tag:theconversation.com,2011:/au/topics/sexually-transmitted-diseases-2054/articlesSexually transmitted diseases – The Conversation2023-12-01T11:41:15Ztag:theconversation.com,2011:article/2185342023-12-01T11:41:15Z2023-12-01T11:41:15ZYes, you can get syphilis of the eye – professor of ophthalmology explains<p>A cluster of cases of ocular syphilis has <a href="https://arstechnica.com/health/2023/11/five-women-got-eye-syphilis-from-the-same-man-raising-questions/">been reported</a> in Michigan, US. The five women infected all contracted the disease from the same sexual partner. </p>
<p>While ocular syphilis is not that common overall, accounting for <a href="https://journals.lww.com/stdjournal/fulltext/2022/10000/reported_neurologic,_ocular,_and_otic.11.aspx">1% of all syphilis cases</a> this probably represents an underestimate of its prevalence.</p>
<p>Why is this important? Ocular syphilis has been described as the great imitator. It can manifest in a multitude of ways and as such the diagnosis can be missed. This is important because it can easily be treated and cured. </p>
<p>Untreated, it can progress over many years causing more damage to multiple organ systems. It is a tragedy if missed. It can affect virtually every tissue in the eye. This <a href="https://www.tandfonline.com/doi/full/10.1080/09273948.2023.2217246">includes</a> the cornea, the iris, the orbit, the eyelids, the retina, the optic nerve and the sclera. It usually presents as an inflammation, but sometimes the presentation is more subtle.</p>
<figure class="align-center ">
<img alt="An anatomy diagram showing parts of the human eye." src="https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/562769/original/file-20231130-25-k3nu1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Parts of the eye.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/human-eye-anatomy-isolated-on-white-1935787477">ImagineDesign/Shutterstock</a></span>
</figcaption>
</figure>
<p>If syphilis is missed, other important treatable infections may also be missed. For example, HIV infection is also common in patients with syphilis. HIV infection <a href="https://www.tandfonline.com/doi/full/10.1080/09273948.2023.2217246">can accelerate the progression of ocular syphilis</a>. Missing an ocular syphilis diagnosis might mean missing an HIV diagnosis too and, again, not treating a treatable disease.</p>
<p>The five women described in Michigan, all infected by the same man, illustrate this point as they had different signs and symptoms, ranging from inflammation in the eye through to paralysis of cranial nerves. In these acute cases, thankfully, a correct diagnosis was promptly made and treatment started. </p>
<p>But sometimes ocular syphilis is not diagnosed and a slow grumbling infection can occur in the retina. This may resemble an inherited eye condition called <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/retinitis-pigmentosa">retinitis pigmentosa</a>. </p>
<p>So a patient may be told there is nothing that can be done as they are thought to have a genetic eye disease and their sight can be left to deteriorate. They may develop further syphilitic complications, such as syphilis affecting the brain. </p>
<h2>Still very prevalent today</h2>
<p>In my own practice, I have “cured” several incurable cases of retinitis pigmentosa because I tested for syphilis and found that the patient <a href="https://www.nature.com/articles/eye1996182">actually had ocular syphilis</a>. So it is important to be aware that sexually transmitted infections are increasing. </p>
<p>Syphilis is caused by a bacterium called <em>Treponema pallidum</em>. It is thought of as an old disease – possibly introduced to Europe by <a href="https://www.tandfonline.com/doi/full/10.1080/09273948.2023.2217246?scroll=top&needAccess=true">Christopher Columbus in 1493</a> – but it is still very prevalent today. Syphilis infections in the UK increased to 8,692 in 2022, up 15% compared with 2021 (7,543). This is the <a href="https://www.gov.uk/government/news/gonorrhoea-and-syphilis-at-record-levels-in-2022">largest number</a> of confirmed infections since 1948.</p>
<p>Doctors must not be shy in testing for it and explaining to patients why it is necessary to do so. In my experience, patients are happy to be tested as it offers the potential to cure their eye condition.</p>
<p>The message from these Michigan cases is that syphilis is increasing as a sexually transmitted disease. It can affect multiple organs including the eye. It can be missed and doctors should always think of the “great imitator” and not be shy in testing for it. If detected, it can be swiftly treated with antibiotics, which is not the case with many other eye diseases.</p><img src="https://counter.theconversation.com/content/218534/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lotery does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Unlike many eye conditions, ocular syphilis is a highly treatable disease. But it needs to be correctly identified.Andrew Lotery, Professor of Ophthalmology, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2073442023-06-09T10:42:20Z2023-06-09T10:42:20ZGonorrhoea and syphilis diagnoses are at their highest in decades – here’s what you need to know about these STIs<figure><img src="https://images.theconversation.com/files/531101/original/file-20230609-5823-jorbr6.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3500%2C2488&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gonorrhoea is now the second most commonly diagnosed STI in the UK.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendering-neisseria-gonorrhoeae-bacteria-640972273">Peddalanka Ramesh Babu/ Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables/sexually-transmitted-infections-and-screening-for-chlamydia-in-england-2022-report#:%7E:text=The%20most%20commonly%20diagnosed%20STIs,herpes%20(24%2C910%2C%206.4%25).">latest data</a> from the UK Health Security Agency shows that diagnoses of gonorrhoea and syphilis have surged in the last year. Shockingly, gonorrhoea rates are the highest they have been since records began in 1918.</p>
<p>Gonorrhoea has increased from 71,133 diagnoses per year before the pandemic to 82,592 in 2022. It’s now the second most commonly diagnosed STI behind chlamydia. In people aged 15-24, rates of gonorrhoea almost doubled in 2021 compared to the year before. Syphilis, which in the early 2000s was almost non-existent in the UK, has increased to 8,692 diagnoses in 2022.</p>
<p>Both these sexually transmitted infections were known by Victorian society. Syphilis was especially feared because of the visible and debilitating symptoms it causes. But the advent of testing and antibiotic treatment has meant most people have forgotten about them – and the risks they can pose. </p>
<h2>What symptoms do they cause?</h2>
<p><em><strong>Gonorrhoea</strong></em></p>
<p><a href="https://www.nhs.uk/conditions/gonorrhoea/">Gonorrhoea</a> is caused by a small round bacteria called gonococcus which infects the urethra, testes, prostate and anus in men, and the vagina, cervix, womb and anus in women. It’s passed from one person to another during unprotected sex. </p>
<p>Untreated, it causes a pus-filled discharge or “drip” from the penis and severe pain while urinating. In women symptoms can be less obvious, but include a watery, green, yellow or sometimes bloodstained vaginal discharge, and pain when urinating.</p>
<p>If the infection spreads to the womb and ovaries this causes <a href="https://www.nhs.uk/conditions/pelvic-inflammatory-disease-pid/">pelvic inflammatory disease</a>. Symptoms include fever and abdominal pain. Pelvic inflammatory disease is treatable but can lead to long-term complications even after the infection has subsided – including fertility problems and greater chance of ectopic pregnancies.</p>
<p>Gonorrhoea used to be easily treated by antibiotics. But in the last ten years, several <a href="https://www.cdc.gov/std/gonorrhea/drug-resistant/default.htm">extremely drug resistant strains</a> have been detected worldwide (including in the UK), making some infections difficult to treat. Drug resistant strains can happen when an infection is partially treated with the wrong antibiotic, or if a person stops treatment before the infection is completely gone. There’s a real and frightening risk that <a href="https://www.who.int/en/news-room/detail/07-07-2017-antibiotic-resistant-gonorrhoea-on-the-rise-new-drugs-needed">gonorrhoea could become untreatable</a> once again, as it was in the 19th century. </p>
<p>For this reason, it’s essential to get diagnosed and treated if you’re experiencing any symptoms. Current treatment involves an <a href="https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/gonorrhoea#:%7E:text=Gonorrhoea%20is%20treated%20with%20antibiotics,it%20more%20difficult%20to%20treat">injection of a single antibiotic</a> alongside close follow-up to ensure the infection is eliminated.</p>
<p><em><strong>Syphilis</strong></em></p>
<p>Syphilis is much less common than gonorrhoea, but it can cause much more harm. </p>
<p>The infection is caused by a small spiral bacterium called <em><a href="https://youtu.be/qL1T4_Dj6n8">Treponema pallidum</a></em>. Without treatment, this bacterium stays in the body and can cause complications that can happen 20 years or more after the infection.</p>
<p>It can also be passed from mother to baby in the womb, and can cause stillbirth or congenital syphilis. This means the child is born infected with syphilis and may develop the <a href="https://rarediseases.org/rare-diseases/congenital-syphilis/#symptoms">unpleasant complications</a> of the infection in childhood. Every pregnant woman in the UK is <a href="https://www.nhs.uk/pregnancy/your-pregnancy-care/screening-for-hepatitis-b-hiv-and-syphilis/#:%7E:text=During%20your%20pregnancy%2C%20you'll,booking%20appointment%20with%20a%20midwife.">screened for syphilis</a>. If detected, the mother will be treated – which also protects the baby from harm.</p>
<p>Syphilis causes <a href="https://www.nhs.uk/conditions/syphilis">three stages of disease</a>. The first stage is a painless lump or ulcer on the genitals or infected area. This usually goes away in a matter of weeks. The second stage is a full-body rash, sometimes with a sore throat and swollen lymph glands. These symptoms can also settle without treatment, though the person remains infected and infectious. The disease now enters a latent phase where it stays in the body while showing no symptoms. It can also still be passed to sexual partners or from pregnant women to their babies. </p>
<figure class="align-center ">
<img alt="A digital drawing of the bacterium Treponema pallidum" src="https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531100/original/file-20230609-15-xewjit.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Syphilis is caused by the bacterium <em>Treponema pallidum</em>.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/treponema-pallidum-syphilis-bacterium-responsible-dangerous-299898134">Peddalanka Ramesh Babu/ Shutterstock</a></span>
</figcaption>
</figure>
<p>In about <a href="https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/syphilis#:%7E:text=The%20third%20stage%20(tertiary%20syphilis)&text=Up%20to%201%20in%203,body%20the%20infection%20spreads%20to.">a third of infected people</a> who are untreated, the disease can return after a number of years as the third stage of <a href="https://www.osmosis.org/answers/tertiary-syphilis">tertiary syphilis</a>. This causes a range of symptoms which were dreaded in the years before effective treatment – including skin and bone disfigurations, nerve pain, heart problems, deafness, blindness, dementia and other neurological symptoms such as difficulty walking and incontinence.</p>
<p>Fortunately syphilis is still <a href="https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/treatment-follow-up.html#a2">very treatable using penicillin</a> or similar antibiotics. As you might expect, once a case is diagnosed, great efforts are made not only to cure the affected person, but to <a href="https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/treatment-follow-up.html#a4">trace and screen sexual partners</a> – going back many years if necessary.</p>
<h2>Why have rates increased?</h2>
<p>It’s not entirely clear why rates of syphilis and gonorrhoea have increased so rapidly in the UK. In part it may be due to a “bounce back” from the restrictions of the pandemic years, and the fact that people were <a href="https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables/sexually-transmitted-infections-and-screening-for-chlamydia-in-england-2022-report#overall-trends">not able to access diagnosis and treatment</a> as readily during that time.</p>
<p>Young people may also have <a href="https://mashable.com/article/online-sex-education-covid-pandemic">missed out on sex education</a> during the pandemic and may not know how to properly protect themselves from STIs. </p>
<p>Sexual health services in England have also experienced <a href="https://www.kingsfund.org.uk/blog/2018/12/sexual-health-services-and-importance-prevention">funding cuts</a> – making it more difficult for some people to access sexual health advice, diagnosis and treatment. Data shows that rates of gonorrhoea in particular are <a href="https://www.futuremedicine.com/doi/10.2217/fmb.14.110">sensitive to social and political change</a>, including changes to funding for sexual health services.</p>
<h2>What can I do to protect myself?</h2>
<p>The best way to protect yourself and your partners against gonorrhoea or syphilis is to get tested before starting a new relationship, and to use condoms with new or casual sexual partners.</p>
<p>If you have a symptom you’re worried about, get it checked. Self-test kits for gonorrhoea and syphilis are <a href="https://sh24.org.uk/stis/gonorrhoea">available online in some areas</a> or you can go to a sexual health clinic if you prefer.</p>
<p>If you’re notified by a partner or clinic that you’ve been in contact with someone who’s been diagnosed with one of these infections, attend a clinic to get screened and treated if necessary.</p>
<p>We’re fortunate that both syphilis and gonorrhoea are still treatable once diagnosed. But it’s important to know about them and to get tested and treated promptly.</p><img src="https://counter.theconversation.com/content/207344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has previously received funding from Bayer PLC, and has been a consultant to NaturalCycles.</span></em></p>Two Victorian STIs are back – here’s how you can protect yourself.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1883282022-12-14T13:13:45Z2022-12-14T13:13:45ZMpox, AIDS and COVID-19 show the challenges of targeting public health messaging to specific groups without causing stigma<figure><img src="https://images.theconversation.com/files/500108/original/file-20221209-33805-9vw3eu.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C1020%2C708&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fear-based public health messaging can both motivate and alienate at-risk groups.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSCrisis1987/8d02dadb8af04606bed1a5f9f6100ba1">AP Photo/Gillian Allen</a></span></figcaption></figure><p>During infectious disease outbreaks, clinicians and public health officials are tasked with providing accurate guidance for the public on how to stay safe and protect themselves and their loved ones. However, <a href="https://doi.org/10.3390%2Fijerph19148550">sensationalized media coverage</a> can distort how the public perceives new emerging infections, including where they come from and how they spread. This can foster <a href="https://doi.org/10.1016/j.lanepe.2022.100536">fear and stigma</a>, especially toward communities that are already mistrustful of the health care system.</p>
<p>The racial and sexual <a href="https://doi.org/10.3389/fpsyg.2021.648086">stigma surrounding monkeypox</a> is what spurred the World Health Organization to <a href="https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease">rename the disease to mpox</a> in November 2022. While this is a step in the right direction, I believe more work needs to be done to reduce the stigma surrounding infectious diseases like mpox.</p>
<p>I am an <a href="https://profiles.dom.pitt.edu/faculty_info.aspx/Ho5747">infectious disease researcher</a> who studies HIV, COVID-19 and mpox. During the COVID-19 pandemic, I was the lead investigator at the University of Pittsburgh for a <a href="https://www.coronaviruspreventionnetwork.org/compass-clinical-study">national survey</a> looking at how COVID-19 has affected different communities. Effective public health communication isn’t easy when conflicting messages may come from many sources, including family and friends, other community members or the internet. But there are ways that public health officials can make their own messaging more inclusive while mitigating stigma.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Posters promoting condom use reading " src="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tailoring public health messages to target groups could improve their reach.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/posters-that-promote-healthy-sexual-behavior-hang-inside-news-photo/160899714">Chip Somodevilla/Getty Images</a></span>
</figcaption>
</figure>
<h2>Creating an inclusive message</h2>
<p>Inclusive public health messaging can motivate the public to make better decisions regarding their personal health and the health of others. This effort often involves engaging the communities most affected by an outbreak. Unfortunately, because these communities are heavily affected by the infection and tend to <a href="https://www.ama-assn.org/delivering-care/health-equity/impact-covid-19-minoritized-and-marginalized-communities">experience some form of inequity</a>, they are often blamed by society for spreading the disease.</p>
<p>COVID-19 drove an increase in hate crimes related to the pandemic against <a href="https://doi.org/10.1007/s12103-020-09545-1">Chinese and other Asian communities</a> in the United States. A <a href="https://healthpolicy.ucla.edu/newsroom/press-releases/pages/details.aspx">2022 UCLA survey</a> found that 8% of Asian American and Pacific Islander adults in California experienced a COVID-19 related hate incident.</p>
<p>Effective public health messaging can focus on the fact that while infections may first affect certain groups of people, they often <a href="https://doi.org/10.1098/rstb.2014.0111">spread to other groups</a> and eventually encompass entire communities. Infections are caused by bacteria, viruses and fungi. They don’t discriminate by race, gender or sexual orientation. Messages that focus on the pathogens, rather than the communities, may reduce stigma.</p>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/resources/reducing-stigma.html">Visually inclusive messages</a> are also likely to engage a greater portion of the community. Examples include making sure that the people represented in posters and flyers, images on TV and websites, and other informational material are from diverse backgrounds. This sends a more unified message that what affects an individual also affects the larger community.</p>
<h2>Avoiding blame and fear</h2>
<p>Many media outlets, especially on social media, use <a href="https://theconversation.com/does-scaring-people-work-when-it-comes-to-health-messaging-a-communication-researcher-explains-how-its-gone-wrong-during-the-covid-19-pandemic-174287">fear-based messaging</a> to report on infectious diseases. While this may reinforce certain protective behaviors, such as using condoms during sex, it may also increase stress and anxiety. Fear-based messages also <a href="http://dx.doi.org/10.1136/bmjgh-2019-001911">worsen stigma</a>, leading to increased discrimination against communities that are already vulnerable and mistrustful of health care. Ultimately, this leads people to avoid seeking health care and can worsen health outcomes.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/TRGZcNMR24o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Normalizing sexual health could help reduce stigma around sexually transmitted infections.</span></figcaption>
</figure>
<p>Public health officials have often used fear-based messaging in response to sexually transmitted infections, or STIs, like <a href="https://doi.org/10.1016%2FS2352-3018(21)00078-3">HIV</a>, <a href="http://dx.doi.org/10.1080/01292986.2017.1384030">chlamydia</a> and <a href="https://doi.org/10.1080/01292980600857831">gonorrhea</a>. Sex itself is <a href="https://magazine.jhsph.edu/2022/stigmas-toll-sexual-and-reproductive-health">highly stigmatized</a> by society. I have found that some of my patients would prefer to avoid getting tested and treated for an STI rather than deal with the <a href="https://www.verywellhealth.com/the-stigma-stds-have-in-society-3133101">shame of having an STI</a>.</p>
<p>Making sexual health and STI testing <a href="https://doi.org/10.1016/j.eclinm.2021.100764">routine and integral</a> parts of overall wellness and health is an important step to reduce the stigma around them. Similarly, messaging that normalizes the challenges faced by people at risk for certain infections could help avoid causing shame.</p>
<h2>Tailoring the message</h2>
<p>Infections affect different people differently. <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html">COVID-19</a> might be a mildly stuffy nose for one person, and it could be months in an intensive care unit hooked up to a ventilator for another. Messages that <a href="https://www.hsph.harvard.edu/ecpe/the-importance-of-getting-the-message-right-in-your-risk-communication-strategy/">focus on the successes</a> of medical and public health interventions that resonate with communities are most likely to be successful.</p>
<p>Different groups have different exposure risks as well. Mpox heavily affected gay and bisexual men in 2022. One reason why was related to how the virus is transmitted. <a href="https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html#">Prior research</a> suggested that mpox was largely transmitted by close skin-to-skin contact, but <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/sex-men-not-skin-contact-fueling-monkeypox-new-research-suggests-rcna43484">emerging studies</a> raised the question of whether the 2022 outbreaks were being driven more by sexual transmission.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person passing poster with health information on mpox" src="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The 2022 mpox outbreaks predominantly affected gay and bisexual men.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/poster-on-commercial-street-in-provincetown-ma-on-the-issue-news-photo/1242177865">Jonathan Wiggs/The Boston Globe via Getty Images</a></span>
</figcaption>
</figure>
<p>There was <a href="https://www.npr.org/2022/07/26/1113713684/monkeypox-stigma-gay-community">controversy</a> as to whether public health messaging should highlight sexual encounters as a potential transmission route. This can risk further stigmatizing gay and bisexual men versus potentially overlooking these key at-risk populations. <a href="https://www.scientificamerican.com/article/monkeypox-is-a-sexually-transmitted-infection-and-knowing-that-can-help-protect-people">Some advocates argued</a> that promoting the message that mpox was primarily transmitted by close contact would prevent resources and interventions from reaching the groups of people most affected by the disease.</p>
