Category: sexual behaviour

COVID-19 restrictions and changing sexual behaviours in MSM in London, UK

A recent article in the journal Sexually Transmitted Infections has looked at changes in behaviour in MSM in London during the Covid 19 pandemic. The study was web-based and only among HIV-negative MSM in a large urban setting.

Objectives: The COVID-19 pandemic and its related restrictions have affected attendance to and delivery of UK sexual healthcare services.

Methods: This was a cross-sectional, anonymous, web-based survey among HIV-negative MSM at high risk of HIV infection who attended  a sexual health and HIV clinic in London in August 2020. They collected data on sociodemographic characteristics, sexual behaviour and related mental well-being experienced during lockdown.

Results: 814 MSM completed the questionnaire: 75% were PrEP users; three quarters reported they have been sexually active, about half  had sex outside their household. The majority reported fewer partners than prior to lockdown. Interestingly 73% had discussed COVID-19 transmission risks with their sexual partners.

One out of five reported guilt for breaching COVID-19 restrictions and three out of four implemented one or more changes to their sexual behaviour. PrEP users reported higher partner number, engagement in ‘chemsex’ and use of sexual health services than non-PrEP users.

Conclusions: COVID-19 restrictions had a considerable impact on sexual behaviour and mental well-being in respondents. High rates of sexual activity and STI diagnoses were reported during lockdown. Changes to sexual health services provision for MSM must respond to high rates of psychological and STI-related morbidity and the challenges faced by this population in accessing services.

Is antiretroviral treatment for HIV increasing the susceptibility to syphilis

Recently, the world has experienced a rapidly escalating outbreak of infectious syphilis primarily affecting men who have sex with men (MSM); many are taking highly active antiretroviral therapy (ARV) for HIV-1 infection.

Treatment with ARV reduces risk of infection (because of greatly reduced viral load) and near-normal life expectancy for those on treatment. The currently accepted hypothesis is that these factors result in increased sexual risk-taking, especially unprotected anal intercourse, leading to more non-HIV-1 sexually transmitted infections, including gonorrhoea, chlamydia and syphilis.

However, syphilis incidence has increased more rapidly than other STDs. In a recent open access article in the journal Sexually Transmitted Infections, Reckart and colleagues hypothesise that ART itself  may alter the innate and acquired immune responses to Treponema pallidum, the bacterium causing infectious syphilis, and that this biological explanation plays an important role in the current syphilis epidemic.

In a leading article in the same journal, Susan Tuddenham and colleagues (only available to subscribers), find the hypothesis intriguing despite some flaws. They go on to suggest that further work is necessary to look at the mechanisms underlying the current syphilis epidemic.

In the same issue David Glidden et al point out that in the early double blind trials with pre-exposure prophylaxis (PrEP) no increase in syphilis was found between those taking PrEP and those taking placebo. These findings would suggest that short term exposure to ART has no effect on the acquired immune responses to Treponema pallidum.

Sexually transmitted infections: challenges ahead

A commissioned article in Lancet Infectious Diseases on July 9, 2017 highlights some of the major issues and challenges facing us in the growing global epidemic of sexually transmitted infections (STI). Authors Prof Mabhus Unemo et al summarise the key issues as follows:

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control.

Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease.

The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials.

Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches.

STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control.

Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation.

Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

Read full article on Lancet Infectious Diseases

Measuring patient experience and outcome in health care settings on receiving care after sexual violence

We are delighted to receive support from STIRF and the Queen Elizabeth Hospital Birmingham Charity (QEHBC) to fund research in the area of sexual violence.

The project aims to increase our understanding of what matters to patients when they attend health care settings after experiencing sexual violence. This is on the background of the reporting of sexual offences in the UK being at the highest level since introduction of the National Crime Recording Standard in 2002, and also an awareness that it can be extremely difficult for patients to present to health care services, disclose what has happened and seek support.

This systematic review will collect data from a wide range of sources and will be reviewed in a robust and thorough manner, to look at patient experience and outcome after attending a range of health care settings. Identifying key themes and practice that are of greatest importance to patients will then be disseminated to a wide and relevant audience so that this can be put into practice.

Rachel Caswell

Risks for pelvic inflammatory disease in students

In the latest issue of the Sexually Transmitted Infections, Phillip Hay and colleagues in the UK report on a prospective study of female students attending 11 universities and 9 further education colleges in London.

At the start, the students were asked to fill a questionnaire and provide a self taken vaginal sample for infection screening. After 12 months, they were assessed for pelvic inflammatory disease (PID), a condition that can lead to infertility and other complications.

PID was found in 1.6% of the particpants. Unsurprisingly the strongest predictor of PID was the presence of Chlamydia trachomatis at the first visit (relative risk (RR) 5.7).

However, adjusting for this, the authors reported that significant predictors of PID were ≥2 sexual partners (RR 4.0) or a new sexual partner during follow-up (RR 2.8), and age <20 years (RR 3.3). Somewhat surprisingly recruitment from a further education college rather than a university also increased the relative risk of PID 2.6 fold, perhaps reflecting different health protection behaviors (eg condom use) between the two groups.

The study concluded that in addition to known risk factors such as multiple or new partners in the last 12 months and younger age, attending a further education college rather than a university were risk factors for PID.

They recommended that sexual health education and screening programs could be targeted at these high-risk groups.

