Sex and travel: studies of sexual behaviour, disease and health promotion in international travellers--a global review

Do travel clinic visitors read information on sexual risk abroad in travel health brochures?

BACKGROUND

A substantial proportion of travel clinic visitors have sexual encounters while abroad. Hence, guidelines on travel health recommend discussing sexual risk in a pre-travel consultation. However, previous studies showed that it often is not discussed. Although travel clinic visitors usually do receive written information on sexual risk abroad, few data are available on whether this information is read. Therefore, this prospective cohort study in travel clinic visitors was performed.

METHODS

Travel clinic visitors were invited to complete a questionnaire after return from their journey.

RESULTS

A total of 130 travellers (55%) responded. Half of them recorded they read the information on sexual risk. Male gender (OR 9.94 95% CI 3.12 - 31.63) and 'travelling with others' (OR 2.7 95% CI 1.29 - 5.78) were significant independent predictors of reading the information on sexual risk. High risk travellers, i.e. those travelling without a steady partner, were less likely to have read it. Although websites and apps were mentioned as better methods of providing information, none of the participants visited the websites on sexual behaviour and sexually transmitted infections recommended in the travel health brochure.

CONCLUSION

Only half of travel clinic visitors read information on sexual risk in the health brochure received in the clinic and none of them visited the related websites mentioned in the brochure. Further research to identify the most effective way to inform travellers about sexual risk is needed.

Exotic imported travel-related infections in Japan

Human social and economic activities as well as changes in the global environment are responsible for outbreaks of emerging and re-emerging infectious diseases. We have encountered 5 cases of asymptomatic schistosomiasis in Japanese travelers who were exposed to cercariae-contaminated freshwater in east Africa. Because all 5 travelers showed normal results upon their return medical examination, Schistosoma, which is not indigenous to Japan, was unfortunately not suspected as the causative agent of this chronic and silent infection. In addition, in 2008, we experienced 2 Japanese cases in an exotic and local pandemic of human trichinellosis which was associated with eating raw soft-shelled turtles in Taiwan. The cause of this emerging pandemic can be attributed to the traditional custom of eating raw soft-shelled turtles. It is important for all travelers to understand that anyone at anytime can be exposed to the threat of a pandemic; therefore, the first step for all travelers is to be aware of worldwide endemicity and keep up to date on the infectious diseases that are prevalent. Concurrently, it is important to identify the presence of slowly and silently expanding infectious diseases and establish surveillance systems to detect not only serious emerging infectious diseases but also chronic and silent infections.

Relationships between female tourists and male locals in Cuzco/Peru: implications for travel health education

BACKGROUND

Health concerns regarding casual sexual encounters during travel have been recognized for some time. The perception that female travellers' motivations are more romantic rather than sexual when entering a relationship with local men may exclude them from receiving appropriate travel health advice. This may pose even greater health risks, not only to themselves but also to their local partners.

METHOD

This paper presents 11 Western female tourists' perceptions of their relationships with local men in Cuzco/Peru, based on in-depth interviews, observations, and informal discussions.

RESULTS

Relationships with local men were often triggered by their physical appearance. Other themes identified were: methods and location of first contact, benefits for the local men, safe sex/condom use, and travel health advice received.

CONCLUSIONS

The findings support calls for more emphasis on sexual health in travel health education. Three aspects should be included: 1) an awareness that unfamiliar environment can cause 'out of character' behaviour, 2) an emphasis on not only to use but to not stop using condoms, and 3) the need to acquire negotiation skills.

On holiday: a risk behavior profile for men who have vacationed at gay resorts

Sexual risk behavior is higher when people vacation as compared to when they are at home. The current study uses survey data to compare sexual risk behavior of gay men who vacation at gay resorts to those who do not. Independent predictors of vacationing at gay resorts included income level, relationship status, ever having attended a circuit party, and HIV serostatus. For men who visit resorts to meet sex partners, independent predictors included relationship status, ever having attended a circuit party, HIV serostatus, number of male sex partners in the past six months, and number of anal insertive male partners using a condom. These results show a need for the development of structural interventions in the gay resort and hotel setting.