<p>One size does not always fit all when it comes to public health messaging. Multiple messages may be necessary for different groups of people based on their risk of infection or severe disease. An August 2022 Centers for Disease Control and Infection survey found that <a href="http://dx.doi.org/10.15585/mmwr.mm7135e1">50% of gay and bisexual men</a> reduced their sexual encounters in response to the mpox outbreak. Since late summer, <a href="https://www.npr.org/sections/health-shots/2022/08/26/1119659681/early-signs-suggest-monkeypox-may-be-slowing-in-the-u-s">mpox rates have been dropping</a> rapidly, and many experts think that both behavior change and vaccination may have contributed to the falling rates. Studies like these further support the importance of directly engaging with communities to encourage healthy behavior change.</p>
<h2>Trusted messengers</h2>
<p>Mistrust is also a barrier to effective messaging. Some communities may be mistrustful of medical and health care systems because of prior histories of exploitation, such as the <a href="https://www.mcgill.ca/oss/article/history/40-years-human-experimentation-america-tuskegee-study">Tuskegee study</a>, where researchers prevented Black participants from receiving syphilis treatment for decades in the mid-20th century, and ongoing fear of mistreatment.</p>
<p>Identifying trusted community champions and health care providers – especially ones who belong to that community – to deliver a public health message may increase its acceptance. One <a href="https://doi.org/10.1257/aer.20181446">2019 study</a>, for example, found that Black men were more likely to accept vaccines, medical advice and engage in health care services if they had a Black health care provider.</p>
<p>Effectively delivering public health messaging is a complicated and challenging process. But talking to and listening to the communities most affected by an outbreak can make a difference.</p><img src="https://counter.theconversation.com/content/188328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ken Ho does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prejudice and stigma can discourage the communities most affected by infectious diseases from seeking care. Inclusive public health messaging can prevent misinformation and guide the most vulnerable.Ken Ho, Assistant Professor of Infectious Diseases, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879092022-10-05T12:20:12Z2022-10-05T12:20:12ZGonorrhea became more drug resistant while attention was on COVID-19 – a molecular biologist explains the sexually transmitted superbug<figure><img src="https://images.theconversation.com/files/484662/original/file-20220914-18-3dakt1.jpg?ixlib=rb-1.1.0&rect=21%2C32%2C7156%2C3977&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The _Neisseria gonorrhoeae_ bacterium causes gonorrhea by infecting mucous membranes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/bacterium-neisseria-gonorrhoeae-gonorrhea-royalty-free-image/1128533488?adppopup=true">Design Cells/iStock Getty Images Plus via Getty Images</a></span></figcaption></figure><p>COVID-19 has rightfully dominated infectious disease news since 2020. However, that doesn’t mean other infectious diseases took a break. In fact, U.S. rates of <a href="https://www.cdc.gov/std/statistics/2020/tables/1.htm">infection by gonorrhea have risen</a> during the pandemic.</p>
<p>Unlike COVID-19, which is a new virus, gonorrhea is an ancient disease. The first known reports of gonorrhea date from <a href="https://doi.org/10.1001/archdermatol.2011.2716">China in 2600 BC</a>, and the disease has plagued humans ever since. Gonorrhea has long been one of the most commonly reported <a href="https://www.cdc.gov/std/statistics/2020/tables/1.htm">bacterial infections in the U.S.</a>. It is caused by the bacterium <em>Neisseria gonorrhoeae</em>, which can infect mucous membranes in the genitals, rectum, throat and eyes. </p>
<p>Gonorrhea is typically transmitted by sexual contact. It is sometimes <a href="https://www.emedicinehealth.com/why_is_gonorrhea_called_the_clap/article_em.htm">referred to as “the clap</a>.” </p>
<p>Prior to the pandemic, there were around <a href="https://www.cdc.gov/std/gonorrhea/arg/public-health-threat/public-health-threat-text-only.htm">1.6 million new gonorrhea infections</a> each year. Over 50% of those cases involved strains of gonorrhea that had <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">become unresponsive to treatment</a> with at least one antibiotic. </p>
<p>In 2020, gonorrhea infections initially <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">went down 30%</a>, most likely due to pandemic lockdowns and social distancing. However, by the end of 2020 – the last year for which data from the Centers for Disease Control and Prevention is available – <a href="https://www.cdc.gov/std/gonorrhea/stats.htm">reported infections were up 10% from 2019</a>. </p>
<p>It is unclear why infections went up even though some social distancing measures were still in place. But the CDC notes that reduced access to health care may have led to longer infections and more opportunity to spread the disease, and sexual activity may have increased when <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">initial shelter-in-place orders were lifted</a>.</p>
<p>As <a href="https://science.psu.edu/bmb/people/kck11">a molecular biologist</a>, I have been <a href="https://scholar.google.com/citations?user=rkmd4gQAAAAJ&hl=en">studying bacteria</a> and working to develop new antibiotics to treat drug-resistant infections for 20 years. Over that time, I’ve seen the problem of antibiotic resistance take on new urgency. </p>
<p>Gonorrhea, in particular, is a major public health concern, but there are concrete steps that people can take to prevent it from getting worse, and new antibiotics and vaccines may improve care in the future. </p>
<h2>How to recognize gonorrhea</h2>
<p>Around <a href="https://doi.org/10.1016/S0091-7435(02)00058-0">half of gonorrhea infections are asymptomatic</a> and can only be detected through screening. Infected people without symptoms can unknowingly spread gonorrhea to others.</p>
<p>Typical early <a href="https://www.mayoclinic.org/diseases-conditions/gonorrhea/symptoms-causes/syc-20351774">signs of symptomatic gonorrhea</a> include a painful or burning sensation when peeing, vaginal or penal discharge, or anal itching, bleeding or discharge. Left untreated, gonorrhea can cause <a href="https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm">blindness and infertility</a>. Antibiotic treatment can cure most cases of gonorrhea as long as the infection is susceptible to <a href="https://www.cdc.gov/std/gonorrhea/treatment.htm">at least one antibiotic</a>.</p>
<p>There is currently only one recommended treatment for gonorrhea in the U.S. – an antibiotic called ceftriaxone – because the bacteria have become resistant to other antibiotics that were <a href="https://www.cdc.gov/std/gonorrhea/treatment.htm">formerly effective against it</a>. Seven different families of antibiotics have been used to treat gonorrhea in the past, but many strains are now resistant to <a href="https://www.who.int/news-room/fact-sheets/detail/multi-drug-resistant-gonorrhoea">one or more of these drugs</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iFwlnljV2Go?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The CDC tracks the emergence and spread of drug-resistant gonorrhea strains.</span></figcaption>
</figure>
<h2>Why gonorrhea is on the rise</h2>
<p>A few factors have contributed to the increase in infections during the COVID-19 pandemic.</p>
<p>Early in the pandemic, most U.S. labs capable of testing for gonorrhea switched to testing for COVID-19. These labs have also been contending with the same <a href="https://www.usnews.com/news/health-news/articles/2022-07-28/staff-shortages-choking-u-s-health-care-system">shortages of staff</a> and <a href="https://www.aamc.org/news-insights/shortages-syringes-dye-diagnostic-exams-how-world-events-are-straining-everyday-health-care-supply">supplies that affect</a> <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">medical facilities across the country</a>.</p>
<p>Many people have <a href="https://doi.org/10.1371/journal.pone.0272609">avoided clinics and hospitals</a> during the pandemic, which has decreased opportunities to identify and treat gonorrhea infections before they spread. In fact, because of decreased screening over the past two and a half years, health care experts don’t know exactly how much antibiotic-resistant gonorrhea has spread.</p>
<p>Also, early in the pandemic, many doctors <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">prescribed antibiotics to COVID-19 patients</a> even though antibiotics do not work on viruses like SARS-CoV-2, the virus that causes COVID-19. Improper <a href="https://www.cdc.gov/antibiotic-use/index.html">use of antibiotics</a> can contribute to greater drug resistance, so it is reasonable to suspect that this has happened with gonorrhea.</p>
<h2>Overuse of antibiotics</h2>
<p>Even prior to the pandemic, resistance to antibiotic treatment for bacterial infections was a growing problem. In the U.S., antibiotic-resistant gonorrhea infections <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">increased by over 70%</a> from 2017-2019.</p>
<p><em>Neisseria gonorrhoeae</em> is a specialist at picking up new genes from other pathogens and from <a href="https://doi.org/10.1038/nrmicro.2017.169">“commensal,” or helpful, bacteria</a>. These helpful bacteria can also become antibiotic-resistant, providing more opportunities for the gonorrhea bacterium to acquire resistant genes.</p>
<p>Strains resistant to ceftriaxone have been observed in other countries, including <a href="https://doi.org/10.1128/AAC.00325-11">Japan</a>, <a href="https://doi.org/10.1038/s41598-021-00675-y">Thailand,</a> <a href="https://doi.org/10.1016/S1473-3099(20)30055-4">Australia and the U.K.</a>, raising the possibility that some gonorrhea infections may soon be completely untreatable. </p>
<h2>Steps toward prevention</h2>
<p>Currently, changes in behavior are among the best ways to limit overall gonorrhea infections – particularly <a href="https://www.who.int/news/item/07-07-2017-antibiotic-resistant-gonorrhoea-on-the-rise-new-drugs-needed">safer sexual behavior and condom use.</a></p>
<p>However, additional efforts are needed to delay or prevent an era of untreatable gonorrhea. </p>
<p>Scientists can create new antibiotics that are effective against resistant strains; however, decreased investment in this research and development over the past 30 years <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358500/">has slowed the introduction</a> of <a href="https://www.idsociety.org/globalassets/idsa/policy--advocacy/current_topics_and_issues/antimicrobial_resistance/10x20/statements/070104-as-antibiotic-discovery-stagnates-a-public-health-crisis-brews.pdf">new antibiotics to a trickle</a>. No new drugs to treat gonorrhea have been introduced since 2019, although <a href="https://doi.org/10.1128/aac.01991-21">two are in the final stage</a> of clinical trials.</p>
<p>Vaccination against gonorrhea isn’t possible presently, but it could be in the future. Vaccines effective against the meningitis bacterium, a close relative of gonorrhea, can sometimes also provide <a href="https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies">protection against gonorrhea</a>. This suggests that a gonorrhea vaccine should be achievable. </p>
<p>The World Health Organization has begun an initiative to <a href="https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies">reduce gonorrhea worldwide by 90%</a> before 2030. This initiative aims to promote safe sexual practices, increase access to high-quality health care for sexually transmitted diseases and expand testing so that asymptomatic infections can be treated before they spread. The initiative is also advocating for increased research into vaccines and new antibiotics to treat gonorrhea.</p>
<p>Setbacks in fighting drug-resistant gonorrhea during the COVID-19 pandemic make these actions even more urgent.</p><img src="https://counter.theconversation.com/content/187909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Keiler receives funding from NIH.</span></em></p>The US currently has only one antibiotic available to treat gonorrhea – and it’s becoming less effective.Kenneth Keiler, Professor of Biochemistry and Molecular Biology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1886282022-08-16T20:39:37Z2022-08-16T20:39:37ZTreating monkeypox like an STI may help control the outbreak, but stigma is a danger<figure><img src="https://images.theconversation.com/files/479474/original/file-20220816-9810-ms19br.jpg?ixlib=rb-1.1.0&rect=0%2C77%2C1789%2C1319&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox is transmitted mainly through direct contact with skin lesions, but the current outbreak is following patterns similar to STIs.</span> <span class="attribution"><span class="source">(NIAID, cropped from original)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The recent monkeypox global outbreak, now declared by the World Health Organization as a <a href="https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern">Public Health Emergency of International Concern</a> (PHEIC), is sadly yet another reason for society to stigmatize and discriminate against the LGTBQ2SA+ community. This is in part because it has been suggested that monkeypox is a sexually transmitted infection (STI).</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">Monkeypox started as a zoonosis</a> (an infection transmitted by contact with animals). However, this close relative of the variola virus (which causes smallpox) can also be transmitted from human to human, mainly through direct contact with the skin lesions. </p>
<p>Although transmission through semen and vaginal secretions has yet to be proven, it can be transmitted during sexual intercourse because of the obvious close contact it entails. </p>
<p>Cases have been identified for decades mainly in West African countries, but it was only recently when cases appeared in Europe and America that it caught the international attention it deserved. Cases continue to rise in many countries, to the point of prompting the WHO to declare it a PHEIC. </p>
<p><a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">One excellent study</a> put together a series of 500 patients distributed across 16 countries. The researchers analyzed patients’ demographics as well as their clinical characteristics. They found that 98 per cent of the cases were men who prefer to have sex with men (MSM). Of note, 41 per cent of the cases were people living with HIV (PLWH). </p>
<h2>Characteristics of lesions</h2>
<p>Another finding was the characteristics of the lesions. Monkeypox used to present with skin lesions mainly on the face, trunk, arms and legs, but most of the reported cases during this global outbreak have had a different presentation. Many cases have lesions in the perineal region (73 per cent) or genitals or even around the mouth. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a black T-shirt is pointing at a large screen showing a series of images of skin lesions." src="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An epidemiologist conducts monkeypox disease training to health investigators at the Salt Lake County Health Department on July 29, 2022, in Salt Lake City.</span>
<span class="attribution"><span class="source">(AP Photo/Rick Bowmer)</span></span>
</figcaption>
</figure>
<p>This could be consistent with sexual transmission as the lesions are presenting at the site of infection, a clinical course also described in <a href="https://doi.org/10.1016/S0140-6736(22)01436-2">this paper from Spain</a>. Additionally, 30 per cent of the patients also have another more common STI such as gonorrhea or syphilis, a pattern frequently found in many STIs. Managing a patient with an STI always implies ruling out other STIs. </p>
<p>Grouping diseases by their mode of transmission is helpful for doctors because it allows us to make mental lists of probable causes when confronted with a case. We call this differential diagnosis. </p>
<p>When a patient presents with a genital lesion, a health-care provider will establish a list of possible diagnoses based on the characteristics of the lesion, the accompanying symptoms and the local epidemiology. This makes it possible to treat empirically (before we can confirm the diagnosis) for the most probable cause. </p>
<h2>What is an STI?</h2>
<p>Any disease passed from one person to another through bodily fluids during a sexual encounter is <a href="https://www.who.int/health-topics/sexually-transmitted-infections#tab=tab_1">considered an STI</a>. However there are diseases that occur more frequently than others and as such are grouped in this category, such as chlamydia and gonorrhea. </p>
<p>Other diseases may be transmitted through genital secretions but are not considered an STI by the medical community. For example, Ebola has been shown to be <a href="https://doi.org/10.1371/journal.pmed.1003273">transmitted through genital secretions</a>, however it is not considered within the group of the more frequent STIs because it is not its main mode of transmission. </p>
<figure class="align-center ">
<img alt="A man in a plaid shirt getting an injection from a woman in a blue dress and face mask, both sitting in folding chairs, seen from behind" src="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montréal in July 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>The mode of presentation of monkeypox during this global outbreak has <a href="https://doi.org/10.1016/S0140-6736(22)01497-0">prompted the medical community</a> to consider monkeypox diagnosis, along with other STIs, in any person who has had a recent unprotected sexual contact, and presents with a painful skin lesion in the genitals, perianal region or mouth.</p>
<p>Considering monkeypox as an STI seems logical in order to face the current outbreak, but the <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-2-february-1-2018/article-5-stigma-sexually-transmitted-infections.html">stigma and discrimination</a> this could cause is a major problem. An infection acquired through sex is still something that causes guilt and fear of rejection by society. STIs are still viewed by many as a <a href="https://slate.com/technology/2019/12/genital-herpes-stigma-history-explained.html">punishment for certain behaviours</a>. </p>
<p>Additionally, classifying monkeypox as an STI may create a false sense of security for people who may think they’re not at risk. Both stigma and a low perception of risk can hinder efforts for early identification of cases, rapid isolation and limitation of the outbreak. Worst of all, stigma related to this outbreak would perpetuate harms to the LGTBQ2SA+ community.</p>
<p>Monkeypox is behaving like an STI during this global outbreak, so including this diagnosis as part of sexual health management may be beneficial to stop transmission. However, bigger efforts addressing stigma and discrimination are necessary.</p><img src="https://counter.theconversation.com/content/188628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Santiago Perez Patrigeon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Monkeypox is not considered an STI but is spreading among sexual partners. Adding sexual health strategies to the public health response is helpful, but there is a danger of stigmatizing MPXV.Santiago Perez Patrigeon, Assistant professor, Division of Infectious Diseases, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1821142022-07-13T12:30:09Z2022-07-13T12:30:09ZManuscripts and art support archaeological evidence that syphilis was in Europe long before explorers could have brought it home from the Americas<figure><img src="https://images.theconversation.com/files/473438/original/file-20220711-26-m03ndy.jpg?ixlib=rb-1.1.0&rect=233%2C137%2C2193%2C1714&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Does a painting from 1400 depict one of Jesus' torturers as suffering from 'saddle nose,' a common effect of syphilis?</span> <span class="attribution"><a class="source" href="https://www.clevelandart.org/art/1945.115">Detail of an Austrian painting c. 1400 of the Passion of Christ, The Cleveland Museum of Art</a></span></figcaption></figure><p>That the arrival of Europeans in the New World in 1492 led to a massive shift in the ecological landscape has been widely accepted <a href="https://www.smithsonianmag.com/history/alfred-w-crosby-on-the-columbian-exchange-98116477/">for the past 50 years</a>. Suddenly a trans-Atlantic exchange – maize for wheat, tomatoes for apples, tobacco for horses – meant that plants and animals were moving between continents for the first time.</p>
<p>It was the same for pathogens, according to historian Alfred W. Crosby and his influential book “<a href="https://www.worldcat.org/title/columbian-exchange-biological-and-cultural-consequences-of-1492/oclc/930378865&referer=brief_results">The Columbian Exchange</a>.” Diseases like smallpox and measles, brought to the Western Hemisphere by the invaders, soon killed <a href="https://theconversation.com/how-smallpox-devastated-the-aztecs-and-helped-spain-conquer-an-american-civilization-500-years-ago-111579">almost the entire Indigenous population</a>. In return, Europeans fell prey to <a href="https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm">syphilis, a venereal disease</a> they picked up from the native people. Crosby’s idea about the exchange of diseases was an interesting one and it made for a good story, suggesting that with the arrival of syphilis in Europe justice of a sort had been done.</p>
<p>The only problem is that this syphilis scenario is wrong, according to <a href="https://doi.org/10.1002/ajpa.23988">ongoing research by paleopathologists</a>, scientists who study skeletal remains for evidence of disease. After decades of painstaking work, they have concluded that the syphilis-causing spirochete bacterium <em>Treponema pallidum</em> already existed in the Old World long before Columbus boarded his ship and sailed to Hispaniola.</p>
<p>As a <a href="https://scholar.google.com/citations?user=K6x0M5sAAAAJ&hl=en&oi=ao">women’s historian</a> who has studied documents and artworks for <a href="https://muse.jhu.edu/article/842358">evidence of syphilis in the medieval period</a>, I believe the paleopathologists are right. Like skeletal remains, paintings show life as it was. Even manuscripts, although more open to interpretation, can reveal the truth once readers open their minds to new possibilities. Here’s a sample of the evidence that <a href="https://www.arc-humanities.org/9781802700480/medieval-syphilis-and-treponemal-disease/">Europeans suffered from syphilis long before they reached the Americas</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="microscopic image of long white worm-like shapes" src="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"><em>Treponema pallidum</em> is a spiral-shaped bacterium that causes the disease syphilis.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/treponema-pallidum-dark-field-preparation-syphilis-image-news-photo/509391914">CDC/Susan Lindsley/Smith Collection/Gado via Getty Images</a></span>
</figcaption>
</figure>
<h2>Evidence from bones and teeth in the Old World</h2>
<p>In a cemetery in West Sussex, U.K., archaeologists uncovered the <a href="https://doi.org/10.1002/ajpa.22630">skeleton of a young man</a> with extensive damage to his skull, clavicles, arms and legs – a combination typical of syphilis. He died in the sixth century. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="skull with hole and areas where bone looks rotted away" src="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=604&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=604&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=604&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=759&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=759&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=759&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">View of a human skull damaged by late-stage syphilis, the kind of evidence paleopathologists can look for.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Skull_damage_from_neurosyphilis.jpg">Canley/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In St. Polten, Austria, a medieval cemetery holds the <a href="https://doi.org/10.1127/anthranz/2015/0504">remains of a child</a> age 6 with deformed teeth consistent with a diagnosis of treponematosis, perhaps a case of <a href="https://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm">congenital syphilis</a>, when the <em>Treponema pallidum</em> bacteria are passed from mother to child during pregnancy or birth.</p>
