The importance of taking an appropriate sexual history from travellers cannot be overemphasised. This poses problems in the busy practice, clinic or hospital setting but it is essential to include such enquiries as a matter of routine. A suitable excuse needs to be found to exclude parents, partners or friends who accompany the patient while this part of the history is taken. People go on holiday to have fun, and for many this includes new sexual experiences, often associated with high-risk partners. This is particularly true for young adults. In one British study, 74% of male migrant tourism workers in a popular coastal resort had sex with tourists, almost half with more than four tourists, and only 40% of respondents had used a condom (Ford and Inman, 1992). Teenagers are just as busy when visiting other European destinations, particularly those associated with the dance-music scene. In a recent study performed in Ibiza, over a third of 846 young adults attending music venues had taken recreational drugs, and 58% of males and 50% of females had at least one new sexual partner during their 1-2 week stay. Twenty-six per cent did not use condoms and 23% had more than one sexual partner (Bellis et al., 2000). We have observed similar risk behaviour in expeditioners and in long-term expatriates, often associated with high levels of alcohol use.
The risk of acquiring sexually transmitted infection abroad is very high and includes 'traditional' infections such as gonorrhoea (often multidrug resistant), syphilis, chancroid and lymphogranuloma venereum (Adler, 1997; Wang and Celum, 1999). The prevalence of HIV in sex workers in many cities and towns in India, Thailand and much of Africa exceeds 60% and is rapidly increasing in many other parts of the world, including the Eastern bloc countries, where syphilis is also reaching epidemic proportions (Tichonova et al., 1997).
Rates of HIV infection in 2000 returning Dutch travellers were low (0.2%) in the late 1980s, despite considerable risk activity while overseas (Houweling and Coutinho, 1991) and compared with more than 1% in returning Belgian expatriate workers (Bonneux et al., 1988) and 1.2% of heterosexual male travellers seen in London (Hawkes et al., 1994). The improved recent Dutch figures may reflect improved attitudes to safe sex, with an increase in condom use to 67% of occasions by the 23% of Dutch expatriates who had sex with casual local partners while on overseas assignments (de Graaf et al., 1997). In the UK, new heterosexual HIV infections have outnumbered those in homosexuals in both 1998 and 1999 and many of these infections are imported from overseas, either directly or indirectly.
HIV is the single most common imported lethal infection but modern management approaches are improving the prognosis. Patients who have been at risk of infection need appropriate counselling with a view to testing for HIV and sexually transmitted infections. This usually implies referral to a genitourinary medicine clinic for a full screen because sexually transmitted diseases may be asymptomatic in both men and women.
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