Sexual behaviour and HIV/sexually transmitted infection risk behaviours in the general population of Slovenia, a low HIV prevalence country in central Europe

Objectives:

To describe sexual and HIV/sexually transmitted infection (STI) risk behaviours in Slovenia.

Methods:

A nationally representative cross-sectional survey of the general population aged 18–49 years in 1999–2001 was conducted. The data were collected by face-to-face interviews and anonymous self-administered questionnaires. Statistical methods for complex survey data were used.

Results:

849 men and 903 women were interviewed. In the past 5 years, both men and women reported a median of one heterosexual partner (means 3.2, 1.5, respectively), concurrent heterosexual partnerships were reported by 24.4% of men and 8.2% of women, heterosexual sex with non-Slovenian partners by 12.6% of men and 12.2% of women, forced sex by 4.8% of women, paid heterosexual sex by 2.6% of men, sex with another man by 0.6% of men and heterosexual sex with an injecting drug user by 1.2% of men and 1.3% of women. In the past year, 22.7% of men and 9.5% of women reported forming at least one new heterosexual partnership. The mean numbers of episodes of heterosexual sex in the previous 4 weeks were 6.1 for men and 6.0 for women. Consistent and inconsistent condom use was reported more frequently among men reporting multiple female partners and those not married or cohabiting.

Conclusions:

Recent patterns of reported sexual behaviour are consistent with a low risk of HIV and STI transmission in Slovenia. The results will inform Slovenian sexual health policies including HIV/STI prevention, and are particularly valuable because population-based data on HIV/STI risk behaviour have not previously been available in low HIV prevalence countries of central Europe.

Understanding sexual relationships between tourists and locals in Cuzco/Peru

BACKGROUND

Casual sexual encounters between tourists and locals have been increasingly discussed. The city of Cuzco/Peru is well known for an increased availability of such sexual opportunities. The objective of this study was to explore tourists' and locals' knowledge, attitudes, and reasoning for engaging in casual sexual relationships.

METHOD

In this qualitative study, 10 locals and 13 tourists were in-depth interviewed (15 women, 8 men, aged 19-50+). Participant and non-participant observations, and informal discussions provided supporting evidence.

RESULTS

For tourists, the relationships with locals ranged from one-night-stands as part of the travel experience and having fun, to commitment for the term of a longer stay, to marriage. From the locals' point of view, these encounters ranged from sexual adventures to increase self-esteem and high standing in their circle of friends, to serious long-term commitments. In both cases, the difference in the physical appearance played a main part in the perceived attraction that had triggered the encounter. Lack of consistent condom use remains a concern along with the locals' profound lack of knowledge of STIs.

CONCLUSIONS

Travel health advisors should place more emphasis on sexual health in pre-travel consultations. The use of condoms cannot be stressed enough. Local health professionals should aggressively increase safe sex health promotion, specifically targeting people related to the tourism industry.

Sexual health and HIV in travellers and expatriates

Travellers engaging in sexual contact with a new partner abroad may be at high risk of acquiring a sexually transmitted infection. This review examines the impact of travel on sexual health and provides prevention, management and treatment recommendations to practising occupational health physicians.

HIV prevention among travelers: why do men not use condoms when they engage in commercial sex overseas?

OBJECTIVES

We investigated factors associated with condom use among men patronizing female sex workers abroad and locally.

STUDY DESIGN

We conducted a survey on 372 local men attending the only public sexually transmitted infections clinic in Singapore between 2001 and 2003.

RESULTS

Condom use was higher among clients patronizing sex workers in Singapore than those patronizing sex workers abroad (87.5% vs. 54.4%, P<0.001). Condom use in both groups was associated with initiation of condom use by the sex workers (adjusted prevalence ratios: 1.67, 95% confidence interval: 1.11-2.49; 1.87, 1.21-2.90) but was not associated with clients' knowledge of disease, self-perceived risk, confidence in condom use, and dislike of condoms. Less sex workers abroad than in Singapore (32.7% vs. 75.6%, P<0.001) initiated condom use.

CONCLUSION

Lower condom use among Singaporean travelers abroad was determined by extrinsic factors, whereby sex workers abroad were less likely to initiate condom use rather than by clients' factors.