<p>In Anatolia in western Turkey, the <a href="https://doi.org/10.1002/oa.802">skeleton of a teenager</a> revealed not only the same deformed incisors as in St. Polten, but also damage to the entire skeleton below the head. Involvement of both teeth and bones in the same specimen, and especially the large number of bones affected in this case, points to syphilis. The victim died in the 13th century – a couple hundred years before Columbus set sail. </p>
<p>And so it goes. While the absolute number of cases is not large, <a href="https://doi.org/10.1002/ajpa.22630">they keep turning up</a>. Some of the evidence appears in the remains of people who <a href="https://www.worldcat.org/title/origine-de-la-syphilis-en-europe-avant-ou-apres-1493-actes-du-colloque-international-de-toulon-25-28-novembre-1993/oclc/884173338&referer=brief_results">lived more than 2,000 years ago</a>.</p>
<p>There is an outstanding issue, however. Damaged bones and teeth seem to hold proof of pre-Columbian syphilis, but there is a possibility that they point to another form of the disease instead. <em>Treponema pallidum</em> appears in several strains. The subspecies that causes syphilis is the deadliest. But two other subspecies of the bacteria cause less serious, if still painful and unsightly, diseases called <a href="https://rarediseases.org/rare-diseases/bejel/">bejel</a> (also known as endemic syphilis) and <a href="https://www.who.int/news-room/fact-sheets/detail/yaws">yaws</a> that are <a href="https://www.merckmanuals.com/home/infections/bacterial-infections-spirochetes/bejel-yaws-and-pinta">not usually transmitted sexually</a>. Nowadays all three can be treated with antibiotics.</p>
<p>How then, to distinguish between the three subspecies and prove that the venereal form had existed in Europe all along?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="detail of medieval painting of Jesus in crown of thorns amid crowd" src="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In an early 15th-century painting, a discerning historian’s eye sees two soldiers (one in yellow, one behind red plume) with facial features indicative of advanced syphilis leading Christ to his crucifixion.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Master_of_the_Karlsruhe_Passion_-_Disrobing_of_Christ.jpeg">The Disrobing of Christ from the Karlsruhe Passion (detail), c.1440. Staatliche Kunsthalle Karlsruhe, Strasbourg</a></span>
</figcaption>
</figure>
<h2>Writers and artists recorded other evidence</h2>
<p>Documentary and artistic evidence can help settle the issue. Of all the pathogens known to humanity, only treponemes produce <a href="https://doi.org/10.1001/archderm.1970.04000070080012">such widely divergent outcomes based on climate and culture</a>, an important clue for finding evidence in manuscripts.</p>
<p>This fact explains my theory that medieval elites suffered more severely from treponematosis than peasants. Their wealthy lifestyle would have protected them from childhood infections their social inferiors picked up in their crowded and unsanitary households. But those childhood sicknesses would have had the benefit of triggering some future immunity in the peasantry.</p>
<p>If members of the elite reached sexual maturity without having had milder infections while growing up, they would be highly susceptible to contracting the disease for the first time during intercourse. A sore on the genitalia contains a massive dose of infectious bacteria compared with the small doses found on the shared clothing or bedding of the peasantry. Peasants who suffered a recurrence of the disease as adults could likely fend it off successfully because of their prior immunity. I contend this was not true for elites who then suffered more devastating illnesses.</p>
<p>In addition to dying young themselves, infected elites risked giving their children congenital syphilis, which often proved fatal to the next generation. Elites and their children died in such high numbers that some noble families <a href="https://global.oup.com/academic/product/the-crisis-of-the-aristocracy-1558-to-1641-9780198213147">had trouble maintaining their bloodlines</a>, a point noted long ago without making a potential connection to syphilis.</p>
<p>One royal who <a href="https://muse.jhu.edu/article/842358">I believe almost certainly died of syphilis</a> was king Edward IV of England (1442-83). One of his councilors wrote that he died of an illness difficult to cure even in a person of lesser status, a cryptic comment not previously understood by historians. But his statement perfectly fits the difference between venereal and endemic syphilis, evidence that suggests both diseases existed in 15th-century England. The <a href="https://yalebooks.yale.edu/book/9780300073720/edward-iv/">king’s symptoms and reputation for sexual promiscuity</a> help confirm my diagnosis.</p>
<p>Evidence for the presence of syphilis in the Old World also comes from art.</p>
<p>Doctors know that <a href="https://doi.org/10.1001/archderm.1970.04000070080012">syphilis can result in</a> “<a href="https://phil.cdc.gov/Details.aspx?pid=17626">saddle nose</a>,” in which spirochetes invade a patient’s nose and cause it to collapse in a distinctive way. Medieval artists from as early as the 12th century depicted this deformity in their work.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side view of man with a collapsed nose, paired with medieval painting of Jesus and a persecutor" src="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In a medieval painting, one of Christ’s tormentors has facial features reminiscent of a syphilis patient’s saddle nose.</span>
<span class="attribution"><a class="source" href="https://www.bl.uk/manuscripts/Viewer.aspx?ref=yates_thompson_ms_13_fs001r">L: British Journal of Plastic Surgery, Vol. 10, McLaren + Penney, The reconstruction of the syphilitic saddle nose: A review of seven cases, Pages 236-252, Copyright 1957–1958. R: The Taymouth Hours, England, mid-14th century. British Library, MS Yates Thompson 13, fol. 120v.</a></span>
</figcaption>
</figure>
<p>I believe they intended to show venereal and not endemic disease because they use saddle nose in depictions of sinful figures, including the men who tortured Christ or killed babies on the orders of King Herod.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Front view of man with a collapsed nose, paired with drawing of a monster with a snub-nosed face on a pair of legs" src="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A gryllus displaying the saddle nose deformity in a drawing from the early 1300s.</span>
<span class="attribution"><a class="source" href="https://www.bl.uk/manuscripts/Viewer.aspx?ref=stowe_ms_17_fs001r">L: British Journal of Plastic Surgery, Vol. 10, McLaren + Penney, The reconstruction of the syphilitic saddle nose: A review of seven cases, Pages 236-252, Copyright 1957–1958. R: The Maastricht Hours, Liège, early 14th century. British Library, MS Stowe 17, fol. 151r.</a></span>
</figcaption>
</figure>
<p>Even the silly gryllus, a medieval monster with a face and legs but no body, was a symbol of human depravity.</p>
<p>Examples abound. Historians have ignored good evidence – as plain as the nose on your face, so to speak – because they believed in the Columbian exchange. Regarding syphilis, however, that intellectual framework now appears outdated.</p><img src="https://counter.theconversation.com/content/182114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marylynn Salmon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The idea that Europeans brought new diseases to the Americas and returned home with others has been widely accepted. But evidence is mounting that for syphilis this scenario is wrong.Marylynn Salmon, Research Associate in History, Smith CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1708522021-12-02T13:43:30Z2021-12-02T13:43:30ZWhy COVID-19 must be included in safer sex messaging on college campuses<figure><img src="https://images.theconversation.com/files/432516/original/file-20211117-21-ov80nw.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C3464%2C2300&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Little information is available to college students on stopping the spread of COVID-19 within an intimate relationship.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-couple-kissing-with-face-protective-mask-royalty-free-image/1265180786?adppopup=true">DisobeyArt/iStock via Getty Images Plus</a></span></figcaption></figure><p>With college students back on campus, and COVID-19 with us <a href="https://theconversation.com/is-covid-19-here-to-stay-a-team-of-biologists-explains-what-it-means-for-a-virus-to-become-endemic-168462">for the foreseeable future</a>, it has become increasingly clear that educators need to develop a <a href="https://www.healthline.com/health/healthy-sex/safer-sex-tips-positions-during-covid-19#covid-19-tips">new definition</a> of safer sex. </p>
<p>Although the virus is <a href="https://www.avert.org/coronavirus/covid19-sex">not a sexually transmitted infection</a>, students can <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html">spread COVID-19</a> through <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html">droplets and particles</a>, especially when within 6 feet of each other. That includes being intimate. </p>
<p>This is why sex education efforts need to inform students not only about sexually transmitted infections, HIV and unintended pregnancy, but also about ways to <a href="https://bestlifeonline.com/new-coronavirus-sex-guidelines/">reduce COVID-19 transmission risk</a>.</p>
<p><a href="https://profiles.ucla.edu/tamra.loeb">As psychologists</a> and <a href="https://www.researchgate.net/profile/Michele-Cooley-Strickland">educators</a> at the University of California, Los Angeles, who <a href="https://www.semel.ucla.edu/profile/gail-wyatt-phd">design interventions</a> to promote the health and well-being of college students, we are aware of the work that has gone into reopening campuses during the pandemic. But despite all the effort, some critical health needs of those students have been entirely overlooked. </p>
<figure class="align-center ">
<img alt="A group of college students on campus." src="https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Much can be done to reduce COVID-19 risk for sexually active students.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/diverse-group-of-college-friends-royalty-free-image/887132600?adppopup=true">Ariel Skelley/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>The CDC missed a chance</h2>
<p>The Centers for Disease Control and Prevention produced <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/colleges-universities/considerations.html#section4">a lengthy document</a>, last updated in November 2021, about college campuses and COVID-19 transmission. The document offers suggestions on how to stop the spread of the virus in all kinds of scenarios, from communal eating to sporting events. But stunningly, we could not find a word about the potential for spreading COVID-19 within an intimate relationship. </p>
<p>This is particularly disturbing when one considers that college students could use some expert advice. Their decision-making skills are not <a href="https://doi.org/10.1016/j.jadohealth.2009.05.016">fully developed</a>, and many college-age students are <a href="https://doi.org/10.1016/j.jadohealth.2009.05.016">impulsive</a>. </p>
<p>Pleasurable and perhaps risky behaviors often win out over possible long-term negative consequences. Just look at the <a href="https://mashable.com/article/how-to-have-safe-sex-during-covid-pandemic-smarter-hookups">rates of STIs</a>, <a href="https://doi.org/10.1080/17538068.2017.1385575">HIV</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/19278182/">unintended pregnancy</a>: Compared with other age groups, the rates are <a href="https://doi.org/10.1080/07448481.2018.1549554">higher among college students</a>. </p>
<h2>Ways to avoid COVID-19</h2>
<p>The irony is that there is much to say and to promote about <a href="https://bestlifeonline.com/coronavirus-sex-new-york-guidelines/">reducing COVID-19 risk</a> for sexually active students. </p>
<p>Here are some evidence-based recommendations: Limit the number of sexual partners. Avoid sexual contact with anyone who has COVID-19 or symptoms. Use condoms and <a href="https://www.cdc.gov/condomeffectiveness/Dental-dam-use.html">dental dams</a>.
Avoid activities involving transmission of fecal-oral material. Wear masks during intimate acts. Avoid kissing. </p>
<p>Also: Wash hands before and after sexual activity. Use clean sex toys. Sanitize areas where sexual activity occurs. Engage in <a href="https://www.avert.org/coronavirus/covid19-sex">self-pleasure</a>. And understand that those who are not symptomatic can still transmit <a href="https://www.cdc.gov/library/covid19/pdf/public_pdfs/2020-06-12-Science-Update_FINAL_public.pdf">COVID-19</a> and some <a href="https://www.aafp.org/dam/AAFP/documents/patient_care/sti/hops19-sti-manual.pdf">STIs</a>. </p>
<h2>Abstinence programs don’t help</h2>
<p>Many <a href="https://mashable.com/article/how-to-have-safe-sex-during-covid-pandemic-smarter-hookups">abstinence programs</a> are based on the premise that abstinence until marriage is the acceptable <a href="https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/human_rights_vol35_2008/human_rights_summer2008/hr_summer08_kantor/">standard of human sexual behavior</a>. </p>
<p>But research has shown that <a href="https://aspe.hhs.gov/reports/impacts-four-title-v-section-510-abstinence-education-programs-1">abstinence programs are ineffective</a> and often lead to increased rates of <a href="https://doi.org/10.1371/journal.pone.0024658">unintended pregnancy</a> and other high risk behaviors. That’s because they limit discussions of STI prevention and birth control; this effectively <a href="https://doi.org/10.1371/journal.pone.0024658">withholds information</a> from young people who are in the midst of making crucial decisions about their health and future.</p>
<p>Instead, <a href="https://doi.org/10.1097/GCO.0b013e3282efdc0b">research shows</a> that programs that provide accurate information in a nonjudgmental way about abstinence, contraception and STI prevention work better, particularly if they also promote communication, decision-making and <a href="https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/human_rights_vol35_2008/human_rights_summer2008/hr_summer08_kantor/">negotiation skills</a>. </p>
<p>These same programs could also add information about preventing the spread of COVID-19 while sexually intimate.</p>
<figure class="align-center ">
<img alt="A young woman on her bed is looking at her smartphone." src="https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">By accessing COVID-19 test results via smartphone, students can easily share them with their intimate partners.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-in-bed-texting-on-phone-royalty-free-image/1311283313?adppopup=true">martin-dim/E! via Getty Images</a></span>
</figcaption>
</figure>
<h2>How schools can help</h2>
<p>Instead of ignoring the issue, university administrators should make sure students have the tools they need to avoid both COVID-19 and STIs. </p>
<p>For example, with just their smartphones, students can easily <a href="https://www.studenthealth.ucla.edu/services/covid-19-testing">schedule COVID-19 tests</a>, get the results and then share them with those they are intimate with. The same can be done with <a href="https://doi.org/10.1007/s10461-019-02718-y">STI, HIV</a> and pregnancy results. </p>
<p>Sharing those results with respect for confidentiality requires widespread promotional campaigns to normalize this new behavior. Schools or campus-based student organizations could ignite a trend on Twitter with a simple but memorable slogan. Here’s one we suggest: “Show me yours and I’ll show you mine.” That’s one of many Twitter-friendly lines that would encourage students to exchange electronic health records. </p>
<p><a href="http://95.138.156.120/article/06/01/2021/UC-San-Diego-offers-students-COVID-test-kits-by-vending-machine">Some campuses</a> already have vending machines <a href="https://newscenter.sdsu.edu/sdsu_newscenter/news_story.aspx?sid=78531">that contain free COVID-19 self-test kits</a>. Results are sent to students electronically. At UCLA, the self-test kits are placed near <a href="https://healtheducation.ucla.edu/what-we-offer/programs/bruin-love-station">sexual health vending machines</a>, which are stocked with condoms, lubricant, emergency contraception and other reproductive and sexual aids. </p>
<h2>Learning to interact again</h2>
<p><a href="https://doi.org/10.18865/ed.30.2.261">Communication between students</a> is critical, particularly when sharing intimate information. But after 18 months away from campus because of COVID-19, some have experienced <a href="https://doi.apa.org/fulltext/2021-00489-001.html">serious social and emotional impacts</a>. For many, peer-to-peer communication skills have declined. This awkwardness makes it particularly difficult when discussing sensitive subjects. </p>
<p>Again, the school can help. One way is to offer students breakout sessions in small groups. This could be done in-class or as extracurricular assignments. Either approach gives <a href="https://www.premiumschools.org/social-anxiety-disorder-college/">socially anxious students</a> – or those recovering from COVID-19 isolation – the outlet they need to interact in person with others. </p>
<h2>How parents can help</h2>
<p>Young people have been bombarded with sexual misinformation from both peers and media. But studies show that intergenerational communication about sexual activity can reduce <a href="https://doi.org/10.1542/peds.2015-0305">risky sexual behaviors</a>. And while sexual health education is <a href="https://www.cdc.gov/healthyyouth/whatworks/what-works-sexual-health-education.htm">effective at reducing unwanted outcomes</a>, it’s enhanced when <a href="https://doi.org/10.1016/j.pcl.2016.11.002">parents are involved</a>. </p>
<p>With the widespread impact of COVID-19, now is a great time to <a href="https://eisnerfoundation.org/">bring parents into the conversation</a>. But they are often an underutilized resource. Many haven’t had sexual health education themselves, they may not know what’s appropriate to share with their children and they may simply be <a href="https://doi.org/10.1016/j.pcl.2016.11.002">uncomfortable with sex topics</a>. </p>
<p>We are still in a time of considerable ambiguity, mistrust and confusion. That applies to both COVID-19 and sexual health. But there is one certainty: Young people need responsible adult guidance to secure a healthy future. And the sooner the better. In the grip of a pandemic, their lives may depend on it.</p><img src="https://counter.theconversation.com/content/170852/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamra Burns Loeb receives funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Gail Wyatt, Phd works at University of California, Los Angeles(UCLA). She receives funding from National Heart, Lung, and Blood Institute of the National Institutes of Health, Cal Wellness Foundation, and Gilead Pharmaceutical Sciences. </span></em></p><p class="fine-print"><em><span>Michele R. Cooley-Strickland is the co-principal investigator of a grant with pending funding from the Eisner Foundation at UCLA. The title of the grant is "Plan A: Intergeneration STI, HIV, and Pregnancy Prevention – ‘Sex, Cookies, & COVID’.”</span></em></p>Schools have not adequately educated students about the increased risks of virus transmission when it comes to being sexually intimate.Tamra Burns Loeb, Adjunct Associate Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los AngelesGail Wyatt, Dena Bat Yaacov Endowed Chair and Distinguished Professor of Psychiatry & Biobehavioral Sciences, University of California, Los AngelesMichele R. Cooley-Strickland, Project Scientist and Clinical Psychologist, Department of Psychiatry and Biobehavioral Sciences, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1573182021-03-18T01:32:42Z2021-03-18T01:32:42ZWhat is Mycoplasma genitalium, the common STI you’ve probably never heard of<figure><img src="https://images.theconversation.com/files/390232/original/file-20210317-21-14e4lym.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C998%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-man-hands-holding-his-crotch-769304695">from www.shutterstock.com</a></span></figcaption></figure><p><em><a href="https://www.fpv.org.au/for-you/sexually-transmissible-infections-blood-borne-viruses/mycoplasma-genitalium">Mycoplasma genitalium</a></em> (MG) is a sexually transmitted infection (STI) with many of the hallmarks of its better-known counterpart, <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/chlamydia">chlamydia</a>.</p>
<p>You can have MG without knowing it, or have symptoms; it can affect men and women, and it can be treated with antibiotics. </p>
<p>However, unlike chlamydia, we only have a limited number of antibiotics to treat it, due to a quirk in its cellular structure and the growing threat of antibiotic resistance. The antibiotics we need to use with resistant MG can also, uncommonly, have serious side-effects.</p>
<p>Here’s what you need to know about this common STI.</p>
<h2>What is it? How do I get it? How common is it?</h2>
<p>MG can affect both men and women, and is passed from person to person via their body fluids when they have sex. That can be via penile-vaginal sex or via penile-anal sex. Transmission via oral sex isn’t thought to be a big factor.</p>
<p>Several studies tell us MG is common, perhaps as common as chlamydia.</p>
<p>UK and US <a href="https://pubmed.ncbi.nlm.nih.gov/26534946/">data</a> <a href="https://pubmed.ncbi.nlm.nih.gov/33560093/">show</a> 1-2% of the adult population have it (making it about <a href="https://pubmed.ncbi.nlm.nih.gov/31794495/">as common as chlamydia</a>), and it is as common in men as in women. </p>
<p>In research yet to be published, when we tested women who walked through the door of our sexual health service in Melbourne, 6% had MG, which was as common as chlamydia (7%) in women in the same study. Of women with MG, roughly the same number had symptoms compared to no symptoms. When we tested <a href="https://pubmed.ncbi.nlm.nih.gov/30882306/">gay men without symptoms</a> who attended our service, 10% had MG.</p>
<p>However, we’re not entirely sure how many people are infected with MG throughout Australia. That’s because Australia has yet to set up a formal surveillance network (we’re in the middle of setting that up at the moment). MG is also not a notifiable disease yet. That means doctors or laboratories don’t have to tell health authorities when they have a case.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Mycoplasma genitalium, as 3D rendered image" src="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mycoplasma genitalium is a sexually transmitted infection that affects men and women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/bacteria-mycoplasma-genitalium-3d-illustration-causative-1415788364">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>How do I know if I have it?</h2>