Sexually abused children should be offered HPV vaccination

Should children exposed to sexual abuse be offered human papillomavirus (HPV) vaccination alongside screening for sexually transmitted infections? A recent article in the Lancet argues for a yes answer.

The WHO defines childhood sexual abuse  as the involvement in sexual activity of a child under the age of 18 years who did not give informed consent or is not developmentally prepared.

The global prevalence of childhood sexual abuse is estimated to be 8–31% for girls and 3–17% for boys. The true figures are probably nearer the upper figure.

According to a review, parents were the perpetrators of about 45% of cases of childhood sexual abuse in the USA, and other relatives were responsible for a further 19%.  Others included figures of authority such as priests and teachers. Survivors of such abuse are often hesitant to report such incidents because of shame and fear of retribution. Thus, the incidence and prevalence of childhood sexual abuse is almost certainly underestimated. Read more

Daily pri-exposure prophylaxis (PrEP) prevents HIV infection in high risk gay men

Daily HIV medicine taken by men who have sex with men (MSM) reduces risk of HIV infection by 86% as was reported by Molina J-M, and colleagues in the ANRS Ipergay trial  at the Conference on Retroviruses and Opportunistic Infections held in Seattle, USA in 2015 (23LB.).

Molina et al reported the final results of a three year study which randomised MSM who were negative for HIV to either take daily HIV prophylaxis with two anti-retroviral drugs in a single tablet immediately or deferred for 1 year.

The study showed that those taking the drugs on a daily basis have a 86% reduction in the risk of being infected by HIV than MSM not taking the drug (p=0.0001). The trial was stopped in October of 2014 and all participants in the  deferred group were offered pre-exposure prophylaxis (PrEP)

As a Lancet editorial commented:

The science is now clear: oral pre-exposure prophylaxis (PrEP) with a coformulation of tenofovir disoproxil fumarate and emtricitabine (Truvada) significantly reduces the risk of HIV infection among individuals at high risk of HIV infection.

The news that PrEP has shown consistent efficacy among those who take it as prescribed should be a cause for celebration, and galvanise action to ensure access to PrEP for those who could benefit the most. But almost 3 years since the US Food and Drug Administration approved tenofovir–emtricitabine for PrEP little is being done on implementation.

With more than 2 million new HIV infections every year worldwide, it is time for that to change.

One in ten men in Britain report paying for sex sometime in their life – a national study

The National Survey of Sexual Attitudes and Lifestyles (NATSAL) is a survey of men and women carried out in the Britain every 10 years. It remains the most extensive and accurate study of sexual behaviour in a carefully selected population of men and women in the UK that reflect the population of sexually active individuals.

Natsal-3 is a  sample survey of 15,162 men and women (6,293 men) aged 16–74 years, resident in Britain, undertaken between September 2010 and August 2012. Participants were interviewed using a combination of face-to-face, computer-assisted, personal interviewing (CAPI) and computer-assisted self-interviewing (CASI). The more sensitive questions, including those on paying for sex and sex while outside the UK, were asked in the CASI.  

Kyle Jones and her colleagues reported on the results of the questions relating to men who admitted to have paid for sex. 

Their results show that round one in 10 men in Britain report having ever paid for sex at some time. These men are more sexually active than men who do not report having had paid for sex. They have a higher number of sexual partners, only a minority (18.4%) of which are paid.

They are also more likely to report a diagnoses of a sexually transmitted infection (STI) even when accounting for their disproportionately larger number of sexual partners (which is considered the most important behavioural variable associated with STI diagnoses).

This evidence strongly supports the idea that this subgroup of men are a bridge for the sort of sexual mixing (dissociative mixing) that increases the spread of STIs.

Men who pay for sex (MPS) are most likely to be aged between 25 and 34 years, single, in managerial or professional occupations, and have high partner numbers.

After adjusting for the key risk behaviour of sexual partner numbers, these men still report many other sexual behaviours, such as having new foreign partners while outside the UK, less attendance at STI clinic and less condom use. They therefore show an increased vulnerability to STI without taking the necessary precautions.

Interestingly, for some reported behaviours, such as sex partners outside the UK, same sex contact, sex partners found online, and concurrent partners (more than one partner at any time), total and paid partner numbers increase.

This suggests that MPS exhibiting these behaviours have higher lifetime partner numbers than other MPS as well as higher paid partner numbers, putting them at a higher risk for STIs than other MPS.

sexual health teaching at schools works for girls better than boys

Men and women, aged 17–24 years, were interviewed from 2010–2012 for third National Survey of Sexual Attitudes and Lifestyles in the UK. The authors  examined how the source of information about sexual matters was associations with sexual behaviours and outcomes.

The study looked at the main source of information (school, a parent or other); age and circumstances of first heterosexual intercourse; unsafe sex and distress about sex in past year; experience of sexually transmitted infection (STI) diagnoses. Women were also asked if they ever had non-volitional sex or an abortion.

The results,  published in the BMJ, concluded that gaining information mainly from school was associated with reduction of a range of negative sexual health outcomes, particularly among women. These included, older age at first sex, less likelihood of unsafe sex and previous STI diagnosis. In all cases the effect was more significant for women.

Women were also more likely to be sexually competent at first sex and less likely to have  non-volitional sex, abortion and distress about sex. 

Gaining information mainly from a parent was associated with some of these, but fewer participants cited parents as a primary source.

The findings emphasise the benefit of school and parents providing information about sexual matters and argue for a stronger focus on the needs of men.