Travel and sexually transmitted infections

Increasing population mobility and increasing frequency and variety of sexually transmitted infections (STI) are closely linked around the globe. Although all mobile populations are at increased risk for acquiring STIs, international travelers are the focus of this review. Several aspects of travel such as opportunity, isolation, and the desire for unique experiences all enhance the likelihood of casual sexual experiences while abroad. The situational loss of inhibition of travel can be markedly enhanced by alcohol and drugs. Several of the most important elements of the complex interaction between travel and STIs are discussed.

Sexually transmitted infections and HIV among travellers: A review

Sexually transmitted infections are often acquired during travel. Infections are most often seen in young adults, travelling without a regular partner and among those who have higher numbers of partners while at home. Alcohol and recreational drug use may increase risk. The risks are highest from having unprotected sex with local partners in developing countries where the prevalence of infection can be many times higher than at home. The risks of acquiring HIV are highest in Africa, followed by South Asia. Special precautions are required by those going to work in health-care settings in high HIV prevalence countries. Travellers may benefit from advice about safer sex, condom use, emergency contraception and vaccination against hepatitis B. In special circumstances a starter pack for HIV post-exposure prophylaxis should be considered. Following return travellers should consider attending specialist services for a screen for sexually transmitted infections and HIV if they are concerned about exposure whilst travelling. A number of reports suggest that travel clinics need to pay more attention to the sexual health of travellers.

Chlamydia trachomatis infection in Sydney women

BACKGROUND

In Australia, reported rates of Chlamydia trachomatis infection have been rising progressively since the mid-1990s. Opportunistic testing of sexually active young women attending clinical services for other reasons has already been implemented in a number of other countries.

AIMS

To help guide chlamydia testing of women, this study aimed to establish factors predictive of chlamydial infection in an Australian clinical setting.

METHODS

Women attending a sexual health service in Sydney who tested positive for C. trachomatis by polymerase chain reaction and who did not have any concurrent urogenital infections (n = 170) were compared with chlamydia-negative controls (n = 170). Factors independently associated with chlamydia were determined using logistic regression.

RESULTS

Although they were present in only a minority of infected women, symptoms of dysuria [adjusted odds ratio (AOR) = 3.2 (95% CI: 1.2-9.1), P = 0.03] and postcoital bleeding [AOR = 2.7 (95% CI: 1.0-7.1), P < 0.05] were each independently associated with chlamydia. Symptoms of vaginal discharge (P = 0.3), abdominal pain (P = 0.2), or intermenstrual bleeding (P = 0.1) did not help to discriminate between infected and uninfected women. The following factors were independently associated with chlamydia: younger age (P = 0.003); being overseas-born [AOR = 2.3 (95% CI: 1.3-4.0), P = 0.005]; sex with a partner from overseas [AOR = 2.0 (95% CI: 1.3-12.3), P = 0.01]; and sex with a partner known or suspected to be chlamydia-infected [AOR = 7.4 (95% CI: 3.6-15.0), P < 0.001].

CONCLUSIONS

Chlamydia testing is clinically indicated in sexually active young women with dysuria, postcoital bleeding or contact with a suspected chlamydia-infected partner. Consideration should be given to enhanced screening programs for travelling and migrant men and women in Australian cities.

HIV and sexual health knowledge and sexual experience among Australian-born and overseas-born students in Sydney

PURPOSE

To examine differences between Australian-born and Asian-born first-year university students in Sydney in their sexual behavior and knowledge about the prevention and transmission of human immunodeficiency virus (HIV) and other sexually transmissible infections (STIs).

METHODS

Students were recruited from a stall during the student Orientation Week in both 2002 and 2003 at the University of New South Wales. A short questionnaire was completed and returned anonymously. Data on age, gender, country of birth, sexual behavior, and sexual health knowledge were collected. A score was calculated based on the sum of the correct answers given to 12 HIV/STI transmission and prevention questions. The students were then divided into three groups according to their country of birth (Australia, Asia, and elsewhere) and their knowledge scores were compared. Students born in certain Asian countries were also asked their perception of the HIV epidemic in their home country compared with Australia.

RESULTS

A total of 1185 first-year students completed the questionnaire. Although older on average, Asian-born students were less likely to have had sexual intercourse and had had fewer sexual partners. They also had consistently poorer HIV/STI knowledge scores than Australian-born students. Students born in China, Hong Kong, Indonesia, Malaysia, and Singapore but not Thailand underestimated the prevalence of HIV in their country of birth in comparison with Australia.