<p>If you do have symptoms, these can resemble those of chlamydia. So the best thing is to go to your GP or sexual health clinic for a checkup, as the treatments are different.</p>
<p>If you’re a man with symptoms, they can vary from mild to moderate and include:</p>
<ul>
<li><p>mild irritation, an itch, or a burning sensation when urinating</p></li>
<li><p>a penile discharge, which may be clear or more like pus.</p></li>
</ul>
<p>For women, symptoms may include:</p>
<ul>
<li><p>a vaginal discharge</p></li>
<li><p>bleeding or pain with sex</p></li>
<li><p>abdominal pain (which may be a sign of <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/pelvic-inflammatory-disease-pid">pelvic inflammatory disease</a>).</p></li>
</ul>
<p>For men or women who have anal sex, symptoms may include:</p>
<ul>
<li>an itch or pain inside the anus, anal discharge and sometimes anal bleeding.</li>
</ul>
<p>Your doctor will take a urine sample for men and a vaginal swab for women. For men or women who have anal sex, they will take a rectal swab, or you will be instructed how to take it yourself. Samples will then be sent for laboratory testing.</p>
<h2>How is it treated?</h2>
<p>Once diagnosed, you’ll be treated with a course of oral antibiotics for about two weeks. Unfortunately, you may need several courses to cure the infection due to <a href="https://pubmed.ncbi.nlm.nih.gov/32622378/">increasing antibiotic resistance</a>. And some of these antibiotics can have side-effects. Occasional, but serious, side-effects include an abnormal heart rhythm, rupture of tendons and nerve damage.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-im-taking-antibiotics-when-will-they-start-working-107528">Health Check: I’m taking antibiotics – when will they start working?</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if I leave it untreated?</h2>
<p>If the infection is left untreated in women, it can cause similar complications to chlamydia. Some women go on to develop <a href="https://pubmed.ncbi.nlm.nih.gov/32701123/">pelvic inflammatory disease</a>, although less commonly than with chlamydia. Pelvic inflammatory disease could, in turn, lead to infertility. If you’re pregnant, it can, uncommonly, lead to premature birth or miscarriage.</p>
<p>If left untreated in men there are no apparent complications but the main risk is men can infect new partners and reinfect treated partners. And for gay men, there’s <a href="https://pubmed.ncbi.nlm.nih.gov/19194271/">some data</a> to suggest a link between MG and HIV, although further studies are needed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-make-your-next-sexual-health-check-less-erm-awkward-72498">How to make your next sexual health check less, erm ... awkward</a>
</strong>
</em>
</p>
<hr>
<h2>Can I still be tested even if I don’t have symptoms?</h2>
<p>Current guidelines both <a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/mycoplasma-genitalium">in Australia</a> and <a href="https://www.bashhguidelines.org/current-guidelines/urethritis-and-cervicitis/mycoplasma-genitalium-2018/">internationally</a> recommend testing people with symptoms, or sexual contacts of known cases. They <a href="https://www.thelancet.com/action/showPdf?pii=S2589-5370%2821%2900059-6">don’t recommend doctors screen</a> people <a href="https://www.theguardian.com/australia-news/2021/mar/17/gps-urged-not-to-test-gay-men-for-sti-super-bug-over-fears-it-will-become-more-antibiotic-resistant">without symptoms</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1371870337932132352"}"></div></p>
<p>When you screen, you have to be confident you have access to highly effective treatments, the treatments do not cause more harm than the condition itself and you have a good understanding of how often the condition progresses to cause complications.</p>
<p>For MG that balance is against screening currently. That’s because there are often no symptoms and we don’t yet fully understand how often the infection progresses to cause harm, although it seems to do so less often than chlamydia. The microorganism has also rapidly become so resistant to antibiotics we are having to use stronger and stronger ones, and multiple courses, to cure. This contrasts to chlamydia, which is easy to cure. </p>
<p>Not only do many antibiotics have side-effects, they affect the bacteria in people’s gut. These bacteria are important to keep us healthy, and if we bombard them with antibiotics it can affect our health and also lead to antibiotic resistance in a whole range of other bacteria, not just MG.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/157318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catriona Bradshaw receives funding from the NHMRC and ARC (government funding). Melbourne Sexual Health Centre has also received research support from Speedx Pty Ltd and Hologic Pty Ltd which are manufacturers of diagnostic assays for Mycoplasma genitalium. </span></em></p>You can have this STI without knowing it, or have symptoms, it can affect men and women, and it can be treated with antibiotics. Left untreated, it may cause complications.Catriona Bradshaw, Professor, Head of Research Translation and Head of the Genital Mycoplasma and Microbiota Group, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1439072020-08-16T20:12:04Z2020-08-16T20:12:04ZFrom STIs to malaria, here are six disease trends we should heed during the pandemic<p>The number of <a href="https://coronavirus.jhu.edu/map.html">COVID-19 deaths</a> globally – more than 750,000 – is now greater than the amount of people who <a href="https://www.who.int/gho/malaria/epidemic/deaths/en/">succumb to malaria</a> most years.</p>
<p>Meanwhile, national statistics show lockdown restrictions in Australia have potentially helped <a href="https://www.abc.net.au/news/2020-07-23/coronavirus-restrictions-cause-flu-cases-to-drop-australia/12480190">reduce the number of flu cases</a>.</p>
<p>So while the pandemic continues to have a huge impact on global health, here are some of the known and likely impacts the virus is having on six other major health challenges. </p>
<p>The results might surprise you.</p>
<h2>1. Sexually transmitted infections</h2>
<p>Some dating apps such as Tinder and Bumble <a href="https://theconversation.com/the-safest-sex-youll-never-have-how-coronavirus-is-changing-online-dating-134382">report</a> an increase in online activity, but is this translating to an increase of meet-ups for sexual activity despite the lockdown?</p>
<p>Researchers from the University of Melbourne are investigating these and other questions in a <a href="https://mspgh.unimelb.edu.au/research-groups/centre-for-epidemiology-and-biostatistics-research/sexual-health/sexual-and-reproductive-health-during-covid-19-coronavirus">survey</a> examining the sexual and reproductive health impacts of COVID-19.</p>
<p>Although this research is ongoing, preliminary analysis suggests a decline in sexual activity among those without cohabitating partners during lockdown, and an increase in solo sex activities such as masturbation and using sex toys. </p>
<p>Adult stores have also <a href="https://www.abc.net.au/news/2020-04-28/sex-shops-help-mental-wellbeing-during-coronavirus/12189202">reported</a> a jump in sales during the lockdown. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-safest-sex-youll-never-have-how-coronavirus-is-changing-online-dating-134382">The safest sex you'll never have: how coronavirus is changing online dating</a>
</strong>
</em>
</p>
<hr>
<p>While early reports suggest a <a href="https://www.abc.net.au/news/2020-05-20/coronavirus-shutdown-leads-to-apparent-drop-in-stis-in-canberra/12264908">possible decline in STIs</a> during the lockdown period, with the resumption of normal life across most of Australia, it’s unclear if this trend will continue. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The shopfront of an adult shop." src="https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352108/original/file-20200811-14-1ownyw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adult shops report a sales jump during lockdown.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/75905404@N00/4281292419/">Flickr/OZinOH</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<h2>2. Respiratory infections</h2>
<p>Each year the flu kills <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0">2,000-3,000 Australians</a>. The measures people are taking to limit COVID-19, such as increased physical distancing, good hand hygiene and face masks, are already having a clear benefit on limiting flu spread.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-coronavirus-lockdown-might-help-limit-this-years-flu-season-but-you-should-still-get-your-flu-jab-anyway-135045">The coronavirus lockdown might help limit this year's flu season – but you should still get your flu jab anyway</a>
</strong>
</em>
</p>
<hr>
<p>Deaths from flu in the first half of 2020 were down to <a href="https://www.abc.net.au/news/2020-07-23/coronavirus-restrictions-cause-flu-cases-to-drop-australia/12480190">just 36</a>, compared with 430 in the same period last year.</p>
<p>While we might expect similar reductions in other respiratory infections, the World Health Organization has <a href="https://www.who.int/news-room/detail/24-03-2020-new-who-recommendations-to-prevent-tuberculosis-aim-to-save-millions-of-lives">major concerns</a> about tuberculosis (TB). Well over a million people worldwide die each year from TB, and extensive <a href="https://www.who.int/tb/areas-of-work/laboratory/contact-investigation/en/">detection and tracing programs</a> are key to reducing deaths.</p>
<p>These TB control programs have already been impacted by the pandemic and the WHO predicts an <a href="https://www.who.int/news-room/q-a-detail/tuberculosis-and-the-covid-19-pandemic">extra 1.4 million people could die</a> as a result over the next five years.</p>
<h2>3. Insect-borne diseases</h2>
<p>Staying home should stop you inhaling someone else’s cough or sneeze, but it probably won’t stop you being bitten by a mosquito.</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/vector-borne-diseases">More than 700,000 people die each year</a> from diseases spread by biting insects, such as malaria, dengue, sleeping sickness and yellow fever.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/can-mosquitoes-spread-coronavirus-134898">Can mosquitoes spread coronavirus?</a>
</strong>
</em>
</p>
<hr>
<p>There are <a href="https://asia.nikkei.com/Spotlight/Coronavirus/Singapore-grapples-with-dengue-fever-while-battling-coronavirus">already signs</a> dengue cases are growing in Southeast Asia in the wake of reduced control measures brought by COVID-19.</p>
<p>Monash University’s Scott O'Neill, director of the World Mosquito Program and dengue expert, predicts we’re facing a perfect storm in which fragile health systems <a href="https://www.worldmosquitoprogram.org/en/news-stories/media-releases/dengue-outbreaks-more-likely-because-covid-19">manage outbreaks of two diseases at once</a>.</p>
<p>In the case of malaria, the WHO estimates deaths in many parts of the world <a href="https://www.who.int/publications/i/item/the-potential-impact-of-health-service-disruptions-on-the-burden-of-malaria">could double this year</a>, killing hundreds of thousands more people if insecticide-treated net campaigns are interrupted because of COVID-19.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A mosquito" src="https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352112/original/file-20200811-19-1sn4n7a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disease-carrying bugs are still biting.</span>
<span class="attribution"><span class="source">Shutterstock/mycteria</span></span>
</figcaption>
</figure>
<h2>4. Non-communicable diseases</h2>
<p>In wealthy countries such as Australia, non-communicable diseases such as cancer, heart disease and stroke are some of the main <a href="https://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0">causes of death</a> and disability. Death from some of these can be reduced by appropriate screening and primary healthcare interventions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/even-in-a-pandemic-continue-with-routine-health-care-and-dont-ignore-a-medical-emergency-136246">Even in a pandemic, continue with routine health care and don't ignore a medical emergency</a>
</strong>
</em>
</p>
<hr>
<p>If people delay going to their doctor to monitor blood pressure or put off routine cancer testing (and <a href="https://www.abc.net.au/news/2020-05-14/coronavirus-medical-testing-delays-could-lead-to-future-sickness/12241812">reports</a> so far suggest this is happening), we will inevitably see more illness and deaths from these causes.</p>
<p>Cancer Australia has launched a campaign, <a href="https://canceraustralia.gov.au/cancer-wont-wait">Cancer Won’t Wait</a>, to remind people to continue to participate in national screening campaigns for breast, cervical and bowel cancers and not to put off seeking medical attention for danger signs of cancer.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/wQgAokTe8_Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>In countries that have relatively good control of COVID-19, increases in these non-communicable diseases are likely to far exceed the deaths directly caused by COVID-19.</p>
<h2>5. Alcohol and substance abuse</h2>
<p>If <a href="https://futurism.com/neoscope/people-memes-cope-coronavirus-panic">social media posts</a> are anything to go by, people could be drinking more frequently and in higher volume than normal during the pandemic.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1237981640820961281"}"></div></p>
<p>According to a <a href="https://fare.org.au/many-australians-using-more-alcohol-and-worried-about-household-drinking/">poll</a> commissioned by the Foundation for Alcohol Research and Education, one in five Australian households are buying more alcohol than normal during the pandemic.</p>
<p>Alcohol contributed to <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2017%7EMain%20Features%7EDeaths%20due%20to%20harmful%20alcohol%20consumption%20in%20Australia%7E4">more than 1,000 deaths</a> in Australia in 2017 alone, and heavier drinking during the pandemic would exacerbate this pattern.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/worried-about-your-drinking-during-lockdown-these-8-signs-might-indicate-a-problem-136289">Worried about your drinking during lockdown? These 8 signs might indicate a problem</a>
</strong>
</em>
</p>
<hr>
<p>Experts also worry about possible <a href="https://pursuit.unimelb.edu.au/articles/australia-s-covid-19-relationship-with-booze">longer-term behavioural changes</a> in drinking at home. </p>
<p>The health impacts of abuse of other substances such as heroin or cocaine during the pandemic remains contentious. Limits on transport and movement are already impacting both the <a href="https://www.unodc.org/unodc/en/press/releases/2020/May/covid-19-is-changing-the-route-of-illicit-drug-flows--says-unodc-report.html">trafficking and use of illicit drugs</a>, but users might replace scarce drugs with other equally hazardous substances.</p>
<h2>6. Mental health</h2>
<p>Mental health disorders have some of the heaviest global health burdens of any type of illness. The social, economic and health impacts of COVID-19 will have huge consequences for mental health for many around the world.</p>
<p>Mental health support services <a href="https://www.abc.net.au/news/2020-08-09/coronavirus-crisis-hitting-mental-health-of-victorians-hard/12539152">have already reported</a> a surge in calls, while hospitals have seen an increase in <a href="https://www.abc.net.au/news/2020-08-08/young-people-self-harming-end-up-in-hospital-emergency-rooms/12532040">presentations of young people after self harm</a>. Australia has launched a <a href="https://www.mentalhealthcommission.gov.au/mental-health-and-wellbeing-pandemic-response-plan">National Mental Health and Wellbeing Pandemic Response Plan</a> backed by an initial A$48.1 million.</p>
<p>The Victorian government announced an <a href="https://www.abc.net.au/news/2020-08-09/coronavirus-crisis-hitting-mental-health-of-victorians-hard/12539152">additional A$60 million</a> for mental health services but much more will likely be needed to avert a crisis in this area.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/as-lockdown-fatigue-sets-in-the-toll-on-mental-health-will-require-an-urgent-response-143817">As 'lockdown fatigue' sets in, the toll on mental health will require an urgent response</a>
</strong>
</em>
</p>
<hr>
<h2>What’s the verdict?</h2>
<p>Although some infectious diseases that are normally spread directly from person to person are already reducing their transmission because of our response to COVID-19, many other diseases will get much worse during and after the pandemic.</p>
<p>Although we can’t ease up our efforts to control the spread of COVID-19, taking our eye off other ongoing illnesses will mean even worse health and economic outcomes. It’s crucial to maintain our focus on prevention, control and elimination for the many other health challenges that impact Australia, and the world.</p><img src="https://counter.theconversation.com/content/143907/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stuart Ralph receives funding from the Australian Research Council and the National Health and Medical Research council. He has previously received funding from the World Health Organization </span></em></p><p class="fine-print"><em><span>Jacqueline Coombe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With all the attention focussed on combating the spread of COVID-19 it’s easy to forget the other health challenges that could affect us all.Stuart Ralph, Associate Professor and malaria researcher, The University of MelbourneJacqueline Coombe, Research Officer, Melbourne School Of Population And Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1425112020-07-16T12:15:28Z2020-07-16T12:15:28ZContact tracing’s long, turbulent history holds lessons for COVID-19<figure><img src="https://images.theconversation.com/files/347383/original/file-20200714-18-1vzdzpb.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2316%2C1517&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Technology is raising a new wave of privacy concerns around contact tracing.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/photos/leopatrizi-contact-tracing">Leo Patrizi via Getty Images</a></span></figcaption></figure><p>To get the <a href="https://coronavirus.jhu.edu/us-map">COVID-19 pandemic</a> under control and keep it from flaring up again, contact tracing is critical, but persuading everyone who tests positive to share where they’ve been and with whom relies on trust and cooperation.</p>
<p>Contact tracing’s long, contested history shows how easily both can be shattered. </p>
<p>Looking back at the reasons for resistance to contact tracing as the U.S. struggled to contain epidemics in the past can help us understand the first signs of pushback against contact tracing in the COVID-19 response, as well as the public health consequences. </p>
<h2>Reporting by code rather than name – sometimes</h2>
<p>The goal of contact tracing is to break the chain of transmission by finding everyone an infected person has been in contact with, testing them if they were exposed and isolating them if they, too, are infected. </p>
<p>Unlike social distancing, which had not been used on such a wide scope and scale since the influenza pandemic of 1918, contact tracing has been a staple of infectious disease control since the 1920s. </p>
<p>At that time, doctors were reluctant to report the names of patients with any condition to health departments. They feared that health departments would “steal” their patients or breach personal information disclosed in a confidential clinical relationship.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=804&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=804&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=804&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1010&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1010&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347258/original/file-20200714-139702-1cbf452.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1010&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A poster from the Office for Emergency Management, Office of War Information, 1941–1945, encouraged people to get tested and treated for sexually transmitted diseases.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Sexually_transmitted_infection">Wikipedia</a></span>
</figcaption>
</figure>
<p>Syphilis changed things. Because sexually transmitted diseases were highly stigmatized, <a href="https://doi.org/10.1111/j.1748-720X.2003.tb00130.x">health officials and physicians struck a compromise</a>. “Upstanding” patients with conditions like syphilis need not be reported by name to state health departments, only by a code. Yet “recalcitrant” patients – poor or marginalized patients who might not keep all doctor’s appointments – were typically reported to health departments by name so health officials could manage them. <a href="https://doi.org/10.1111/j.1748-720X.2003.tb00130.x">Prostitutes were often jailed to contain disease spread.</a> </p>
<p>By the time penicillin was developed in the 1940s, the country faced an imperative to <a href="http://hearth.library.cornell.edu/cgi/t/text/pageviewer-idx?c=hearth;rgn=full%20text;idno=4732756_879_008;view=image;seq=1">“find the missing million”</a> people who were infected and spreading the disease. Health officials would test and treat infected people’s contacts in order to “stamp out VD.” In this context, reporting patients by code instead of by name was no longer conceivable given the scope and scale of the crisis. </p>
<p>In the 1960s, when rates of syphilis soared again, physicians were <a href="https://muse.jhu.edu/book/25608">required to report cases to health departments</a>, which had the manpower to interview patients and follow up all contacts. Physicians had long exercised an ethical duty to warn sexual contacts, but as a health department practice, contact tracing fundamentally relied on the cooperation of patients. Confidentiality, therefore, became standard practice. Investigators would never confirm the name of the patient to a contact, even if it could only be one person, like a spouse.</p>
<h2>AIDS: When patient trust broke down</h2>
<p>During the early years of the AIDS epidemic, trust in the confidentiality of contact tracing broke down.</p>
<p>Homosexuality or sodomy was still <a href="https://www.law.cornell.edu/supct/html/02-102.ZO.html">illegal in several states</a> in the mid-1980s, and compiling lists of the names of gay men and their sexual contacts felt not only stigmatizing but risky.</p>
<p>With no effective treatment for AIDS, activists challenged the benefit of taking that risk with contact tracing. One activist <a href="https://muse.jhu.edu/book/25608">compared name-based reporting and contact tracing to the Holocaust</a>: “The road to the gas chamber began with lists in Weimar, Germany.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347370/original/file-20200714-139702-9buiit.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">AIDS prevention counseling centers advised at-risk populations in New York in the 1980s.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/young-man-is-photographed-receiving-aids-prevention-news-photo/174525968">Yvonne Hemsey/Getty Images</a></span>
</figcaption>
</figure>
<p>Some of that fear was stoked by a California Supreme Court decision that psychiatrists had a duty to warn if they believed one of their patients might harm another person. As the judges in the case, <a href="https://law.justia.com/cases/california/supreme-court/3d/17/425.html">Tarasoff v. Regents of the University of California</a>, famously wrote, “The protective privilege ends where the public peril begins.”</p>
