness, predominantly in the high risk group of young people.
Gonorrhoea infection is caused by an organism, Neisseria gonorrhoeae (N. gonorrhoeae) which is highly infectious and a bacterial sexually transmitted pathogen. In heterosexuals, its occurrence is associated with age (<25 years), black ethnicity, and socioeconomic deprivation (Bergen, 2006). Estimates from the Health Protection Agency have suggested that the disease may possibly be more common in men who have sex with men than in heterosexual men (McMillan, 2000; Bignell, 2006). At the endocervix and urethra in women, the disease is also asymptomatic, and usually (>90%) asymptomatic in the rectum and oropharynx in both women and men (Hook, 1999; Knox, 2002). In the GUM clinics and various health services, testing for N. gonorrhoeae is a core factor of screening for STIs. Although there is not much evidence to direct testing, every mucosal site correlated with the disease symptoms ought to be tested for infection (Barlow, 1978; Harry, 1997; CDC, 2002; Ghanem, 2004; Bergen, 2006). Screening measures are subjective to an individual’s sexual history and repeat screening may be encouraged (Miller, 2003). Gonorrhoea incidence falls by 11% in the UK: The number of new gonorrhoea infections in the United Kingdom fell from 18 649 in 2007 to 16 629 in 2008, the lowest number recorded since 1999.
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Syphilis is caused by infection from Teponema pallidum subspecies pallidum, is a mucocutaneous STI with high infectivity the early infectious stages. It may also be transmitted through the placenta in pregnant women from week nine of gestation onwards. Screening is recommended for all asymptomatic patients attending GUM clinic or those attending other health services are referred appropriately (Nicoll, 2002). Incidence of syphilis also showed a 4% fall, from 2633 in 2007 to 2524 in 2008, (HPA, n.d). Over the last year, there has been almost three times the number of heterosexual cases of syphilis in south London than were diagnosed in 2001 (25 in 2001, 72 in 2002 and over 40 cases in the first five months of this year) (HPA, 2008).
Human Papilloma Virus
The spread of genital HPV is normally spread during intimate, skin to skin or sexual contact. It is also asymptomatic and can be dormant for years. HPV high risk strains are 16, 18, 31, 33 and 45, which are likely to increase the probability of getting cervical cancer. These strains exist in nearly every woman with cancer of the cervix. Although HPV testing is still not regularly accessible, the National Health Service is considering it to be included in the screening programme of cancer of the cervix. Women who test positive for high risk types of HPV are more likely to need treatment for borderline or mildly abnormal cervical smears. Although in ninety percent of HPV cases, clearance of the virus occurs naturally within two years. Yet, continued use of condoms may possibly facilitate in lowering the risk of infection from genital HPV. Infection from HVP is now being prevented through administration of vaccines for types of HPV that causes cervical cancer. The Gardasil and Cervarix cervical cancer vaccines were licensed in the UK in 2007.
However, the genital warts strains 6 and 11 which can be diagnosed by inspecting the genital area of an individual and are usually in the form of small (or large) bump or groups of bumps. They normally develop within weeks or months following sexual contact with an infected partner who might be asymptomatic. Sometimes if treatment is not administered, they might disappear, or remain unaltered and not cancerous.
Approaches to prevention and Control of sexually transmitted infections
The health of the people and the social and economic success of the UK are extremely connected. The related economic and social costs to public health are enormous and surpass UK’s future. Marmot’s (2010) six recommendations further support the prevention and control of STIs in UK’s population. In two of the six recommendations he states that, “enabling all children, young people and adults to maximise their capabilities and have control over their lives” and that of “strengthening the role and impact of ill-health excellent well-being over their lives”. It is vital that UK’s population is educated on sexual health issues so that they are able to make well informed sex decisions that contribute to their well-being and reducing the burden caused by STIs. Marmot’s report further emphasised other research work (Picket & Wilkinson, 2009) that “it is not only the poor who suffer from the effects of inequality, but the majority of the population”. High priority should therefore be given to the integration of STI control measures into primary health care. The worldwide interest in and resources committed to preventing AIDS provide a unique opportunity for health workers to make considerable progress in controlling the other STIs.