CONCLUSION

The combination of poorer knowledge, apparent misconception of the extent of HIV epidemic in their home country (or Australia), and potential later frequent travel indicates a potential risk for later transmission of HIV/STIs. The university is an underused setting for prevention health education.

Sexual tourism: implications for travelers and the destination culture

Health care providers in a variety of settings need to improve their ability--along with the capabilities of supporting laboratories, surveillance systems, and services for sex partner management--to diagnose and treat STI. Whether the travel health care sector, as such, is willing to take on the additional burden of STI-related screening and risk reduction counseling has been raised by some authors. Currently, the burden of providing formalized STI care falls on the public sector; however, in the United States, most STI are actually diagnosed in the offices of private physicians. Given that the United States has the highest STI rates of any industrialized country, the undeniable synergy between STI and HIV acquisition, the failure of many American providers to screen for C trachomatis despite clear guidelines, the global resurgence of syphilis and extension of resistant N gonorrhoeae and of HIV, and the risk behaviors consistently reported by travelers, it is hard to argue against travel specialists' joining the daunting battle against these recalcitrant infections and their often devastating consequences. Most of the relevant diagnostic tests are relatively affordable, and patient-centered risk-reduction counseling, once mastered, can be brief and easily integrated into the overall conversation about protecting oneself during travel.

Quality of travel health advice in higher-education establishments in the United Kingdom and its relationship to the demographic background of the provider

BACKGROUND

The number of international trips undertaken by residents of the United Kingdom has risen dramatically over the past 50 years. Likewise, the numbers studying in higher education have also shown a huge increase. This study aimed to assess the appropriateness of advice given to traveling students by higher education-based health services and to relate this to the demography and experience of the professionals involved.

METHODS

A postal questionnaire describing three hypothetical groups of students traveling to different parts of the world was sent to 335 doctors and nurses. These clinicians belonged to the British Association of Health Services in Higher Education. They worked in 105 practices that serve higher-educational establishments in the United Kingdom. Main outcome measures included whether appropriate immunizations were advised and given correctly through the National Health Service (NHS) or privately, and whether appropriate advice was given regarding malaria, human immunodeficiency virus (HIV), and miscellaneous risks. The sources of information used to advise travelers were also asked, and the effect of demographic characteristics of the respondents on the quality of advice was investigated.

RESULTS

Two hundred fifteen (64%) questionnaires were returned. The mean score for whether the correct immunizations were advised was 77%, and for whether these were given correctly through the NHS or privately was 79.6%. For malaria, HIV, and miscellaneous risks, the scores were lower at 65%, 38%, and 32%, respectively. The score for correct immunizations was significantly affected by sex, with females respondents scoring higher (p = .036). Previous training in travel medicine improved scores for immunizations (p = .034) and for the correct choice being given through the NHS or privately (p = .006). Age, hours worked, role, and size of practice had no influence on scores. Charts in the general practice free newspapers were the most popular source of information.

CONCLUSIONS

Practices serving higher-education establishments usually give appropriate advice to travelers in terms of the immunizations required, whether these are available through the NHS or privately, and about reducing risks of malaria. This is not the case regarding advice pertaining to HIV and miscellaneous risks. Previous training in travel medicine seems to correlate with the giving of more appropriate advice.

A description of travel medicine in general practice: a postal questionnaire survey

BACKGROUND

Travel-related diseases are important aspects of public health. The number of UK residents traveling abroad is increasing at a rate of 16% a year, thereby increasing exposure to travel-related morbidity. Provision of comprehensive pretravel health advice is essential to reduce this trend. In the UK, pretravel health advice is predominantly provided through general practices.

METHODS

A postal questionnaire was sent to all 91 general practices in South Cheshire Health Authority. The questionnaires were to be completed by the lead advisor in travel medicine for each practice. Questions were asked on service provision, training and reference resources used, subjects advised on, and health promotion material used. Nonresponders were contacted and sent a further questionnaire.