<p>For the gay community, as well as for people who injected drugs, the fear was not simply that sexuality and sexual behavior might be inadvertently disclosed in the process of contract tracing, but actively disclosed. Indeed, despite his cooperation, this is exactly what happened in the case of NuShawn Williams – a New York state man who reported relationships with dozens if not hundreds of sexual partners, including girls under the age of 16. Health departments <a href="http://doi.org/10.2105/ajph.82.8.1158">renamed the process “partner notification.”</a></p>
<h2>Technology raises new privacy concerns</h2>
<p>Today, in the era of COVID-19, citizens and lawmakers alike have expressed profound concerns about the kind of sweeping intrusion that <a href="https://theconversation.com/how-apple-and-google-will-let-your-phone-warn-you-if-youve-been-exposed-to-the-coronavirus-136597">new, technology-driven forms of contact tracing advanced</a> by Apple and Google could bring.</p>
<p>A group that calls itself Free Ohio Now, while open to traditional contact tracing involving individuals working under the auspices of the health department, is alarmed by the prospect of electronic contact tracing. Member Tom Hach explained, <a href="https://www.wfmj.com/story/42155789/free-ohio-now-group-takes-issue-with-method-of-contact-tracing">“The door becomes wide open if you use electronic</a>, it’s basically electronic surveillance, and that can be used for many things down the road that this particular application can broadened in the future.”</p>
<p>Unlike <a href="https://www.theguardian.com/world/2020/apr/01/chinas-coronavirus-health-code-apps-raise-concerns-over-privacy">China’s apps</a>, Apple and Google plan to rely on U.S. mobile users’ consent. The dilemma for public health officials is that if not enough people agree to use the apps, the apps lose their value for containing the virus’s spread.</p>
<p>Ultimately, Americans face a <a href="http://doi.org/10.1001/jama.2020.8570">trade-off between public health and privacy</a>. For these reasons, health departments around the nation have been hiring thousands of human contact tracers who work by phone and uphold confidentiality.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=330&fit=crop&dpr=1 600w, https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=330&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=330&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=415&fit=crop&dpr=1 754w, https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=415&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/347376/original/file-20200714-18-4wwciw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=415&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Arizona National Guard members conduct exposure notification calls.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thenationalguard/50062753716">Tech. Sgt. Michael Matkin/Air National Guard</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Yet in Texas, a state <a href="https://theconversation.com/covid-19-messes-with-texas-what-went-wrong-and-what-other-states-can-learn-as-younger-people-get-sick-141563">hit hard by the latest surge in cases</a>, even those traditional methods are drawing fire, echoing the concerns voiced in the early years of the AIDS epidemic. Grant Byum, explaining the position of his group Texans Against Contract Tracing, said COVID-19 may be real but “it’s just not been a hugely significant issue as far as deaths and <a href="https://www.wbap.com/2020/05/25/protest-against-contact-tracing-to-be-held-on-tuesday/">we just think it’s extreme overkill.”</a></p>
<h2>Drawing the line between ‘cops’ and ‘docs’</h2>
<p>In a context in which some people continue to claim COVID-19 is a hoax, in which masks are contested and in which social distancing is challenged as a violation of individual rights, contact tracing is at risk of politicization.</p>
<p>Minnesota Public Safety Commissioner John Harrington <a href="https://www.vox.com/recode/2020/6/1/21277393/minnesota-protesters-contact-tracing-covid-19">sparked more fears</a> when he used the term “contact tracing” to describe how police track down suspects. The remark stirred unfounded concerns that police could gain access to COVID-19 case reports to determine who had attended protests over police brutality.</p>
<p>There’s never been a more important time to draw a bright line between cops and docs when it comes to the health of populations hit hardest by COVID-19. But there are times when public health relies on the legal system in order to fulfill its mission. In New York’s Rockland County, health officials resorted to <a href="https://thehill.com/policy/healthcare/505437-new-york-county-issues-subpoenas-to-people-refusing-to-talk-to-contact">subpoenas</a> to compel individuals who attended a party associated with an outbreak to cooperate with contact tracers.</p>
<p>Contract tracing is a key to helping states avoid a return to sweeping social distancing measures like stay-at-home orders and business closures. Trust that one’s name and medical information will be kept confidential is core to its success. Without that trust, even individuals who might want to help identify potential contacts may feel silence is safer.</p>
<p>But contact tracing also relies on speed. We not only <a href="https://www.cnbc.com/2020/06/26/coronavirus-contact-tracing-is-not-going-well-fauci-says.html">need more contract tracers in the U.S.</a>, we need more cooperation. If too many individuals refuse to participate, public health risks losing one of the single best means of halting the resurgence of COVID-19.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/142511/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Lauren Fairchild has received funding from NIH and NSF. </span></em></p><p class="fine-print"><em><span>Ronald Bayer has received funding from NIH and NSF.</span></em></p><p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Trust in the confidentiality of contact tracing broke down during the AIDS epidemic. Today, it’s faltering again.Amy Lauren Fairchild, Dean and Professor, College of Public Health, The Ohio State UniversityLawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityRonald Bayer, Professor Sociomedical Sciences, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1242982019-09-27T16:33:03Z2019-09-27T16:33:03ZWhy it makes medical – and mathematical – sense to finally vaccinate boys against the HPV virus<figure><img src="https://images.theconversation.com/files/294518/original/file-20190927-185403-1pvjg7m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/human-papillomavirus-infection-virus-hpv-most-1214814547?src=KS_rpQ3IFnNFbiN8lP5OZQ-1-0">Shutterstock/Naeblys</a></span></figcaption></figure><p>From September 2019, boys aged 12 and 13 in the UK are <a href="https://www.gponline.com/hpv-vaccination-programme-will-expand-cover-boys-september/article/1590326">being offered free vaccination</a> against the Human Papillomavirus (HPV) for the first time. HPV causes cervical cancer, and girls and young women have been receiving the vaccine for over ten years. So why is it being rolled out for boys too? And why only now?</p>
<p>One reason for giving the vaccine to boys is that the <a href="https://academic.oup.com/jnci/article/87/11/796/1141620">vast majority</a> of cases of cervical cancer-causing HPV infections are transmitted through sexual intercourse. Men can carry the virus without symptoms and pass it on to their sexual partners. </p>
<p>In fact, HPV is the most frequently sexually transmitted disease <a href="https://www.sciencedirect.com/science/article/abs/pii/S129795891000007X?via%3Dihub">in the world</a>, and over 60% of all cervical cancers are caused by two HPV strains. Cervical cancer itself is the <a href="https://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/">fourth most common cancer in women</a>, with around <a href="https://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/">half a million new cases</a> and <a href="https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer">over quarter of a million deaths</a> reported worldwide each year. </p>
<p>Unsurprisingly, given this high prevalence, when the first vaccines against HPV were <a href="https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/gardasil-vaccine-safety">approved in the US in 2006</a>, there was great hope surrounding their potential. Mathematical modelling <a href="https://www.sciencedirect.com/science/article/pii/S0264410X09008949?via%3Dihub">studies carried out</a> around that time indicated that the most cost effective strategy would be to immunise adolescent girls between the ages of 12 and 13 – the likely <a href="https://www.bmj.com/content/337/bmj.a769">future sufferers of cervical cancer</a>.</p>
<p>But, as I uncover in my new book <a href="https://amzn.to/2MkmdcM">The Maths of Life and Death</a> (along with many other surprising occasions where maths has played a crucial, but sometimes unseen, role) the mathematical models didn’t capture the whole picture. Most of the analyses did not include an important feature of HPV in their assumptions: that the strains of HPV guarded against by the vaccine can also cause a range of non-cervical diseases in <a href="https://www.nature.com/articles/6603501">both women and men</a>.</p>
<p>In July of 2018, a new mathematical <a href="https://doi.org/10.1016/J.EPIDEM.2017.06.004">study</a> led to <a href="https://www.gov.uk/government/publications/jcvi-statement-extending-the-hpv-vaccination-programme-conclusions">a recommendation</a> that all boys in the UK be given the HPV vaccination at the same age as girls.</p>
<p>This is in part because as well as causing cervical cancer, <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/cncr.23758">HPV types 16 and 18 contribute</a> to 50% of penile cancers, 80% of anal cancers, 20% of mouth, and 30% of throat cancers. In both <a href="https://doi.org/10.1002/cncr.23758">the US</a> and <a href="https://hpvcentre.net/statistics/reports/GBR_FS.pdf">the UK</a>, the majority of cancers caused by HPV are <a href="https://doi.org/10.1136/BMJ.B4928">not cervical</a>.</p>
<p>This fact came to the fore when the actor Michael Douglas was asked, during his recovery from throat cancer, if he regretted his lifetime of smoking and drinking. The actor candidly replied that he had no regrets about this, because his cancer had been caused by HPV, which he <a href="https://www.theguardian.com/film/2013/jun/02/michael-douglas-oral-sex-cancer">contracted through oral sex</a>. </p>
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<img alt="" src="https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=503&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=503&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=503&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=632&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=632&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294522/original/file-20190927-185407-4shss6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=632&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Michael Douglas spoke candidly about HPV.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-ny-usa-may-8-636190979?src=pHRu-sX1lpvq7XptoJz8Ew-1-49">Shutterstock/lev radin</a></span>
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<p>Warts and verrucas are also caused by different types of HPV, and <a href="https://www.independent.co.uk/news/science/hpv-vaccination-study-cervical-cancer-treatment-health-a8862946.html">80% of people</a> in the UK will be infected with one strain of HPV at some point during their lives. </p>
<p>So cervical cancer is an important part of the HPV picture, but it is not, by any means, the whole story. It seemed that the link to other cancers and diseases had been underestimated.</p>
<h2>The rest of the picture</h2>
<p>The public, perhaps aware only of HPV’s role in cervical cancer, seemed to accept the decision to only vaccinate females. Why would we waste money vaccinating boys if they don’t suffer from the headline HPV cancer?</p>
<p>On top of this, mathematical models into the <a href="https://www.bmj.com/content/337/bmj.a769">impact of HPV vaccination suggested</a> that by vaccinating a sufficiently high proportion of females, the prevalence of HPV-related diseases in males would also decline.</p>
<p>But imagine the outrage if a vaccination for human immunodeficiency virus (HIV) was given only to women for free, in the hope that men would be protected through women’s immunity.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/parents-want-the-hpv-vaccine-for-their-sons-new-research-86594">Parents want the HPV vaccine for their sons – new research</a>
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<p>Perhaps the first point that critics would make (aside from the issues of partial vaccination coverage and vaccine inefficiency) would be about the protection of gay men – why should they be left defenceless against one of the most deadly viruses of our time, just because they don’t have sex with women? </p>
<p>Exactly the same argument holds true in the case of HPV. Early mathematical studies had ignored the impact of same sex couplings on the dynamics of HPV spread.</p>
<p>Models that include homosexual relationships suggest a <a href="https://doi.org/10.1073/pnas.0707332105">higher rate of sexual disease transmission</a> than those which consider only heterosexual relationships. And the prevalence prevalence of HPV in men who have sex with men is <a href="https://doi.org/10.1371/journal.pone.0139524">significantly higher</a> than in the general population. </p>
<p>When models were recalibrated to take into account homosexual relationships, protection afforded against non-cervical cancers, and new information on the length of protection that the HPV vaccination provides, it was found that vaccinating boys as well as girls became a more cost-effective option.</p>
<p>Now that the vaccination is finally here, available to boys as well as girls – in a move which will reduce the rates of many kinds of cancer as well as other HPV-related diseases. </p>
<p>This is good news for all of us. And on a personal note I am delighted that my son, as well as my daughter, will now be afforded equal protection against catching and spreading the virus that killed their grandmother. In the case of cervical cancer, as with many of the other cases I have <a href="https://amzn.to/2MkmdcM">investigated</a>, maths really can be a matter of life and death.</p><img src="https://counter.theconversation.com/content/124298/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christian Yates does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Everyone will benefit from wider HPV vaccinations.Christian Yates, Senior Lecturer in Mathematical Biology, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1183372019-06-10T20:08:08Z2019-06-10T20:08:08ZAround half of 17-year-olds have had sex and they’re more responsible than you think<figure><img src="https://images.theconversation.com/files/278261/original/file-20190606-2772-1u2sa6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Australia's teens get their sexual information from a variety of sources and seem to know a lot about STIs.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/plTEYtXwXok">Kevin Laminto/Unsplash</a></span></figcaption></figure><p>Just under half of year 10 to 12 students have had sex, according to research <a href="http://www.teenhealth.org.au">released today</a>. </p>
<p>They know more about sexually transmitted infections (STIs) than you might think and are using a variety of sources for their sexual health information.</p>
<p>But there’s room to improve condom use and STI testing for sexually active teens.
Only 13% of all those surveyed thought they were likely to get an STI.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/good-sex-ed-doesnt-lead-to-teen-pregnancy-it-prevents-it-60036">Good sex ed doesn't lead to teen pregnancy, it prevents it</a>
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<p>In 2018, we surveyed 6,327 secondary students in years 10 to 12 from across Australia in all kinds of schools, for the Sixth National Survey of Secondary Students and Sexual Health.</p>
<p>We asked them a range of questions about their sexual health. These included where they turned to for information about sexual health, and how often. We asked if they liked their sex education. And yes, we asked about their sexual activity, or lack of it.</p>
<p>All up, 47% of students told us they had sex – defined as vaginal and/or anal intercourse regardless of the gender of the partner. </p>
<p>That might sound a lot. But rest assured, it was age-dependent. Year 10s were much less likely to have had sex yet (34% had ever had sex) compared to year 11s (46%) and 12s (56%).</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-i-need-to-shave-my-pubic-hair-before-having-sex-114614">'Do I need to shave my pubic hair before having sex?'</a>
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<p>Recent US reports suggest <a href="https://www.theatlantic.com/magazine/archive/2018/12/the-sex-recession/573949/">teens are having less sex</a> than they used to. The US Centers for Disease Control found between 1991 and 2017 the percentage of students who’d had intercourse dropped from 54% to 40%.</p>
<p><a href="http://www.publish.csiro.au/SH/SH14113">In Australia</a> since 2012, the rate has dropped 3% from 50%, which is within the margin of error, meaning there might be no actual decline.</p>
<p>The average age at which students had begun engaging in various sexual activities ranged from 13 for masturbation to 15 for mutual touching and oral sex. </p>
<p>The average age for the 47% who had experienced sexual intercourse in our survey was about 16 years old. This is slightly lower than other researchers <a href="http://www.publish.csiro.au/SH/SH14113">have found</a>. But our survey results may not represent Australian teens as a whole.</p>
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<a href="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Of teens who were sexually active, most were in a relationship or had a partner about the same age.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/6mRo659CPmM">Japheth Mast/Unsplash</a></span>
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<p>Of those who were sexually active, most (76%) were having sex in their homes, in a relationship (65%) or with a partner about the same age as them (86%). </p>
<p>They largely reported responsible behaviours. These included discussing having sex (81%) beforehand and protecting their health (77%). They used condoms (56%) and/or the pill (41%).</p>
<p>In short, teens in Australia are doing pretty well in relation to sex. And this isn’t new: the findings echo what has been seen in previous versions of the same survey over the past 25 years.</p>
<h2>How about unwanted sex?</h2>
<p>We also continue to find about a quarter (28%) reported some kind of unwanted sex at some point in their lives. </p>
<p>“Unwanted” means very different experiences for different people. A quarter (23%) of those reporting unwanted experiences wrote in comments. Many suggested it was a sense of “meh” or “just wasn’t really into it at the time”. But they provided no indication of regret.</p>
<p>While the survey did not ask about rape or sexual assault, slightly less than 1% of all participants did write explicitly about such experiences.</p>
<p>Despite this, we found 93% wanted their last sexual encounter. Overall, 85% indicated they felt extremely good and happy about their last experience and fewer (less than 20%) reported feeling upset, worried or guilty. </p>
<p>Shifts in school-based sex education to include a greater emphasis on relationships and skills in communication might, in part, explain the good sex teens are reporting.</p>
<h2>How about smartphones and sexting?</h2>
<p>Some things have changed, like using the internet to find sexual health information. That’s almost double what was reported in 2013 (44% then, 79% now). This isn’t surprising, given the pervasiveness of the internet today – 88% did the survey on an internet-enabled mobile device.</p>
<p>Rates of sexting seemed to have gone down by about 3% across each of the specific behaviours asked about. Overall about a third of students had engaged in some form of sexting. For those who were sexting, it was mostly with a partner or friend and only a few times in the previous two months.</p>
<h2>Good marks, but room for improvement</h2>
<p>So when it comes to sex and sexual health, Australia’s students are receiving pretty good marks. But there is room to continue improving.</p>
<p>The levels of reported unwanted sex, and the complexity of it, suggest a more nuanced approach may be warranted. Talking to teens about unwanted sex could expand beyond rape, sexual assault and issues of consent to cover communicating about desires and pleasure in a relationship leading to hopefully less “meh”.</p>
<p><a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">Rates of STIs</a> among young people suggest there is room to improve condom use and testing among sexually active teens. Only 13% thought they were likely to get an STI.</p>
<p>Luckily, Australian teens are having healthy conversations with partners, part of realising a happy, healthy and pleasurable sex life.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-to-make-your-next-sexual-health-check-less-erm-awkward-72498">How to make your next sexual health check less, erm ... awkward</a>
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<img src="https://counter.theconversation.com/content/118337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher M Fisher receives funding from the Commonwealth Department of Health. </span></em></p>Australia’s year 10-12 students are getting good marks when it comes to sexual health, according to new research out today. But there’s room for improvement.Christopher M Fisher, Associate Profressor in Young Peoples Sexual Health & Sex Education, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1166102019-05-12T09:28:30Z2019-05-12T09:28:30ZWhat Nigerian students told us about transactional sex on campus<figure><img src="https://images.theconversation.com/files/273594/original/file-20190509-183109-1dskdu7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><span class="source">Red Confidential/Shutterstock</span></span></figcaption></figure><p>Transactional sex among female undergraduates in Nigeria is a <a href="https://www.degruyter.com/downloadpdf/j/humaff.2012.22.issue-2/s13374-012-0020-5/s13374-012-0020-5.pdf">social reality</a>. The practice has been reported on regularly in the mainstream <a href="https://punchng.com/explaining-sex-for-marks/">media</a> and explored in various <a href="http://ir.library.ui.edu.ng:8080/bitstream/123456789/1021/1/%2815%29ui_art_nwokocha_transactional_2007.pdf">research papers</a>. </p>
<p>This cross generational relationship is widespread in <a href="https://www.icrw.org/wp-content/uploads/2016/10/Cross-generational-and-Transactional-Sexual-Relations-in-Sub-Saharan-Africa-Prevalence-of-Behavior-and-Implications-for-Negotiating-Safer-Sexual-Practices.pdf">sub-Saharan Africa</a>, and across the world where sponsors are commonly known as <a href="https://www.telegraph.co.uk/news/newstopics/howaboutthat/11388993/Universities-where-students-sign-up-to-sugar-daddy-dating-site-to-pay-fees.html">“sugar daddies”</a>.</p>
<p>In <a href="https://www.degruyter.com/downloadpdf/j/humaff.2012.22.issue-2/s13374-012-0020-5/s13374-012-0020-5.pdf">our study</a> on transactional sex in Nigerian universities, my colleague and I looked at the symbiotic relationship between some female Nigerian undergraduate students and <em>aristos</em> – wealthy, married or unmarried men. The students have transactional sex with the <em>aristos</em> in exchange for financial, social or educational support. </p>
