Summary and highlights from the International Union against Sexually Transmitted Infections Congress 2014,Malta

Migration and STIs

Migration has been recorded throughout human history; however, recently there has been a significant increase in movement of populations due to a range of political, humanitarian, economic and environmental pressures. Immigration poses many health challenges not only for the migrating population but also for the resident population and has therefore becomes an important factor in global health and social development. It has been noticed that in recent years, there has been a return of hitherto rare STIs to our national territories that had previously been on the decline – a possibly direct implication of migration. Migration was a particularly relevant conference theme given Malta’s geographic location means it receives high numbers of migrants from sub-Saharan Africa (SSA). Malta does not impose mandatory screening for HIV in migrants, and concerns have been expressed particularly concerning vertical transmission and whether services could manage late presenting HIV-infected pregnant women or those arriving with very young families. However, a retrospective study by Grimaud et al. ¹ found that due to the standardised practice of screening during pregnancy, and comprehensive management guidelines followed if an HIV-infected mother is detected, there have been no recorded cases of mother-to-child transmission in this population.

Spain and Portugal are also common destinations for migrants from SSA. STI risk in this migrant population is high. In women in particular this is not only due to factors reducing access to healthcare but also due to the increased vulnerability to violence and sexual abuse. Rates of HIV/AIDS infection in sub-Saharan African women living in Western Europe are particularly high. A Belgian study by Arrey et al. ² focused on the disproportionate levels of stigma SSA migrant women experience, especially if they are HIV positive. These levels of perceived and enacted stigma may be addressed by improvements in support services. The authors conclude that an effective culture-specific HIV programme should be set up to encourage migrant patients’ empowerment within the host country.

The theme of global shift in prevalence of certain STIs was also developed in the plenary session entitled ‘STIs in people who travel’. De Vries reported that 5–50% of travellers have casual sex whilst abroad, and the GeoSentinel surveillance of illness in returned travellers reported that 0.9% of ill travellers were diagnosed with an STI.^3,4 A Dutch study by Whelan et al. ⁵ looked at long-term Dutch travellers visiting subtropical regions and reported that 35% had sexual intercourse with more than one partner, 42% had sexual intercourse with a local partner and 39% of those were unprotected sexual contacts. These data confirm findings from previous studies that found that reported sexual partners overseas are associated with high-risk sexual behaviours. Focus has therefore shifted to prevention. In Sweden, studies were conducted looking at pre-travel prevention in two high-risk groups – MSM and young people. It was found that pre-travel education would be accessed if it was in the form of a brief reminder or accessible via the internet.^6,7 Even for the MSM group, the researchers felt that efforts were most likely to be productive in the younger age groups. ⁷

Advances in diagnostics

The continuing developments in nucleic acid amplification testing (NAAT) has enhanced our ability to detect very small amounts of material; however, this has led to fears that tests are too sensitive. Jonathan Ross presented research that investigated the extent of surface contamination with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). Thirteen per cent of the surfaces tested within an STI clinical facility for investigating and managing patients were found to be positive. The quantity of nucleic acid detected, however, was low so risk of infection transmission is likely to be small. This group also reported that improvements in hand hygiene and clinic cleaning practices did not reduce the rates of contamination. It has therefore been recommend that the best intervention for reducing the risk of contamination is to provide clear instructions to patients taking self-taken samples (importantly to avoid using wet hands to handle or touch specimens). It has also been proposed that NAAT could be used to monitor rates of contamination. ⁸ Another similar study this time from Australia tried to generate contamination in specimens through deliberate attempts to inoculate urine specimens with swabs and digits that had touched various surfaces in the unit. This study was constructed to look principally at the risk that STIs identified in children in some remote communities may have been misdiagnosed due to specimen contamination. The researchers looked at 140 specimens across 10 locations and found they did not generate contaminated specimens through a standardised finger contamination-based procedure that was designed to exaggerate any such risks. ⁹

The conference had a series of presentations showing the clinical utility of near patient point-of-care (POC) tests for CT and GC. These in-clinic tests produce results within short time periods and can potentially reduce rates of transmission and complications as well as offering highly acceptable testing and treatment solutions to clients. Two studies highlighted their value in deprived and remote regions such as sub-Saharan Africa where only 60–75% of individuals return for treatment and in remote aboriginal communities in Australia, where the average delay between testing and treatment is 26 days. ¹⁰ One such test, Cepheid Xpert CT/GC, has a turnaround time of 90 min and is equivalent in performance to traditional laboratory NAATs. ¹⁰ Adams et al. ¹¹ produced a mathematical model that allowed cost comparison between standard care and a proposed POC pathway. It was found that not only could there be a reduction in cost per patient, but there could also be a 10 min reduction in healthcare professionals’ time per patient. However, Hislop et al. ¹² found that only 54% of patients would be willing to wait up to 30 min for results, and even fewer (38%) would be willing to wait between 30 and 120 min.

The move towards self-taken samples combined with POC tests has led to the opening of the services such as the Dean Street Express clinic, London. This particular service is focussed on the needs of asymptomatic patients, in particular MSMs, and has shown to be popular with service users. This clinic presented results from a nurse-led service that had grown service provision exponentially over the previous year and was now seeing in excess of 2800 clients each month. ¹³ This walk-in service could process a patient within 30 min, and results were on average made available to clients within 3.5 h enabling swift action to halt onward transmission if needed. More detailed economic modelling of this strategy or the possible impact on high-risk behaviour has not to date been fully evaluated. However, it has been clearly established that patients are keen to have such a service.

John White concluded the symposium with a discussion around the future of STI testing. It was highlighted that clinicians should be demanding more from manufacturers in the form of results with added value, for example, a positive GC result should be accompanied by a marker of sensitivity or resistance for ceftriaxone. There is an increasing availability of more sensitive and affordable multiplex tests many of which have ‘rapid’ in-clinic potential, but more research is required in this area. There are also fears that multiplex NAAT tests, which can test for up to 25 pathogens, may cause problems especially in asymptomatic patients, where the need for treatment is harder to determine and further research into the harms, benefits and cost-effectiveness of ‘testing for everything’ is required. He also wondered whether in the long run a move towards home-based testing with diagnosis that can be accessed through the internet and facilitated by computerised history, triage and imaging is inevitable. However, there is still a requirement for STI clinicians to provide opinions, explanation of results and prescriptions for treatment.

Mycoplasma: The first untreatable STI?

Jørgen Scov Jensen in a provocatively entitled plenary presentation looked at the growing problems of primary mycoplasma resistance to macrolides and quinolones. He showed the alarming rates of azithromycin resistance now developing across the world linked in part to wide-scale azithromycin usage. He also charted the rise of moxifloxacin resistance and looked forward to the next generation of antibiotics that have shown activity against this organism.

The IUSTI congresses are invariably focused around real-world patient management and clinical decision making. In a series of well attended plenary debates, the audience looked at the deglamourisation of risky sex and the need for patient disclosure in genital HSV-1 infection. Interestingly, the audience concluded that disclosure should not be mandated.