RESULTS

A response rate of 86% (78/91) was achieved. Of the lead advisors, 97% were nurses and 3% general practitioners. Thirty-eight sources of advice were quoted, the commonest of which comprised wall immunization charts (72%). Duration of consultation ranged from less than 5 min to over 30 min, with a median and mode of 11 to 15 min. Most respondents reported advising on most travel-associated risks, 40% of practices lacked a protocol, and 83% of providers had attended a training course on travel medicine for 2 days or less.

CONCLUSIONS

This survey identified inadequacies of training and use of multiple sources of reference which may lead to inconsistencies in advice. Most practitioners could not define their workload in travel medicine. For effective protection of travelers, a careful risk assessment, clear risk communication and health education with detailed health promotion are necessary, but these are not likely to be provided within an average consultation time of 11 to 15 min. There is no evidence of consistent governance, planned training and monitoring of service quality of travel medicine practice. This may be due to lack of a national policy on best practice and guidance in this subject. National protocols with validated information resources, set standards of training, along with adequate consultation time for educating, advising, and prescribing, will lead to improved health of the traveling public.

Sexually transmitted infections in travelers: implications for prevention and control

Sexually transmissible diseases (STDs), the most common notifiable infectious conditions, remain major threats to reproductive and public health worldwide. Travelers are particularly vulnerable to STDs, because of voluntary or involuntary sexual behavior while abroad, and are significant vectors who introduce new pathogens and resistant strains to unaffected parts of the world. This article outlines some key issues that travel medicine specialists and other clinicians should revisit when providing services to travelers. We discuss obstacles to promoting sexual health, including the diversity of the target group, unanticipated opportunities for sexual risk, ambivalent cooperation by the travel and tourism industries, poorly developed travel health sectors, illegal migration and sex tourism, and lack of research about the association between travel and STDs. We also outlined some programmatic aspects of public health that should be identified and addressed for the promotion of sexual health among travelers.

Preparing the traveller

The four steps for giving travellers the foundation for healthy journeys are to assess their health, analyse their itineraries, select vaccines, and provide education about prevention and self-treatment of travel-related diseases. This process takes time. Since there is a risk of information overload, travellers should leave the clinic with some written advice for reinforcement. The order of these steps can be tailored to what best suits the travel clinic, but vaccinating early in the process allows monitoring for adverse reactions. Face-to-face discussion is vital for explaining the use and side-effects of medications. Those who provide a travel medicine service should be seeing many travellers and should seek specialist training. In 2003, the International Society of Travel Medicine introduced a certificate of knowledge examination in travel medicine. We cannot make travellers bullet-proof but it is possible to make them bullet-resistant. The pre-travel visit should minimise health risks specific to the journey, give travellers the capability to handle most minor medical problems, and allow them to identify when to seek local care during the trip or on return.

Travel epidemiology--a global perspective

In order to have a rational approach to necessary preventive measures it is essential to know the health risks. The 80 million travellers each year with destinations in Africa, Asia, Latin America, Pacific Islands and remote areas in Eastern Europe are exposed to a broad range of pathogens that are rarely encountered at home. The risk depends on the degree of endemicity in the area visited, the duration of stay, the individual behaviour and the preventive measures taken. Travellers' diarrhoea (TD) is the most frequent ailment of visitors to countries with poor hygiene. The incidence rate is 25-90% in the first 2 weeks abroad. The risk of TD is far less in travellers originating in a high risk country, as some immunity develops. Malaria is an important risk for travellers going to endemic areas. Without chemoprophylaxis, the monthly incidence is high in some destinations, among them frequently visited tropical Africa where 80-95% of the infections are due to Plasmodium falciparum. The incidence rates are lower in most endemic areas of Asia and Latin America where Plasmodium vivax predominates. The risk is nil in all capital cities of South America and SE Asia, as well as in many frequently visited tourist destinations. The diseases preventable by immunization will be discussed in a separate paper (Vaccination priorities; page 175). Sexually transmitted diseases occur frequently, as some travellers (5% of Europeans) engage in casual sex, approximately half of them without being protected by a condom. The prevalence for HIV-infection, syphilis, gonorrhoea, etc. often exceeds 50% in prostitutes. In some European countries, a major proportion of heterosexuals with newly acquired HIV-infection have acquired it while abroad.