<p>Because a great deal of these relationships happen undercover, there are no solid figures on the number of women involved in them. But there are many reasons that these relationships happen. It’s a practice that’s driven by economic hardship, a desire to network socially, and peer influence. </p>
<p>To understand more about these relationships <a href="https://www.degruyter.com/downloadpdf/j/humaff.2012.22.issue-2/s13374-012-0020-5/s13374-012-0020-5.pdf">we conducted</a> 30 interviews with female undergraduates – commonly known as “runs-girls”. </p>
<p>We found that the students engage in transactional sex for pleasure and money. Typically, wealthy students would be with an <em>aristo</em> for pleasure, while those who needed financial support did it for the money. Most of the women we spoke to viewed it as a critical survival life investment strategy and rejected the “prostitution” label. </p>
<p>Although these relationships could offer the students economic, emotional, and political support, their effects can also be negative. The students expose themselves to sexually transmitted infections, physical violence and academic setbacks, because the relationships can distract from their studies. </p>
<p>Those with sexually transmitted infections risk of spreading these to their boyfriends, while also suffering economic losses seeking treatment. </p>
<h2>Finding clients</h2>
<p><em>Aristos</em> are usually wealthy postgraduate students, lecturers, politicians, business people and military personnel. They are people with wealth and authority. </p>
<p>The students looked for these clients on and off campus, using connections and referrals. They then familiarised themselves with the potential client’s routine, aiming to eventually manufacture an encounter. </p>
<p>There’s usually a generational gap between the “runs-girls” and the <em>aristos</em>. The students often refer to their clients as “uncle”, “daddy” and, more recently, “aristo”. All of these bring connotations of the person’s expected role: to take care of the student. </p>
<p>If the students don’t have much financial support from their families, these relationships provide them with that security. Some started as a one-off “date”, for which they got a sum of money. But longer-term relationships also developed in some instances. </p>
<p>In return for sex, the women were given luxury possessions, like cars and mobile phones; investments for businesses they might start; or work placements when they finish their studies. </p>
<p>As one female student said: </p>
<blockquote>
<p>The type of connection I have with politicians, lecturers, and military men cannot be purchased with money. At times, when I have problem, all I do is to make a call, depending on the nature of challenges…</p>
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<p>In Nigeria, <a href="https://www.nigerianstat.gov.ng/">about 23%</a> of young people are unemployed. These connections, with people of influence, may be a ticket to employment. As one “runs-girl” revealed:</p>
<blockquote>
<p>One of my clients who happened to be a commissioner connected my senior sister to get a job at immigration even without any much stress…</p>
</blockquote>
<p>Transactional sex isn’t limited to financially strapped students. We spoke to rich female students who engaged in it for sexual fulfilment. One 24 year old student said:</p>
<blockquote>
<p>I am from a rich home, my father is even a Major (in the army), and my mother a nurse, but I’m involved in campus runs because of sexual satisfaction, although nothing goes for nothing, because sex is for enjoyment. I have a guy that I help financially, and on the long run he pays me back with sex. </p>
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<h2>Challenges</h2>
<p>In this research we identified a few challenges. </p>
<p>Some “runs-girls” accepted offers of unprotected sex for better pay. This put them at risk of catching sexually transmitted infections and, consequently, the cost of treatment. As one student said:</p>
<blockquote>
<p>I am always scared of having naked (unprotected) sex. Most times I use (a) condom because one can never know a man that has HIV/AIDS. Although sometimes some men always want naked sex and in that case, they will have to pay triple than what is earlier bargained. Part of the money realised as a runs-girl are used in revitalising the body, in which I go to the hospital once in a month to examine myself.</p>
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<p>Other risks are that the women could be physically harmed. This is particularly true if the clients choose not to pay an agreed amount. </p>
<p>Their education could also suffer as they may choose to engage in “runs” rather than go to class. </p>
<h2>Action needed</h2>
<p>Getting the government or even universities to take action will prove difficult because our evidence suggests that policy makers, politicians and the business class are involved, as <em>aristos</em>. </p>
<p>Nevertheless, given the risks associated, something ought to be done.</p>
<p>One possible solution might be to establish part-time jobs for vulnerable students, and to institute courses about running businesses so that young women can earn money independently. </p>
<p>In addition, institutions should put together and roll out communications campaigns <a href="https://www.ui.edu.ng/content/gender-mainstreaming-office-0">that teach</a> young people about the implications of transactional sex.</p><img src="https://counter.theconversation.com/content/116610/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oludayo Tade does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In some Nigerian universities, wealthy female students engage in trasnactional sex for pleasure, while those that needed financial support did it for the money.Oludayo Tade, Researcher in criminology, victimology, electronic frauds and cybercrime, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1136672019-03-19T14:11:52Z2019-03-19T14:11:52ZPasha 11: Sexually transmitted infections in South Africa<figure><img src="https://images.theconversation.com/files/264131/original/file-20190315-28468-rrcidq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>South Africa has had to focus heavily on the fight against HIV and AIDS given the country’s high infection rates. As a result, sexually transmitted infections have often been ignored. </p>
<p>In this episode, Tendesayi Kufa-Chakezha – an epidemiologist and public health specialist at the country’s National Institute for Communicable Diseases – takes us through why it’s so important for people to get over the stigma of talking about sexually transmitted infections, and to make sure they get treatment. </p>
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Read more:
<a href="https://theconversation.com/preventing-sexually-transmitted-infections-why-south-africa-isnt-winning-111546">Preventing sexually transmitted infections: why South Africa isn't winning</a>
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<p><strong>Photo:</strong>
Orawan Pattarawimonchai
Condoms package on yellow pink background. A condom used to reduce the probability of pregnancy or sexually transmitted disease (STD). Safe sex and reproductive health concept. <a href="https://www.shutterstock.com/image-photo/condoms-package-on-yellow-pink-background-1136235002">Shutterstock</a></p>
<p><strong>Music</strong>
“Happy African Village” by John Bartmann found on <a href="http://freemusicarchive.org/music/John_Bartmann/Public_Domain_Soundtrack_Music_Album_One/happy-african-village">FreeMusicArchive.org</a> licensed under <a href="https://creativecommons.org/publicdomain/zero/1.0/">CC0 1</a>.</p><img src="https://counter.theconversation.com/content/113667/count.gif" alt="The Conversation" width="1" height="1" />
Why it's important South Africa doesn't ignore sexually transmitted infections.Ozayr Patel, Digital EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1115462019-02-13T13:22:47Z2019-02-13T13:22:47ZPreventing sexually transmitted infections: why South Africa isn’t winning<figure><img src="https://images.theconversation.com/files/258722/original/file-20190213-181619-mhgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">STIs are a serious health threat. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Sexually transmitted infections (STIs) are a serious public health issue. It’s estimated that globally, more than a <a href="https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)">million people</a> are diagnosed with one or more sexually transmitted infections like gonorrhoea, chlamydia or syphilis every day. What’s more concerning is that the prevalence of infection with chlamydia for example, have remained unchanged <a href="https://www.thelancet.com/commissions/sexually-transmitted-infections?dgcid=homepage-tile_banner_STI">over the past 10 years</a> despite better screening in developed countries.</p>
<p>As the name suggests, STIs are spread mainly through sexual contact. This includes vaginal, anal and oral sex; some infections can also be spread by non-sexual means – for example, from mother to child during pregnancy or childbirth. </p>
<p>STIs can have devastating effects on sexual, reproductive and general health. They can also lead to a number of complications. If left untreated chlamydia and gonorrhoea can cause damage to reproductive organs and result in long term complications such as infertility. People can even die if certain STIs such as syphilis are left untreated, or if they have complications such as pelvic inflammatory disease in the case of chlamydia. </p>
<p>To make matters worse, STIs increase the risk of <a href="https://www.catie.ca/en/pif/spring-2012/stis-what-role-do-they-play-hiv-transmission">HIV infection and transmission</a>. This is because the body’s response, which is meant to help fight the sexually transmitted infection, causes a concentration of “activated” immune cells in the infected area. It then becomes easy for HIV to infect and replicate in the immune cells that are “activated”.</p>
<p>So it’s cause for concern that South Africa, with – <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">7.9 million people living with HIV in 2017</a> – also has a high volume of STIs.</p>
<p>In <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205863">2017</a> there were an estimated 2.3 million new cases of gonorrhoea, 1.9 million new chlamydia cases and 23,175 new syphilis cases among women aged between 15 and 49. Among men of the same age there were an estimated 2.2 million new cases of gonorrhoea, 3.9 million new cases of chlamydia and 47,500 new cases of syphilis. </p>
<p>These high numbers of STI cases in South Africa have partly been due to inadequate prevention and treatment gaps. Some people with STIs such as chlamydia, may go untreated because they don’t show any symptoms. </p>
<p>Better STI screening for high risk clients – regardless of symptoms – and better training of healthcare workers is necessary. In addition, structural problems such as limited access to client-friendly STI detection and treatment services need to be addressed. Of course, all of this costs money, which is in short supply. That’s why the need for better prevention cannot be overstated. </p>
<h2>STI prevention in the past</h2>
<p>Prevention of STIs other than HIV has largely taken a backseat while the country focused on HIV prevention. HIV prevention concentrated on reducing the number of sexual partners people have, increasing the correct and consistent use of condoms, early detection and treatment, and promotion of male circumcision. These measures were of some benefit in preventing other STIs. </p>
<p>But the increasing availability of <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable">antiretroviral drugs and advances in research</a> have brought a new message to people living with HIV: an HIV positive person with an undetectable viral load can’t transmit the virus to their HIV negative partner. </p>
<p>This message, however, does not directly address the transmission of STIs other than HIV. It focuses on HIV and how to manage it, but forgets that people with HIV may be vulnerable to other STIs. </p>
<p>Pre-exposure prophylaxis – another HIV prevention tool – involves taking antiretroviral medication to prevent HIV infection. <a href="https://prepfacts.org/prep/the-research/">Research</a> has shown that, if taken consistently and as intended, it can reduce the risk of acquiring HIV. But pre-exposure prophylaxis doesn’t protect people from other STIs. </p>
<p>Services to test for and treat STIs are included in pre-exposure prophylaxis services as a way of assessing levels of unprotected sex and sexual risk taking among users. But the take home message about the prevention of STIs in these settings is not clear. What counselling on STIs are pre-exposure prophylaxis clients receiving or should they be receiving? How should pre-exposure prophylaxis be promoted without compromising STI prevention? </p>
<h2>Renewed focus on STI prevention</h2>
<p>Strategies to prevent STIs must take into account the changes and advances in HIV prevention and treatment. Policies must answer a number of questions.</p>
<p>For instance, how can having fewer sexual partners, the correct and consistent use of condoms, the early STI detection and treatment of oneself and one’s partners, and male circumcision be made “fashionable” when HIV is not the death sentence that it used to be? </p>
<p>And what’s the best way to communicate that the knowledge of infections in oneself and the partner are key to preventing both HIV and other STIs? </p>
<p>It’s also important to explore how best to design prevention services that communicate how STIs and HIV happen in the context of transient, short-term or longer relationships. Policy makers need to understand, too, how people can be empowered to form, maintain or terminate relationships in a manner that does not place them in harm’s way with respect to HIV, STIs or intimate partner violence.</p>
<p>All of these issues must be urgently considered if South Africa is to tackle its STI problem as effectively as it’s been able to deal with HIV.</p><img src="https://counter.theconversation.com/content/111546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tendesayi Kufa-Chakezha does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>STI prevention was largely driven by HIV prevention. With changes in HIV prevention initiatives that don’t really take into account other STIs, there’s need to refocus STI prevention.Tendesayi Kufa-Chakezha, Epidemiologist and Public Health Specialist, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/943022018-04-05T06:41:03Z2018-04-05T06:41:03Z‘Super gonorrhoea’ raises the stakes in the war against superbugs<figure><img src="https://images.theconversation.com/files/213320/original/file-20180405-189798-nbplrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antibiotic resistance is not new but recent developments increase the urgency for action.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There has been a lot of news over the past few weeks about the rise of superbugs and antibiotic overuse, including a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">nasty sexually transmitted infection</a> in the United Kingdom. A British man is the first in the world to be diagnosed with a strain of gonorrhoea resistant to all strains of antibiotics used to treat the infection. </p>
<p>Superbugs have tended to pose the greatest risk to people with compromised immune systems, such as cancer patients, and those who were injured or underwent surgery. But the sexual transmission of these bugs means antibiotic resistant infections can spread much more widely.</p>
<p>So what exactly are superbugs, and how scared should we be?</p>
<h2>Super but not new</h2>
<p>“Superbugs” aren’t the bug equivalent of superheroes. The term describes bacteria that have become resistant to antibiotics. How “super” they are depends on how many antibiotics they have become resistant to. </p>
<p>“Antibiotic resistance” and “drug-resistant infections” also refer to the same phenomena. They describe microorganisms that have evolved to become impervious to being killed by treatment with antibiotics. </p>
<p>There is a common misconception that antibiotic resistance means your body has become resistant to antibiotics. This is not true.</p>
<p>Antibiotic resistance is nothing new. Alexander Fleming’s 1945 <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf">Nobel Prize acceptance speech for the discovery of penicillin</a> discusses the development of resistance. He includes a scenario of Patient X, who:</p>
<blockquote>
<p>buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails.</p>
</blockquote>
<p>Indeed, resistance has been reported for <em>every</em> antibiotic ever introduced – <a href="https://antimicrobialresistance101.files.wordpress.com/2015/04/antibiotic-resistance-history-graph.png">generally within a few years</a> of deployment.</p>
<h2>How do they become resistant?</h2>
<p>Bacteria are able to fight antibiotics by a variety of methods:</p>
<ul>
<li>They build stronger cell walls to stop the drugs from entering</li>
<li>They actively spit them out so the antibiotic can’t reach a lethal concentration inside the cell</li>
<li>They produce enzymes that modify and inactivate the antibiotics and</li>
<li>They alter the target of the antibiotic so it no longer interacts with the drug.</li>
</ul>
<p>One or more of these resistance mechanisms may already be naturally present in a very small fraction of the millions of bacteria exposed to an antibiotic. This is called “innate resistance”. Most of the bacteria are killed, but this small population survives and grows. </p>
<p>In other cases, resistance develops through evolution (a process known as “induced resistance”). Bacteria grow rapidly. Under optimal conditions the population can double in as few as 15-30 minutes. </p>
<p>When exposed to sub-lethal doses of antibiotic, bacteria can become tolerant. They accumulate beneficial mutations over multiple generations. They then pass on this resistance to their progeny when they divide.</p>
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Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
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<p>Bacteria are also very promiscuous. They exchange pieces of genetic material (plasmids) that carry the codes for resistance. This allows for the rapid spread of resistance between different types of bacteria. </p>
<p>An example is highlighted by <a href="https://www.theaustralian.com.au/news/world/the-times/drug-resistance-spreads-to-humans-at-shocking-rate/news-story/fc0d3487e6f353a1f4569c1770721d34">recent news reports</a> of resistance to a “last resort” antibiotic, colistin. A gene called mcr-1 (mobilized colistin resistance) was found to be contained in plasmids in <em>E. coli</em> bacteria collected from Chinese pig farms in 2011 (<a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00424-7/fulltext">though it was not reported until 2015</a>). </p>
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<span class="caption">A gene that makes bugs resistant to antibiotics of ‘last resort’ was found in Chinese pig farms.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1060871903?src=8TKC8hWSjSmYq38tXIvwjw-1-22&size=medium_jpg">Zawinul/Shutterstock</a></span>
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<p>While colistin resistance was already known, the potential for resistance to be quickly spread by this new mechanism is of great concern. For some infections, colistin is the only antibiotic that still works. Indeed, the mcr-1 gene has now been found in <a href="https://www.nature.com/articles/s41467-018-03205-z">multiple types of bacteria in more than 30 countries</a> (including a <a href="http://www.cidrap.umn.edu/news-perspective/2016/05/highly-resistant-mcr-1-superbug-found-us-first-time">patient in the United States in 2016</a>).</p>
<p>The <a href="http://www.searo.who.int/mediacentre/releases/2015/1612/en/">World Health Organisation is now warning</a> that we face a return to a “pre-antibotic era”. It warns:</p>
<blockquote>
<p>Common infections and minor injuries which have been possible to treat for decades may once again kill millions. Resistance to antibiotics will make complex surgeries and management of several chronic illnesses like cancer extremely difficult.</p>
</blockquote>
<p>Before antibiotics, 40% of deaths were due to infection. If we do not act, <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">a review commissioned by the United Kingdom government</a> predicts that by 2050 drug-resistant infections could cause 10 million annual deaths.</p>
<h2>How did we get here?</h2>
<p>This rise in resistance is largely driven by excessive antibiotic use. The same UK report indicates that up to two-thirds of the world’s antibiotics are not used to treat humans, but are given to animals grown for food. This animal use is often as a food additive, not as therapeutic treatment for an infection. </p>
<p>Of the remaining antibiotics used in humans, up to two-thirds may be inappropriately prescribed. </p>
<p>This huge overuse of antibiotics inevitably drives the development of resistance by unnecessarily exposing a much greater population of bacteria to antibiotics. Sub-lethal concentrations, such as in waste water from farms, fosters resistance. </p>
<p>Alarmingly, <a href="http://www.pnas.org/content/early/2018/03/20/1717295115">a recent study</a> shows that <a href="https://www.theguardian.com/science/2018/mar/26/calls-to-rein-in-antibiotic-use-after-study-shows-65-increase-worldwide">our use of antibiotics is increasing even more</a>.</p>
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Read more:
<a href="https://theconversation.com/why-the-health-and-agriculture-sectors-need-to-work-together-to-stop-antibiotic-resistance-69031">Why the health and agriculture sectors need to work together to stop antibiotic resistance</a>
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<p>So, given we already have <a href="https://www.statnews.com/2017/01/12/nevada-woman-superbug-resistant/">people dying from bacteria resistant to all known antibiotics</a>, and these bacteria are <a href="https://apnews.com/afcee30eb24848d38f9b855fbcc9a4ba">becoming increasingly prevalent</a>, what’s stopping a global pandemic tomorrow? </p>
<p>It really comes down to the fact that, unless you’re immunocompromised or have an injury allowing the bacteria to get into your body, most bacteria aren’t particularly effective at spreading infections. </p>
<p>This is why the <a href="https://news.nationalgeographic.com/2018/03/gonorrhea-evolving-untreatable-spd/">reports</a> of a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">“super-gonorrhea” case in the UK </a> are alarming. The sexually transmitted bacteria (<em>Neisseria gonorrhoeae</em>) <a href="http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/">causes nearly 80 million infections a year</a>. This bacteria now has the potential to carry and spread high levels of antibiotic resistance through a much larger population of both people and other bacteria.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Super-gonorrhea has the potential to spread antibiotic resistance to many more people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/white-mattress-after-waking-morning-sun-1058016380?src=idJzfv5Tw4DqSyPgT08sBA-1-42">The Five Aggregates/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Fight against superbugs</h2>