Sexually transmitted infection control programmes have been and will continue to be the most prominent in public health management and have been at an increase since the mid nineties with rates of unwanted pregnancies still being reported to be high. Strategies to prevent transmission of organisms spread by intimate human contact must remain flexible and adapt to the social, technical, clinical, financial and political realities. A strategy of primary prevention, based on sexual behavioural change combined with the provision of adequate clinical services, is vital for the control of STI. In response to the re-emergence of these diseases in the UK, it was decided by the Department of Health to open for the first time ever STD clinics across the country to help reduce the burden of the STIs. These clinics are staffed with a multidisciplinary group of specialists that offer sexual health services to different age groups of the community.
Given the unequal burden of STIs for young people, it is imperative to ascertain effective prevention programmes. Although enhancing access to Chlamydia testing has been an important and urgent focus of Chlamydia awareness programmes and has led to renewed efforts to increase access to Chlamydia testing (WHO, 2001; Santer 2000; Santer, 2003). As more people including this identified group learn their Chlamydia status, and in recognition of the long latent period of the disease before symptoms prevail, factors related to Chlamydia awareness remain crucial to identify in order to design comprehensive Chlamydia management services that meet the needs of the population at risk of infection (Brabin, et al, 2009).
A study by Shiely, et al (2009) showed that in Ireland, age specific behavioural interventions could be effective by targeting increased use of condoms to decrease STI incidences. Also in order to boost condom use, a 5% reduction from 13.5% in taxation on condoms could be implemented at policy level. Other studies also revealed age as a risk factor for STI transmission and to that regard there should be enhanced sex education promotion to the target group to enhance behavioural changes (Manhart, et al, 2004; Fenton, et al, 2005). A further study also showed that diagnosis of a viral STI was not associated with multiple partners but however it was possible for females who had more than one sexual partner to be more likely to use protection since they will be more experienced and aware of STI infection (Fenton, et al, 2005).
Although condom use has increased in prevalence almost everywhere, but rates remain low in the UK and many other developing countries. The huge variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.
Accomplishing excellent sexual health for the population of the UK has always created its own distinctive challenges. Meagre sexual health is often disproportionately impacting on those who are already at risk and experiencing inequalities, for instance the young people, black and minority ethnic groups, those in lower socio-economic class, and gay men. While there has been so much public health interest and commitment of resources to preventing AIDS, an opportunity exists for health workers to make significant progress in the control of other STIs as well. Thus the need for comprehensive behavioural interventions that would tackle the social context for individual-level programmes, support and sustainability of behavioural change, and the structural factors that is contributory to risky sexual behaviour.
The National Institute for Health and Clinical Excellence (NICE) suggested the need for health professionals to identify individuals at higher risk of becoming infected with STIs, ascertained by one’s sexual history, and organize one to one talks to minimise the risk of infection. However, the sexual health guidance recommends a variety of circumstances for assessing risk of infections which include opportunities where a health professional discusses with a patient contraception, abortion or pregnancy or when conducting cervical smear test, giving an STI test, giving travel immunisation, and during regular care or a new registration by a patient. Any individual identified to be at high risk of getting infected, should be referred to trained health worker for one-to-one talks in an attempt to minimise risky behaviour. Additionally for those who have been tested positive, should be assisted in having their partners tested and treated.
Responsibility for the National Chlamydia Screening Programme (NCSP) was taken over in 2005 by the Health Protection Agency from the Department of Health. Screening is conducted in various locations across the UK, the main ones being youth services, community contraceptive services, general practices, education premises (universities or colleges). Statistics for the programme have revealed that more women are getting screened than men, while an increased number of men are testing positive. Efforts are still being made in most areas to attempt to tackle this variance in trying to reach out to the young men. More partnership work is required to tackle the variances including that of offering screening in health clubs such as gyms and boxing clubs. Although diagnostic testing in sexual health has now been increasingly quicker and easier for patients and the staff, it is crucial that care was personalised especially when engaging with a health worker. Since STIs are prevalent in both asymptomatic and symptomatic individuals, due to their behaviour, diagnosis, management and follow up require skilled and trained individuals. If a health worker is adequately trained and has knowledge of STIs, it helps in preparing the patient for an STI test and understanding the effects if the test was to be positive.
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