Travel Medicine and Infectious Disease (2014) 12, 5e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
EDITORIAL
Travel, syphilis and HIV In this issue of Travel Medicine and Infectious Disease, Salavec and co-authors report the case of two HIV-infected male partners who repeatedly acquired syphilis in the context of international travel [1]. The report highlights a number of important issues and challenges related to the prevention and management of sexually transmitted infections (STIs) in the general population and in travelers in particular. The prevalence of syphilis decreased to very low levels in high resource settings over the last decades, mainly as a consequence of an expanded coverage of health systems and the availability of effective diagnostic and treatment tools. In this scenario, individuals who acquire the infection during international travel have the potential to act as infectious foci and start epidemic outbreaks. An epidemic of syphilis imported mainly by heterosexual men from Russia caused one sporadic cluster in Finland in 1995 [2], similar to that described this time for the administrative region of Hradec Kralove. The concept that travel is a risk factor for the acquisition of STIs is well accepted: a recent pooled meta-analysis showed that one out of five travelers have casual sex during travel, with almost 50% of such sexual encounters being unprotected [3]. Moreover, syphilis was one of the most common diagnoses among travelers and migrants with STI described in a recent analysis of the data from GeoSentinel travel medicine clinics worldwide [4]. HIV infection emerged in the last 30 years as the most dangerous of all STIs. Despite the fact that its transmission coefficient during sexual contacts is much lower than that of syphilis, requiring a large amount of exposure to ensure a high probability of transmission, a substantial burden of incident HIV infection has also been demonstrated among travelers [4]. In the GeoSentinel analysis the proportionate morbidity estimates of incident HIV infection (ie, the time from acquisition until 4e6 months after infection) in ill travelers was the second most common STI diagnosis in patients seen after travel [4]. Acute HIV infection was diagnosed in 117 (0.18%) of 64 335 patients seen after travel. It is speculated that such high rate could be justified by the relatively higher attention of travelers about
symptoms, including those of the acute retroviral syndrome. The increasing body of knowledge on STIs and travel underline the potential role of travel clinics in individual care and public health protection against STIs. Clearly, the most important tool in this game would be represented by primary prevention of STI acquisition and transmission in travelers through education and promotion of safe behaviors. However, travel clinics could also effectively collaborate with STI clinics to efficiently and timely identify new cases of STIs, and limit and finally control outbreaks through contact tracing. Each of these interventions present challenges. The Achille’s heel in the fight against STIs is the limited capacity of health services to modify human behaviors, as shown by Savalec’s report. The only randomized controlled trial on this topic showed that a motivational intervention was not superior to standard STI advice in reducing casual sex or promoting condom use [5]. Possibly, the most worrisome element emerging from Savalec and co-workers’ report, is that travelers with HIV infection may spread HIV to sexual partners in the destination country. The infected traveler who was not on antiretroviral therapy was likely to have high viral loads in blood and semen and could efficiently transmit HIV during casual unprotected sex encounters. In combination with early syphilis, the likelihood of sexual transmission of HIV is increased of several times making the association extremely dangerous in terms of infectious potential. Although not explicitly stated in the report, it seems likely that the travelers described in the paper engaged in sex tourism. This complex phenomenon is neglected in the scientific literature although an awareness of the theoretical concept of sex tourism would be essential in order to provide high quality care, and face its legal and human rights implications [6]. Early diagnosis and treatment of STIs after casual sex during travel is a neglected area: there is no published evidence to guide planning for structured, scheduled screening of STIs after return. Syphilis very commonly goes unrecognized even in its symptomatic stages. In these case
1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.11.006
6 reports, the presence of signs and symptoms of secondary syphilis in one of the couple member did not cause any patient’s concern and had been otherwise missed by clinical services (being detected by regular serologic screening only). However, whenever the suspicion of syphilis is raised, the diagnostic process is straight-forward. User-friendly and unsophisticated treponemal (i.e TPHA) and non treponemal tests (i.e. RPR or VDRL) are both expected to be reactive. Treatment of syphilis is easy, being based on penicillin, and fully effective regardless of HIV infection, since penicillin resistant syphilis has not been demonstrated so far. It is based on the intramuscular administration of one single dose (early syphilis) or three doses at weekly intervals (late syphilis) of benzathin penicillin. Serological follow-up should always be carried out to confirm treatment efficacy and, as syphilis does not elicit protective immunity, to promptly identify re-infections. Effective treatment is demonstrated by the significant reduction of titers in non-treponemal tests 12 months after treatment, and re-infection is flagged by any significant resurgence of the titer thereafter. Serological monitoring is recommended in HIV infected persons and represents a useful indicator for the effectiveness of safe sexual behavior programs among HIV infected individuals on care. The need to screen for central nervous system involvement among HIV infected people is an unsolved controversial issue. More research is required to steer specific pre-travel STI intervention to reduce infection and transmission, and on most effective harm reduction strategies whenever exposure occurs. Meanwhile, some STI information and recommendation for screening tests should be given to travelers at risk. The crux of the matter is that it is almost impossible in a pre-travel setting to identify which travellers are at risk. Some or all?