Sexual behavior of international travelers visiting Peru

BACKGROUND

Sexual behavior of travelers to Latin America and the sexual behavior of US travelers in general are poorly characterized.

GOAL

The goal of the study was to evaluate sexual risk factors of travelers to Peru.

STUDY DESIGN

Anonymous written questionnaires were administered to 442/507 (87%) of the individuals approached in the international departures area of the Lima airport.

RESULTS

Of the 442 respondents, 54 (12.2%) had new sex partners during their stay. Sex with a local partner (35/52; 67.3%) was more frequent than sex with other travelers (18/52; 34.6%) or with sex workers (4/52; 7.7%). Risk factors for a new sex partner included male sex (relative risk, 1.94), single marital status (relative risk, 2.59), duration of stay longer than 30 days (relative risk, 5.05), traveling alone or with friends (relative risk, 2.88), and bisexual orientation (relative risk, 4.94). Frequency of sexual activity among US travelers was greater than that among travelers from other countries (15.2% [22/145] versus 10.6% [30/282]; NS). Condoms were consistently used by 12/50 (24%) and sometimes used by 10/50 (20%), including 8/20 United States travelers and 13/29 travelers from other countries.

CONCLUSION

Behaviors and risk factors are similar to those described for travelers to Africa, Asia, and Eastern Europe. Behavior of US travelers did not differ from that of other travelers.

Sexually transmitted diseases in travelers

Prevention of sexually transmitted diseases (STDs) is a low priority among travel clinic services, despite increasing evidence that travelers have an increased risk of acquiring such infections. A proportion of 5%-50% of short-term travelers engage in casual sex while abroad, and this rate is even higher among long-term travelers. Few publications are available on STD preventive interventions among travelers. Education and counseling are recognized as key components of risk reduction. New efforts should be put forth with regard to identifying effective tools to promote safer sexual behaviors and to reduce the spread of infection by promoting condom use. Travelers at increased risk should be identified for targeted interventions; research to validate proposed markers of increased risk is prospectively needed. Hepatitis B infection is the only STD that is preventable by vaccination. The feasibility and cost-effectiveness of STD screening in travelers after exposure is a virtually unexplored field, though it may represent an important component of STD control strategies in developed countries.

The health-development link: travel as a public health issue

The process of globalization has rendered societies interdependent on one another and has fostered the movement of people, goods and ideas at unprecedented speed and volume. Global travel has grown from 25 million in 1950 to 500 million in 1993, and estimations by 2010 reach 1 billion. The increased intensity and quantity of travel has resulted in greater vulnerability to the domino-type spread of old, new and re-emerging infectious diseases. Travelers and local populations are also vulnerable to death and disability due to accidents, violence and injuries, chronic diseases such as those due to substance abuse (tobacco, alcohol and others), and to undesirable behaviors such as those related to sex-tourism. This article argues that tourism, understood as any type of travel, is one of the most important sectors of the economy in many countries and, therefore, can contribute to community and national development. It also asserts that travel, as a factor in the spread of disease, lies in the realm of public health inquiry. It calls for greater collaboration between the tourism-travel industry and community, national and global leaders to promote and enforce "responsible tourism."

Preparation of the HIV-infected Traveler to the Tropics

Pre-travel advice and planning can help the HIV-infected traveler minimize the unavoidable risks of tropical travel. Issues to cover: the diagnosis, staging, and stabilization of HIV infection and its sequelae; adequacy of the supply of medications currently used; optimal sources of medical care in planned destinations; potential HIV-related legal restrictions on travel; special risks associated with the medical geography of the traveler's route and planned activities; the need to avoid food-, water-, and vector-borne diseases; any appropriate vaccination, chemoprophylaxis, and antimicrobial agents; and arrangement for adequate medical follow-up upon the traveler's return.

Condom acceptance is higher among travelers in Uganda

OBJECTIVE

To examine the role played by mobile residents in the spread of HIV through rural Uganda.

DESIGN

Travel history and sexual network data were collected from a random sample of 1627 residents aged 15-49 years in Rakai District, Uganda during 1994.

METHODS

Travelers and non-travelers are compared with respect to socio-demographic attributes, risk exposure, knowledge, attitudes and use of condoms using descriptive statistics and multivariate logistic regression. A demographic profile of travelers' partners is developed using information from a local network survey module.