<p>It’s not all doom and gloom. Nations and international organisations are increasingly devoting attention and resources to fight the rise of antibiotic resistance. Strategies include more sparing use of existing antibiotics, and <a href="https://longitudeprize.org/">investment and incentives to develop diagnostics</a> that can decide when antibiotics are needed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-the-drugs-dont-work-how-we-can-turn-the-tide-of-antimicrobial-resistance-71711">When the drugs don’t work: how we can turn the tide of antimicrobial resistance</a>
</strong>
</em>
</p>
<hr>
<p>Non-antibiotic approaches, such as vaccines, phage therapy, and microbiome manipulation, are garnering increased consideration. </p>
<p>Initiatives to re-invigorate the discovery of new antibiotics include efforts such as <a href="https://www.gardp.org/">The Global Antibiotic Research & Development Partnership</a>, the <a href="http://www.carb-x.org/">Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator</a>, and Australia’s own global effort to crowdsource antibiotics from international chemists, <a href="http://www.co-add.org">The Community for Open Antimicrobial Drug Discovery</a>. </p>
<p>We must keep our attention on the threat posed by drug resistant infections and invest in antimicrobial research to keep the potential global catastrophe at bay.</p><img src="https://counter.theconversation.com/content/94302/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Blaskovich receives funding from the NHMRC, Australian Academy of Technology and Engineering, the Aiustralian Department of Industry, Innovation and Science, and the Wellcome Trust for antibiotic-related research. He works for the Community for Open Antimicrobial Drug Discovery, an initiative to discover new antibiotics. He is an inventor on several patents describing new antibiotics.</span></em></p>Superbugs used to pose the greatest risk to people with compromised immune systems and those who had surgery. But their sexual transmission means antibiotic resistance can spread much more widely.Mark Blaskovich, Senior Research Officer, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/845012017-10-02T16:49:56Z2017-10-02T16:49:56ZAfrican boys and girls enter teens with gender stereotypes firmly set<figure><img src="https://images.theconversation.com/files/187956/original/file-20170928-1442-pkyrp2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to a Global Adolescent Study boys are given more freedom and independence than girls.</span> <span class="attribution"><span class="source">Reuters</span></span></figcaption></figure><p><em>A team of international experts have just published the most comprehensive analysis to date of how children on the cusp of adolescence perceive growing up as a boy or girl. The <a href="http://www.geastudy.org/">Global Adolescent Study</a> involved a series of interviews conducted over the last four years with hundreds of early adolescents and their parents in 15 countries. These included Burkina Faso, the Democratic Republic of Congo, Egypt, Kenya, Malawi, Nigeria and South Africa. We asked lead researcher Kristin Mmari to explain the significance of the study</em> </p>
<p><strong>What did the 15-country global study set out to establish?</strong></p>
<p>Our overarching question was to explore how boys and girls from diverse cultural settings experience their transitions into adolescence. Questions we were interested in finding answers to included: what changes? How do these changes vary by boys versus girls? How do these changes vary by geographic and cultural location? </p>
<p>We wanted to address these questions because the way in which adolescents experience biological and social changes differ. Factors that play a role include gender, cognitive abilities, educational, emotional, life experiences as well as cultural and social contexts. Yet information on how these factors manifest and inform gender differences across contexts is quite limited, particularly from low and middle-income countries. </p>
<p>A particularly interesting, yet unknown aspect of early adolescence, is how boys and girls establish relationships that ultimately shape their sexual and overall health from early to late adolescence.</p>
<p><strong>What are the most important findings from African countries involved in the study?</strong></p>
<p>So far, only Assuit in Egypt, Nairobi, Kenya, and Ile Ife, Nigeria have been involved. Another four countries, the Democratic Republic of Congo, Burkina Faso, Malawi, and South Africa, will be included in future products and analyses. </p>
<p>The key takeaways from the study so far are: </p>
<ul>
<li><p>First global study to demonstrate that we can measure gender norms around the world among this young age group <a href="http://www.jahonline.org/issue/S1054-139X(17)X0014-1">ages 10-14 years old</a>. Before this study, it was not known whether adolescents in this age group would be able to accurately provide information about what it meant to be an ‘adolescent’ and the attitudes and beliefs about gender that influenced their transition into adolescence. Not only did we learn that it’s possible to collect data from this age group across multiple cultural settings, but that in fact, adolescents are astute observers. </p></li>
<li><p>There are consistent forms of patriarchy around the world: girls are perceived to be vulnerable and in need of protection to preserve their sexual and reproductive health. Their mobility and social space is greatly reduced and often enforced by parents to “preserve their reputation”. Girls who are observed to be seen with boys are automatically assumed to be in romantic and sexual relationships with them, and this can often ruin their reputation or their families. </p></li>
<li><p>Boys expand their social space and are given much more freedom and independence. But they also face increased risks related to the environment, such as increased engagement in violence and/or substance misuse. </p></li>
<li><p>There were more similarities than differences between the sub-Saharan African contexts and the other sites included in the study. However, boy-girl relationships were frowned upon and subjected girls to sexual and reproductive health risks, such as pregnancy and gender based violence; as a consequence, many parents did not want their daughters in the company of boys.</p></li>
</ul>
<p><strong>The goal of the study was to get insights that could be used to inform policies that promote sexual and reproductive well-being. What insights were gained and what key interventions should follow?</strong></p>
<p>We already know that norms around gender inequitable lead to poor health outcomes among older adolescents and young adults. For example, research has shown that when men and boys adhere to traditional views about masculinity, they are more likely to report having used violence against a partner, to have a sexually transmitted infection, and used substances <a href="http://journals.sagepub.com/doi/abs/10.1177/1097184X06298778">Pulerwitz and Barker, 2008</a>. Other studies have found correlations between beliefs in gender inequitable norms and HIV transmission rates, contraceptive use, and gender based violence (Barker and Ricardo, 2005).</p>
<p>This study shows that these norms are being solidified much earlier than we thought. Interventions then need to start earlier and should include both boys and girls. They should also address gender as a system that’s made up of multiple actors, ranging from parents, teachers, peers, neighbourhoods, and the broader media and policy environment. </p>
<p><strong>What happens next?</strong></p>
<p>Phase 2 of the study will be a large quantitative survey to examine the extent to which changes in beliefs of gender inequitable norms lead to changes in health outcomes, and the factors that may contribute to these changes.</p><img src="https://counter.theconversation.com/content/84501/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kristin Mmari does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Do boys and girls from diverse cultural settings experience their transitions into adolescence? Their cultural differences don’t make a difference, but their genders do.Kristin Mmari, Associate Professor, Bloomberg School of Public Health, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/695522017-01-03T20:13:55Z2017-01-03T20:13:55ZPrepare for a healthy holiday with this A-to-E guide<figure><img src="https://images.theconversation.com/files/150465/original/image-20161216-26077-3e3ni2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most ill health can be avoided on family holidays through research and planning in advance, plus smart packing. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/534992203?src=as1IsLvnWSXxcMtpIEARZA-1-70&id=534992203&size=huge_jpg">from www.shutterstock.com </a></span></figcaption></figure><p>So your well-earned holiday is finally here. But before you pack your swim gear, magazines and camera, take a moment to think about your health.</p>
<p>Experiencing an illness in a foreign destination can be very challenging. Obviously it will reduce the quality of your trip, but it can also leave travellers with unexpected costs and exposed to a foreign medical system. On occasion, serious complications can follow. </p>
<p>More than <a href="http://www.abs.gov.au/ausstats/abs@.nsf/products/961B6B53B87C130ACA2574030010BD05">nine million Australians</a> travel internationally per year, with most trips undertaken by people between the ages of 25 and 55. The top ten <a href="http://www.abs.gov.au/ausstats/abs@.nsf/products/961B6B53B87C130ACA2574030010BD05">most popular destinations</a> for Australians are New Zealand, Indonesia, the USA, UK, Thailand, China, Singapore, Japan, Fiji and India. </p>
<p>A range of new health problems can be encountered during travel, and existing health problems can be exacerbated. Staying healthy is all about being informed, prepared and sensible.</p>
<p>The <a href="http://wwwnc.cdc.gov/eid/article/15/11/09-1147_article">leading causes</a> of infection-related illness during travel are <a href="http://www.bmj.com/content/353/bmj.i1937">travellers’ diarrhoea</a>, <a href="http://www.mja.com.au/journal/2002/177/4/9-infections-returned-traveller">respiratory infections and infections transmitted by mosquitoes</a>. </p>
<p>Minimise your chances of experiencing these by following a simple ABCDE.</p>
<h2>A: Allow time to prepare</h2>
<p>Around popular holiday periods, it pays to allow plenty of time to book an appointment at a travel clinic, or a local medical clinic that offers travel vaccinations.</p>
<p>Some vaccinations have two or three doses and may need four weeks for the course to be completed. Examples include vaccines for <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">Japanese encephalitis</a> and <a href="https://theconversation.com/explainer-the-rabies-virus-28654">rabies</a>. </p>
<p>If travelling as a family, several visits may be required for preparing children for travel certain destinations.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=602&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=602&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=602&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=756&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=756&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150463/original/image-20161216-26077-1osi44d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=756&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Indonesia is a popular holiday destination for Australians.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/rueful/6671265895/in/photolist-bavYVM-pXSVcu-n4jBKP-fG1med-phyKiE-biZ1Jk-n4f2Re-bTneje-ogbThR-dtPhwA-9QwroC-dtP2EQ-nhq8eA-4psFFh-n49Dk4-n4aN1M-n4ba2L-dJFmfU-gwTiLK-fG17kQ-o1aTQQ-dJApLB-a8ibfk-cNa3VY-jCJaBY-ChT86B-n3HXiX-qZWMG5-dtHH9Z-96b49x-4poD6X-oyYqCD-b5Foja-fwLdnk-gwSFWs-bN7Cm2-bhP4LM-a15UFd-ohKTqW-ab9Qwp-dJFZTb-bhPF6F-fG1mP9-baBzzx-5HJkHP-bizSLz-5HNdLm-a133GK-dJFbPo-7pMoai">rueful/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Keep in mind that your travel medicine practitioner may need detailed information about your exact itinerary, your past childhood vaccinations, your medical history and medications. If you have all this information readily available, you can get the most out of your travel consultation.</p>
<p>If you have an existing medical condition, get checked out to make sure it’s being managed as expected. For example, blood pressure medications may need to be adjusted if your blood pressure is either too high or too low. </p>
<p>Yellow fever immunisations and other live vaccines – those that contain active components – should be avoided if you are on medications that reduce your immunity, such as steroids like <a href="http://www.nps.org.au/medicines/hormonal-and-metabolic-system/corticosteroids-oral-and-injectable/prednisolone-corticosteroids-oral-and-injectable">prednisolone</a>. You may need alterations to immunosuppressive medications some weeks before you travel, or an official letter exempting you from a vaccine that is necessary for entry into certain countries (as is the case with yellow fever vaccine). </p>
<h2>B: Behaviour - think about it</h2>
<p>Holiday makers often seek to get out of their comfort zones. But it’s worth avoiding the temptation to completely let your hair down: behaviours you would never entertain in the home setting should be avoided in a foreign setting as well. You may also need to alter some of your daily living behaviours. </p>
<p>Traveller’s diarrhoea can largely be avoided by using bottled water in any setting that you consume water, including staying hydrated, brushing your teeth, washing fruit and salads, and making ice blocks and other drinks. </p>
<p>Eat food from venues that appear to adhere to good food hygiene standards – although this can be difficult to judge. Avoid hawker food or street food where items may have been left for long periods at temperatures where bacteria can multiply. When uncertain of hygiene standards, selecting packaged food is the safest choice.</p>
<p>Respiratory infections are common in travellers. If you find yourself in a crowded setting where someone appears unwell and is coughing, create a distance to reduce the risk of being infected. Alcohol-based hand gels are useful to maintain hand hygiene and may protect you from infection due to common colds and other viruses that linger on surfaces.</p>
<p>Smart packing is also important. You should travel with sunscreen and clothes that protect you from sun exposure, and repellent that has an active component to repel insects if travelling to an area where mosquitoes can transmit infections such as <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">dengue</a>, <a href="https://theconversation.com/does-zika-virus-pose-a-threat-to-australia-53557">Zika</a> and <a href="https://theconversation.com/how-the-world-can-cut-malaria-cases-by-90-in-the-next-15-years-47146">malaria</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150651/original/image-20161219-26093-ecnvw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dengue is a virus transmitted by mosquitoes.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/techbirmingham/298209271/in/photolist-CPCsdq-nMZZee-nMZepS-smpea-o5n6F1-49MHMV-8hGfqB-cveRHb-o3r7wL-nMZasV-6huJv-c7LP9-53Vqkb-e8Cnfk-4eVCHg-qw7BqG-4p7niT-jqTnfj-6CK1SQ-qjGiLn-5c6Cm-4p29oX-qjP63U-pnT92J-qjSpvT-6hvFb-4CkWVr-6hvjM-6hvqR-o5tydZ-8PrkPU-6hvxv-6hvuA-byQJS-CDN877-q3iXy5-bEP4XD-9wTQQu-4pbrDo-9hARcT-5c6Cv-7PmtaW-xnoj4-stKUrP-5r8BHK-9hE8hu-cCWwQJ-5r32eK-52qrga-yEDee">echbirmingham/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Avoid acquiring a sexually transmitted infection by using barrier protection (condoms) for sexual intercourse. </p>
<h2>C: Check safety, and have a check up</h2>
<p>Review travel warnings at a reputable website, such as <a href="http://smartraveller.gov.au/Pages/default.aspx">SmartTraveller</a>. </p>
<p>A general check up is advised to ensure your health is stable. Health conditions such as inflammatory bowel disease, diabetes or a lowered immune system may put you at greater risk of travellers’ diarrhoea. Cancer or recent operations can increase risk of developing a <a href="http://jamanetwork.com/journals/jama/fullarticle/2297171">blood clot</a>. </p>
<p>Check ups are also a good opportunity to ensure that your vaccinations are up-to-date (see below). </p>
<h2>D: Drugs (medications) and vaccines are vital</h2>
<p>Medications that can reduce the time or severity of travellers’ diarrhoea are recommended for almost any destination, but particularly when travelling to developing countries where food hygiene standards can be variable. Examples include antibiotics such as azithromycin that treat bacterial causes of diarrhoea, and drugs such as tinidazole to treat parasitic causes of diarrhoea. </p>
<p>Medications such as doxycycline or malarone that protect against being infected with malaria are recommended in <a href="https://www.cdc.gov/malaria/about/distribution.html">some regions</a> within Africa, Asia, South America and the Pacific. </p>
<p><a href="https://theconversation.com/zika-a-rare-benign-virus-suddenly-turns-nasty-and-heads-for-the-us-52792">Zika virus</a> infection generally causes a mild illness or no symptoms at all. Pregnant female travellers are advised to avoid travel to a Zika endemic area. Couples planning a pregnancy in the near future should seek advice from a health professional if travelling to a Zika endemic country. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150655/original/image-20161219-28140-ymaga.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sunburn can easily be prevented with appropriate clothing, hats and sunscreen.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/nicksie2008/16575104096/in/photolist-rfFJYQ-J2aXh9-esqGcC-tFnag7-9xxtJx-8mRBC1-9bwwao-abNiQK-pbxD2P-CJ4J-81vT16-bCwXbe-4JuBn9-6eRV5i-fLEpN1-6G8bVz-4xLzAM-8fYBiq-5sy4z8-6bKKxR-6hZtvk-9YWwre-9Z3wf3-5qyoAK-2yMKQg-6ZBZ3h-8nNdxo-aAZbU-FGAuZu-nP4KBP-qz5xT-VcKn7-6mSyzN-pyzbk-dGzUsd-bonmUT-nwP7JV-jMbmCJ-jtHZJW-dUhRHG-8qHpnL-76HccA-hQgixL-o46yqu-a76fLS-6XuRKd-8cBCH2-6HqJ7r-36hFn2-9QzTec">nicksie2008/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>If you’re travelling to destinations that are above 2500 metres (such Cusco in Peru), talk to your doctor about medications that help prevent or manage altitude sickness. </p>
<p>The normal schedule of vaccinations provided to Australians may not cover you for illnesses found in your holiday destination. Extra vaccinations are necessary for certain destinations. </p>
<p>For example, <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">yellow fever</a> is transmitted by mosquitoes and can cause anything from mild fevers to a severe illness involving multiple organs. Vaccination against yellow fever is required for entry into countries with known yellow fever transmission, and for returning back to Australia if visiting an area of known transmission.</p>
<p>Australians may consider vaccinations against the following diseases before travel to popular holiday destinations:</p>
<ul>
<li>Hepatitis A</li>
<li>Hepatitis B</li>
<li>Influenza</li>
<li>Japanese encephalitis</li>
<li>Meningococcal disease</li>
<li>Rabies</li>
<li>Tuberculosis</li>
<li>Typhoid</li>
<li>Varicella (Chickenpox) </li>
<li>Yellow fever</li>
<li>Cholera</li>
<li>Measles</li>
<li>Polio</li>
<li>Tetanus</li>
</ul>
<p>A full <a href="https://wwwnc.cdc.gov/travel/destinations/list/">list of countries and recommended vaccinations</a> has been compiled by the USA’s Centers for Disease Control and Prevention. </p>
<p>Even if you’re previously been vaccinated for some of these conditions, as time passes you may require boosters to strengthen your immunity. </p>
<h2>E: Enjoy your trip!</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150876/original/image-20161220-26724-1wqfrqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Relax, you’ve earned a break.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/530479720?src=2QoyDn5t1yavJYuyCgxyeg-1-80&id=530479720&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/69552/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Irani Thevarajan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Simple steps can lower your risk of bringing home traveller’s diarrhoea, respiratory infections and mosquito-borne diseases from your holiday.Irani Thevarajan, Honorary Fellow Nossal Institute for Global Health and Infectious Diseases Physician, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/707672017-01-03T16:52:16Z2017-01-03T16:52:16ZWhy some girls grow breasts early – and how new findings could cut cancer risks<figure><img src="https://images.theconversation.com/files/151583/original/image-20170103-29222-7bm0oz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Where first is not best.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-508653874/stock-photo-young-girl-with-beautiful-hair-standing-on-the-road-in-colorful-autumn-forest-back-view-original-wallpaper-with-space-for-your-montage.html?src=RptKaMYCbO4dOuMRr0yQkw-1-61">kovop58</a></span></figcaption></figure><p>When a girl’s breasts start growing early, it can be a sign she will develop certain diseases later in life. There is <a href="http://www.nature.com/articles/srep11208">evidence</a> of early puberty leading to increased risk of obesity, type 2 diabetes, heart disease and cancer – <a href="https://breast-cancer-research.biomedcentral.com/articles/10.1186/bcr3613">particularly</a> breast cancer. Girls who develop breasts before the age of ten have around a 20% higher risk of breast cancer in later life than girls who develop breasts between the ages of 11 and 12. </p>
<p>If you could prevent breasts from growing early, you might be able to reduce the girl’s risks of developing these diseases. Until now, unfortunately, scientists have poorly understood the processes that make some girls develop younger than others. But <a href="http://dev.biologists.org/">new findings</a> from our research at the University of Glasgow solve a large part of the mystery and could have important health implications as a result. </p>
<p>It is <a href="http://pediatrics.aappublications.org/content/early/2013/10/30/peds.2012-3773">usual for</a> girls to develop breasts around the age of ten, though <a href="https://www.ncbi.nlm.nih.gov/pubmed/17489932">plenty</a> start earlier or later and this is often seen as normal and harmless. Yet the higher risks of earlier developers ending up with breast cancer or the other diseases are a significant concern, not to mention other psychological and physical problems that can crop up. </p>
<p>In addition to potential feelings of isolation and embarrassment, early puberty is <a href="http://www.nature.com/ng/journal/v48/n6/full/ng.3551.html">linked to</a> earlier sexual activity, which can lead to emotional damage as well as unwanted pregnancies and sexually transmitted diseases. Studies show correlations with <a href="https://www.researchgate.net/profile/Riittakerttu_Kaltiala-Heino/publication/10647348_Early_puberty_is_associated_with_mental_health_problems_in_middle_adolescence/links/0912f50df117acaf3e000000.pdf">depression</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761220/">eating disorders</a>; and early developers <a href="https://www.ncbi.nlm.nih.gov/pubmed/15073143">tend to be</a> tall for their age but actually shorter as adults. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/151588/original/image-20170103-18653-16zzdvb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘Why me?’</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-465216848/stock-photo-sad-girl-on-the-riverbank.html?src=jRqQUHmAQx1t874vWhzoIA-8-9">Anna Jurkovska</a></span>
</figcaption>
</figure>
<p>The bad news is that throughout the world, puberty <a href="http://humupd.oxfordjournals.org/content/7/3/287.full.pdf">is beginning</a> earlier and earlier. In the US, it is <a href="http://www.webmd.com/children/guide/causes-symptoms#1">believed to be</a> happening a full year earlier than a few decades ago. However, the reasons are largely unknown. </p>