Editorial
Conflict of interest None.
References [1] Salavec M, Bostik V, Kapla J, Plisek S, Prasil P, Prymula R, et al. A repeated syphilis infection imported from Thailand in an HIV positive couple of men who-have-sex-with-men in Czech Republic. Trav Med Infect Dis 2013;12(1):84e7. [2] Hiltunen-Back E, Haikala O, Koskela P, Vaalasti A, Reunala T. Epidemics due to imported syphilis in Finland. Sex Transm Dis 2002 Dec;29(12):746e51. [3] Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and metanalysis. Int J Infect Dis 2010;14:e842e51. [4] Matteelli A, Schlagenhauf P, Carvalho ACC, Weld L, Davis XM, Wilder-Smith A, et al., for the GeoSentinel Surveillance Network. Travel-associated sexually transmitted infections: an observational cross-sectional study of the GeoSentinel surveillance database. Lancet Infect Dis 2013;13:205e13. [5] Senn N, de VS, Berdoz D, Genton B. Motivational brief intervention for the prevention of sexually transmitted infections in travelers: a randomized controlled trial. BMC Infect Dis 2011;11:300. [6] Bauer IL. Romance tourism or female sex tourism? Trav Med Infect Dis 2013;12(1):20e8.
Alberto Matteelli* Silvia Odolini Clinic of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy *Corresponding author. E-mail address: [email protected] (A. Matteelli)
19 November 2013
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
EDITORIAL
Travel, syphilis and HIV In this issue of Travel Medicine and Infectious Disease, Salavec and co-authors report the case of two HIV-infected male partners who repeatedly acquired syphilis in the context of international travel [1]. The report highlights a number of important issues and challenges related to the prevention and management of sexually transmitted infections (STIs) in the general population and in travelers in particular. The prevalence of syphilis decreased to very low levels in high resource settings over the last decades, mainly as a consequence of an expanded coverage of health systems and the availability of effective diagnostic and treatment tools. In this scenario, individuals who acquire the infection during international travel have the potential to act as infectious foci and start epidemic outbreaks. An epidemic of syphilis imported mainly by heterosexual men from Russia caused one sporadic cluster in Finland in 1995 [2], similar to that described this time for the administrative region of Hradec Kralove. The concept that travel is a risk factor for the acquisition of STIs is well accepted: a recent pooled meta-analysis showed that one out of five travelers have casual sex during travel, with almost 50% of such sexual encounters being unprotected [3]. Moreover, syphilis was one of the most common diagnoses among travelers and migrants with STI described in a recent analysis of the data from GeoSentinel travel medicine clinics worldwide [4]. HIV infection emerged in the last 30 years as the most dangerous of all STIs. Despite the fact that its transmission coefficient during sexual contacts is much lower than that of syphilis, requiring a large amount of exposure to ensure a high probability of transmission, a substantial burden of incident HIV infection has also been demonstrated among travelers [4]. In the GeoSentinel analysis the proportionate morbidity estimates of incident HIV infection (ie, the time from acquisition until 4e6 months after infection) in ill travelers was the second most common STI diagnosis in patients seen after travel [4]. Acute HIV infection was diagnosed in 117 (0.18%) of 64 335 patients seen after travel. It is speculated that such high rate could be justified by the relatively higher attention of travelers about
symptoms, including those of the acute retroviral syndrome. The increasing body of knowledge on STIs and travel underline the potential role of travel clinics in individual care and public health protection against STIs. Clearly, the most important tool in this game would be represented by primary prevention of STI acquisition and transmission in travelers through education and promotion of safe behaviors. However, travel clinics could also effectively collaborate with STI clinics to efficiently and timely identify new cases of STIs, and limit and finally control outbreaks through contact tracing. Each of these interventions present challenges. The Achille’s heel in the fight against STIs is the limited capacity of health services to modify human behaviors, as shown by Savalec’s report. The only randomized controlled trial on this topic showed that a motivational intervention was not superior to