RESULTS

The population is highly mobile, with over 70% reporting travel to a potentially higher risk destination in the past year. Travelers are somewhat more likely to have higher levels of sexual risk behavior, but the risk appears to be offset by significantly greater knowledge, acceptance, and use of condoms. In multivariate analysis, the sexual risk differential for travelers is explained by occupational exposure and higher socio-economic status. The differential in condom acceptance, by contrast, appears to be associated with travel itself. Condom use with non-spousal partners is three times higher among travelers than non-travelers (P< 0.001), and travel remains a significant predictor after controlling for age, education, residence, occupation and multiple partners. Travelers are more likely to use condoms with both their local and non-local partners. Partners of male travelers are likely to be younger and better educated than those of male non-travelers.

CONCLUSIONS

The mobile population in this rural region appears willing to adopt risk reduction measures appropriate to their exposure. This suggests that targeting condom promotion programs to travelers and their partners is likely to be effective in reducing the spatial diffusion of HIV, and may be an efficient method for spreading behavioral change into rural areas.

The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 1: Strategies used before or instead of sex

BACKGROUND/OBJECTIVE

Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimise their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies.

METHODS

Data from clinical and research observations, computer searches, and historical texts were pooled.

RESULTS

In addition to discriminating between potential sexual partners, a variety of behaviours before or instead of sex were identified that have been perceived to alter STD risk. Traditional STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as the maintenance of social order, paternity guarantee, and eugenics. They also varied in popularity in time and place. Some examples were displacement activities such as masturbation or exercise, circumcision, infibulation, shaving, vaccination, or requiring partners to be tested for infection. Social and moral forces typically discourage non-marital sex, and this affects most people most of the time but few people all of the time.

CONCLUSION

The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.

Screening returning travelers

Posttravel screening is the clinical and laboratory assessment of an individual aimed at uncovering occult infections, pathology, or health risks, the treatment of which will yield a significant health benefit to the individual. Screening must be tailored to the different risk patterns associated with different travel categories (e.g., missionary, tourist). Screening, predominantly a secondary prevention strategy, is most cost-effective when integrated with primary prevention strategies aimed at preventing future travel related illness (Table 6). The screening process begins with a medical history that allows a definition of risks and a tailored approach to laboratory tests. The screening tests currently available for STDs, tuberculosis, and parasitic infections have been reviewed, and although cost-effectiveness data are not available for most post-travel screening tests, recommended approaches are proposed. Traditionally, screening has been directed at uncovering occult infectious disease (STDs, tuberculosis, and parasitic infections). Important benefits can be gained, however, by including screening questions and tests for those diseases that are the major causes of mortality, both in nontraveling and in traveling North Americans, that is, the atherosclerotic and neoplastic diseases and trauma, especially vehicular.

The compromised traveler

Compromised travelers represent a diverse and challenging group of individuals. They include HIV-infected patients who are at risk for potentially adverse reactions to immunizations, and new exposures to enteric water-borne opportunistic pathogens associated with chronic infections. Such travelers may encounter unfamiliar opportunistic fungi and classical tropical infections, such as leishmaniasis, whose pathogenesis can be enhanced by the presence of prior HIV infection. Other immunocompromised groups include those who are functionally or anatomically asplenic, and patients who are iatrogenically immunosuppressed from medications utilized for solid organ transplantation, chemotherapy, or treatment of malignancies. This population of travelers also includes those with diabetes mellitus who may require adjustments in their dosing, administration, and possibly even the types of insulin used on their trips. These patients are also at greater risk for acquisition of tuberculosis, severe community-acquired pneumonia, urinary tract infections, and pyomyositis. Older travelers present both the infectious disease and travel medicine specialist with issues such events, malignancy-related infections, myocardial infarction, and other forms of cardiopulmonary compromise, which the authors address in this article.

The sexual health of travelers

Sex and travel do not infrequently coincide as pleasurable occupations. This articles explores the possible risks of unsafe sexual activity in a travel-related context, gives guidelines on how to decrease risks for both partners, and outlines how to manage the exposed or infected traveler on his or her return home. Both sexually transmitted infections and contraception are covered.