standard STI advice in reducing casual sex or promoting condom use [5]. Possibly, the most worrisome element emerging from Savalec and co-workers’ report, is that travelers with HIV infection may spread HIV to sexual partners in the destination country. The infected traveler who was not on antiretroviral therapy was likely to have high viral loads in blood and semen and could efficiently transmit HIV during casual unprotected sex encounters. In combination with early syphilis, the likelihood of sexual transmission of HIV is increased of several times making the association extremely dangerous in terms of infectious potential. Although not explicitly stated in the report, it seems likely that the travelers described in the paper engaged in sex tourism. This complex phenomenon is neglected in the scientific literature although an awareness of the theoretical concept of sex tourism would be essential in order to provide high quality care, and face its legal and human rights implications [6]. Early diagnosis and treatment of STIs after casual sex during travel is a neglected area: there is no published evidence to guide planning for structured, scheduled screening of STIs after return. Syphilis very commonly goes unrecognized even in its symptomatic stages. In these case
1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.11.006
6 reports, the presence of signs and symptoms of secondary syphilis in one of the couple member did not cause any patient’s concern and had been otherwise missed by clinical services (being detected by regular serologic screening only). However, whenever the suspicion of syphilis is raised, the diagnostic process is straight-forward. User-friendly and unsophisticated treponemal (i.e TPHA) and non treponemal tests (i.e. RPR or VDRL) are both expected to be reactive. Treatment of syphilis is easy, being based on penicillin, and fully effective regardless of HIV infection, since penicillin resistant syphilis has not been demonstrated so far. It is based on the intramuscular administration of one single dose (early syphilis) or three doses at weekly intervals (late syphilis) of benzathin penicillin. Serological follow-up should always be carried out to confirm treatment efficacy and, as syphilis does not elicit protective immunity, to promptly identify re-infections. Effective treatment is demonstrated by the significant reduction of titers in non-treponemal tests 12 months after treatment, and re-infection is flagged by any significant resurgence of the titer thereafter. Serological monitoring is recommended in HIV infected persons and represents a useful indicator for the effectiveness of safe sexual behavior programs among HIV infected individuals on care. The need to screen for central nervous system involvement among HIV infected people is an unsolved controversial issue. More research is required to steer specific pre-travel STI intervention to reduce infection and transmission, and on most effective harm reduction strategies whenever exposure occurs. Meanwhile, some STI information and recommendation for screening tests should be given to travelers at risk. The crux of the matter is that it is almost impossible in a pre-travel setting to identify which travellers are at risk. Some or all?
Editorial
Conflict of interest None.
References [1] Salavec M, Bostik V, Kapla J, Plisek S, Prasil P, Prymula R, et al. A repeated syphilis infection imported from Thailand in an HIV positive couple of men who-have-sex-with-men in Czech Republic. Trav Med Infect Dis 2013;12(1):84e7. [2] Hiltunen-Back E, Haikala O, Koskela P, Vaalasti A, Reunala T. Epidemics due to imported syphilis in Finland. Sex Transm Dis 2002 Dec;29(12):746e51. [3] Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and metanalysis. Int J Infect Dis 2010;14:e842e51. [4] Matteelli A, Schlagenhauf P, Carvalho ACC, Weld L, Davis XM, Wilder-Smith A, et al., for the GeoSentinel Surveillance Network. Travel-associated sexually transmitted infections: an observational cross-sectional study of the GeoSentinel surveillance database. Lancet Infect Dis 2013;13:205e13. [5] Senn N, de VS, Berdoz D, Genton B. Motivational brief intervention for the prevention of sexually transmitted infections in travelers: a randomized controlled trial. BMC Infect Dis 2011;11:300. [6] Bauer IL. Romance tourism or female sex tourism? Trav Med Infect Dis 2013;12(1):20e8.
Alberto Matteelli* Silvia Odolini Clinic of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy *Corresponding author. E-mail address: [email protected] (A. Matteelli)
19 November 2013