<p>A number of studies <a href="https://www.ncbi.nlm.nih.gov/pubmed/17332182">have shown</a> an association with childhood obesity. But while this is a popular theory as obesity is <a href="http://press.endocrine.org/doi/abs/10.1210/jcem.82.9.4235">known to</a> affect hormone levels, it does not explain why onset <a href="http://adc.bmj.com/content/early/2016/09/26/archdischild-2016-310475.full">varies substantially</a> between different ethnic and socio-economic groups – earlier among black girls and those from poorer backgrounds. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572204/">Another theory</a> is that we are increasingly exposed to chemicals in the environment which mimic hormones that may be accelerating puberty.</p>
<h2>How breasts develop</h2>
<p>For girls to begin to develop breasts, a thin layer of specialised cells called epithelial branches must form within the tissue. These branches provide the breasts with a structural scaffold for their fatty tissue, allowing them to develop in size and shape. </p>
<p>The branches continue to grow and change throughout a woman’s reproductive lifetime – uniquely for human tissue. They stop growing in early adulthood when breasts are fully developed, but start again during pregnancy to make way for milk-producing glands, then transform once more when a mother stops breastfeeding. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=762&fit=crop&dpr=1 600w, https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=762&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=762&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=958&fit=crop&dpr=1 754w, https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=958&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/151590/original/image-20170103-18641-17u92hd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=958&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Breast intentions.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/x1klima/15221016421">x1klima</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The branches depend on certain hormones but crucially also immune cells called macrophages, which help them change during each process. Until now it had not been clear how these cells arrive at the correct place and time. </p>
<p>What our research has revealed is the role played by an immune molecule called ACKR2 in this process. ACKR2 stops the macrophages from moving into the breasts until the female is old enough, which prevents premature breast development. We found that mice that do not have ACKR2 start puberty early because the macrophage cells arrive in the breasts prematurely. </p>
<h2>Future responses</h2>
<p>Doctors currently only slow down the onset of puberty in children if it starts before the age of seven and if it is caused by a hormonal imbalance. They do this by administering drugs that stop the pituitary glands from producing the hormones that trigger puberty. Now that we know that ACKR2 is a key molecule in preventing premature breast development, there may be a strong argument for developing new pharmaceutical interventions – particularly given the range of problems associated with the condition. </p>
<p>The next step is to carry out studies in human patients to find out whether pre-pubertal girls with low levels of ACKR2 go on to develop breasts early. If so, it may be possible to predict early puberty by testing young children and boosting levels of the molecule to halt the process. </p>
<p>It would then be for those in charge of health spending to decide whether the risks of later disease and the other problems associated with early breast development are grave enough to justify this course of action. They would have to take account of the fact that researchers still need to definitively determine the molecular mechanisms by which early puberty raises the risk of disease. </p>
<p>At this stage, however, there are grounds for optimism. We could be talking about an intervention that leads to significant health benefits and enhances the quality of girls’ lives – both as children and adults.</p><img src="https://counter.theconversation.com/content/70767/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gillian Wilson receives funding from the Medical Research Council. </span></em></p>Until now, the processes that lead some girls to start developing before others have been poorly understood.Gillian Wilson, Research Associate, Institute of Infection Immunity and Inflammation , University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/508502016-02-07T19:06:41Z2016-02-07T19:06:41ZWe need a cure for bacterial vaginosis, one of the great enigmas in women’s health<figure><img src="https://images.theconversation.com/files/110243/original/image-20160204-5826-zpjw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bacterial vaginosis affects at least 12% of Australian women.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This article is part of our series examining hidden women’s conditions. You can also read today’s pieces on why women <a href="http://theconversation.com/why-women-see-their-gp-more-than-men-49051">see their GP</a> more than men; and the need to empower women with <a href="http://theconversation.com/vulvas-periods-and-leaks-women-need-the-right-words-to-seek-help-for-conditions-down-there-53638">appropriate language</a> to seek help when their body “malfunctions”.</em></p>
<p>Few have heard of bacterial vaginosis (BV) although it’s a relatively common condition. It affects at least <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0057688">12% of Australian women</a>, <a href="http://journals.lww.com/greenjournal/Abstract/2007/01000/Prevalence_of_Bacterial_Vaginosis__2001_2004.18.aspx">30% of American women</a> and up to <a href="http://jama.jamanetwork.com/article.aspx?articleid=1157494&resultclick=1">50% in parts of Africa</a>.</p>
<p>Symptoms <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bacterial-vaginosis">include a watery, milky discharge</a> and fishy odour coming from the vagina. </p>
<p>Women with BV are <a href="http://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm">more likely to get</a> sexually transmitted infections (STIs) – such as chlamydia, gonorrhoea and herpes – and to transmit or acquire HIV. They are more likely to develop pelvic inflammatory disease, a painful condition that can result in infertility. </p>
<p>Pregnant women with BV are <a href="http://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm">more likely to suffer miscarriages</a> and deliver premature and low birth-weight babies.</p>
<p>Studies have shown women’s self-esteem, sexual relationships and quality of life <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074378">suffer significantly</a> from this infection. Women have reported BV symptoms make them feel embarrassed, “dirty” and concerned others may be able to detect their odour.</p>
<p>Many women with BV symptoms think they are <a href="http://medicinetoday.com.au/2004/june/feature-article/vulval-itch-all-itches-not-thrush!">experiencing thrush</a>, and commonly report being treated for this. But BV doesn’t cause itching and there is often a noticeable fishy odour. Improper treatment for this condition leads to persistent symptoms, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074378">frustration and distress</a>.</p>
<h2>Why BV is hard to treat</h2>
<p>Bacterial vaginosis is caused by groups of bacteria. This makes it different from other genital infections, such as chlamydia and gonorrhoea, where one bacterium is responsible. </p>
<p>While the cause of BV remains the subject of ongoing research, we do know there is a marked <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa043802">disruption of the vaginal bacterial community</a> in women with BV compared to those with a healthy vaginal state.</p>
<p>BV is associated with a <a href="http://www.sciencedirect.com/science/article/pii/S0002937801772353">decreased number of good bacteria</a>, known as lactobacilli, and an increase in bad bacteria. Lactobacilli dominate the healthy vagina, fighting bad bacteria and other other disease-causing agents.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">BV is associated with a decrease in good bacteria in the vagina, and increase in bad.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Latest research into the bacterial profile of the vagina has suggested that as well as this imbalance, women with BV have a <a href="http://journals.lww.com/greenjournal/Abstract/2005/11000/Adherent_Biofilms_in_Bacterial_Vaginosis.19.aspx">bacterial biofilm</a> on their vaginal wall.</p>
<p>This is a kind of network and scaffolding of bacteria that cause cells to stick to each other. The biofilm blocks the body’s defence mechanisms and <a href="http://www.sciencedirect.com/science/article/pii/S0002937807008150">protects bacteria against antibiotics</a> which have difficulty penetrating the biofilm.</p>
<p>Current <a href="http://reproduct-endo.com/article/view/55214">treatment guidelines</a> include seven days of either oral antibiotic tablets or the insertion of a vaginal antibiotic cream for seven nights. </p>
<p>These antibiotics have 80% to 90% cure rates one month after treatment. But more than half of treated women get BV back again <a href="http://jid.oxfordjournals.org/content/193/11/1478.short">within six months</a>. </p>
<p>No other <a href="http://www.ncbi.nlm.nih.gov/pubmed/16647911">treatment approaches</a> (longer antibiotic regimens, combinations of different antibiotics or supplementing <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0034540">antibiotics with probiotics</a> to try and restore the healthy vaginal bacterial balance) have resulted in a sustained, long-term cure. </p>
<p>This is likely due to the bugs causing BV persisting after treatment or because women are being reinfected by their partners.</p>
<h2>Sexual transmission</h2>
<p>Trials between 1985 and 1997, where males were treated alongside their female partners, didn’t consistently reduce BV recurrence rates. These trials <a href="http://journals.lww.com/stdjournal/Abstract/2012/10000/Systematic_Review_of_Randomized_Trials_of.15.aspx">have since been shown</a> as flawed and inconclusive.</p>
<p>Now there is mounting evidence to suggest sex is strongly linked with the acquisition of BV and its recurrence in treated women.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is mounting evidence of sexual transmission.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/oid-w/7750998534/in/photolist-cNVTPL-fPf9X7-qpAQ1-yMPWCm-MMM9b-tAET4-cKreAJ-cLB82J-cMGJMG-bP9DE-MNc1x-9abtXG-8oNQQ-cVPFvd-7DAGSL-8BpXwP-afYnY5-4GXQSh-fnBkq-7R9upo-4GTFjt-4GXQZ7-o4qu2-5Pu7UN-afpKdW-3aUFQd-qpAKC-5nXoWh-efhMWd-9abtXL-MMNWA-MNfTx-MMUjZ-MN4Uq-MN8Mk-a3oDt6-qpAPH-daxfRf-qpAQu-4dQK6t-qpAL7-9abtXJ-7xzam-8DRiTY-75fdpB-6Pje4q-j9Zrd-2VoeKM-bfj35r-9aJe12">Miles Cave/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Studies have found women with male sexual partners who <a href="http://cid.oxfordjournals.org/content/47/11/1426.short">didn’t use condoms were consistently</a> more likely to have BV. And women who have been treated and then <a href="http://cid.oxfordjournals.org/content/56/6/777.short">re-exposed to the same partner</a> were more likely to get their BV back. </p>
<p>Studies exploring bacterial communities on the penis have found <a href="http://mbio.asm.org/content/6/3/e00589-15.full">BV-linked bugs</a> under the foreskin and at the end of the urine tube. These were more common in men whose partners had BV than in those whose partners didn’t.</p>
<p>In African trials, female partners of <a href="http://www.sciencedirect.com/science/article/pii/S0140673607603134">circumcised males were found to have less BV</a> than those of uncircumcised males.</p>
<p>Despite men not having associated symptoms, the data support the hypothesis that in treated women, sex with an untreated partner may be re-introducing the BV bugs responsible for high recurrence rates.</p>
<p>Other <a href="http://cid.oxfordjournals.org/content/60/7/1042.short">studies have shown women</a> with female sexual partners were more likely to develop BV if they had more partners or a partner with BV. </p>
<h2>We need a cure</h2>
<p>The current state of BV treatment is unacceptable. Despite mounting evidence of sexual transmission, treatment of male and female partners of women with BV is not recommended by international <a href="http://www.cdc.gov/std/tg2015/references.htm#595">guidelines</a>, based on the trials two decades ago.</p>
<p>There are few conditions where doctors know that more than 50% of patients will be back with symptoms within six months. This characteristic of BV highlights the importance of finding the cause of high reinfection rates.</p>
<p>Failure to find a single organism responsible for BV and the difficulty in establishing whether BV is sexually transmitted have all been significant barriers to making progress with a cure.</p>
<p>A number of treatment strategies must be explored, include conducting well-designed clinical trials of partner treatment to see if eradicating the bacteria from women and their partners simultaneously (as we do routinely for STIs such as chlamydia) improves the cure rate.</p>
<p>It is quite possible that no single strategy will eliminate BV in all women and that combinations of approaches may be needed; including using antibiotics with biofilm-disrupting agents and partner treatment. </p>
<p>Drugs that <a href="http://cid.oxfordjournals.org/content/early/2015/04/29/cid.civ353.short">disrupt biofilm</a> are highly experimental, but will also be subject to clinical trials over the next few years and may prove essential in the fight to eradicate BV.</p><img src="https://counter.theconversation.com/content/50850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catriona Bradshaw receives funding from The NHMRC</span></em></p><p class="fine-print"><em><span>Lenka Vodstrcil does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Few women have heard of bacterial vaginosis (BV) and often confuse its symptoms with thrush. But improper treatment of BV can lead to persistent symptoms and distress.Lenka Vodstrcil, Research Fellow, Melbourne Sexual Health Centre, Monash UniversityCatriona Bradshaw, Associate Professor, Melbourne School of Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/448662015-07-30T05:16:51Z2015-07-30T05:16:51ZCould HIV-prevention pills actually increase infection risk by cutting condom use?<figure><img src="https://images.theconversation.com/files/89491/original/image-20150723-22811-1qtowp4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>It’s been hailed as a major breakthrough and one of the much-needed tools to “<a href="http://www.theguardian.com/commentisfree/2015/feb/26/hiv-treatment-game-changer-truvada-nhs-trial">end HIV</a>”. But there are <a href="http://betablog.org/re-thinking-risk-compensation-conversation-kim-koester/">also concerns</a> about pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV-negative people to prevent them from becoming infected with the virus. Will people taking PrEP stop using condoms and could this actually lead to an increase in HIV and sexually transmitted infections (STIs)?</p>
<p>PrEP appears to be a highly effective method of reducing risk of HIV transmission. Adding to growing <a href="http://www.cdc.gov/hiv/prevention/research/prep/">international evidence</a>, the <a href="http://www.aidsmap.com/Pre-exposure-prophylaxis-PrEP-stops-86-of-HIV-infections-in-PROUD-study/page/2947319/">Proud trial</a> tested the use of PrEP with gay and bisexual men in England and found a reduction in HIV transmission of 86% amongst men who took PrEP every day. Truvada, the drug used in the Proud trial, is not currently licensed for use as PrEP in the UK. However, as a result of the findings, there has been a <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/make-new-hiv-protection-pill-available-on-the-nhs-say-sexual-health-campaigners-9387332.html">concerted effort</a> by HIV policymakers and community activists to make Truvada available as PrEP on the NHS as soon as possible.</p>
<p>Evidence to date has shown mixed results when it comes to continued condom use with PrEP. The Proud trial, which recruited participants reporting some but not exclusive use of condoms, found the number of people not using condoms remained the same throughout the study. STI rates across both trial arms – the group that received PrEP immediately and the group that had to wait 12 months – also remained similar. Evidence from three locations from the <a href="http://www.aidsmap.com/How-will-people-use-PrEP-iPrEx-users-talk-condoms-pills-anxiety-and-relief/page/2894961/">iPrEX study</a> in the US suggests that, although some younger participants reduced condom use, in most cases PrEP did not reduce condom use but did reduce stress, fear, and guilt.</p>
<p>We need to consider who might be willing to use PrEP. A <a href="http://www.bhiva.org/140404JamieFrankis.aspx">number of surveys</a> with gay and bisexual men in the UK have shown that men reporting lower levels of condom use and who are at higher risk of HIV are interested in PrEP. Introducing PrEP to this group might not necessarily reduce condom use, but could protect against HIV infections where condoms are not already being used. In this way, PrEP could fill a gap in HIV prevention for those individuals who find it difficult, or are unable, to use condoms as their main means of preventing HIV.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tried and tested protection.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Our <a href="http://bmjopen.bmj.com/content/4/11/e005717.full">PrEP research</a> in Scotland with gay and bisexual men, and men and women from migrant African communities, found that concerns about PrEP went beyond condom use. Participants in our qualitative study highlighted anxieties around the immediate and long-term side-effects of PrEP, a lack of trust that PrEP would work, and a belief that they were not at high-enough risk to merit taking a daily pill to prevent HIV. In addition, given that PrEP is not 100% effective, skills amongst participants in calculating risk reduction in relation to PrEP appeared to be mixed and will be an important factor in the effective “real-world” use of PrEP.</p>
<p>But our study also highlighted the fear that others would stop using condoms as a result of PrEP. One man compared the impact of PrEP to “women burning their bras” because he was concerned that other men would stop using condoms and threaten a 30-year history of HIV-prevention based on condom use. This suggests that many people still see condoms as the main HIV-prevention tool and demonstrates the need to engage with these fears and identify how PrEP might fit into, rather than disrupt, existing HIV prevention strategies.</p>
<p>Given the <a href="http://www.independent.co.uk/news/uk/home-news/pride-in-london-nhs-to-come-under-pressure-to-provide-miracle-hiv-prevention-pill-10349303.html">likely introduction</a> of PrEP in the UK in the not-too-distant future, we need to draw on existing evidence to encourage its equitable introduction into health services and access by those most at risk of HIV. There needs to be clear guidance and support for using PrEP in combination with existing HIV-prevention strategies, including condoms. We need to find acceptable, effective and clear ways of explaining PrEP to potential users and work to improve understandings and skills in assessing and reducing risk. </p>
<p>Finally, we need to address existing – and sometimes conflicting – <a href="http://www.aidsmap.com/PrEP-wars-debating-pre-exposure-prophylaxis-in-the-gay-community/page/2572027/">community concerns</a> about PrEP . We need to find ways of talking openly about what a range of HIV prevention options might look like, without moralising or judging individual practices. Good sexual health needs to recognise the dynamic lives of people affected by HIV. No matter how well PrEP might work, it alone will not be the magic bullet to end HIV.</p><img src="https://counter.theconversation.com/content/44866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa McDaid receives funding from the UK Medical Research Council, Scottish Chief Scientist Office and the National Institute for Health Research.</span></em></p><p class="fine-print"><em><span>Ingrid Young holds a fellowship funded by the Scottish Chief Scientist Office (CSO).</span></em></p>PrEP drugs to prevent people contracting HIV mustn’t disrupt existing sexual health strategies.Lisa McDaid, Programme leader, MRC/CSO Social and Public Health Sciences Unit, University of GlasgowIngrid Young, Research fellow, MRC/CSO Social and Public Health Sciences Unit, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/442752015-07-30T05:16:45Z2015-07-30T05:16:45ZHow to get more men using condoms – put the pleasure back into sex<figure><img src="https://images.theconversation.com/files/90150/original/image-20150729-30882-14odzyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Pleasure, excitement and intimacy are <a href="http://link.springer.com/article/10.1007/s10508-007-9213-0#page-1">powerful drivers</a> in young people’s sexual decision making. But they are rarely considered when it comes to strategies for reducing the risk of sexually transmitted infections (STIs) or promoting condom use.</p>
<p>Stubbornly <a href="http://www.hpa.org.uk/stiannualdatatables">high rates of STIs</a> in the UK, particularly among under-25s, demonstrate that the plethora of <a href="http://www.fpa.org.uk/campaigns/sexual-health-week">messages and campaigns</a> focused on risk of infection as the driver for condom use have failed to resonate with young people. Or more accurately, with all young people, all the time. It is time to move away from building messages around sex as a risk of infection or pregnancy, and instead to develop campaigns around sex as pleasure, intimacy and excitement.</p>
<p>Some <a href="http://thepleasureproject.org/">recent practice</a> <a href="http://jennyhiggins.net/publications/">and research</a> is starting to put the pleasure agenda in the foreground of sexual health. For example, <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302567">recent empirical research</a> in the United States has highlighted how young people’s motivation to seek pleasure was the most important factor behind their lack of condom use. This priority means pleasure is a factor we can’t afford to neglect.</p>
<p>For young men, sex is also pivotal in the construction of their sense of masculinity. <a href="http://search.proquest.com/openview/8bf834a946e0656d72adfcb686deb761/1?pq-origsite=gscholar">Pressures on young men</a> to be good at sex, to take the lead and to maintain and sustain an erection are high. Condom use can threaten or undermine these imperatives by placing this performance at risk. Young men fear that the interruption to apply a condom may cause them to lose their erection and make them appear fumbling and unsure. It requires a level of negotiation and discussion which they can find difficult and embarrassing and it does not fit their conception of sex as spontaneous and exciting.</p>
<p>This combination means that, despite having the knowledge about its importance, condom use in itself constitutes a more immediate and significant risk to young men than that of infection, which is often seen as <a href="https://theconversation.com/have-young-people-stopped-fearing-sexually-transmitted-infections-44341">trivial and treatable</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">That’s one way to get over the awkwardness.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Embracing and seeking to control risk is a <a href="https://books.google.co.uk/books?hl=en&lr=&id=_FSSAgAAQBAJ&oi=fnd&pg=PP1&dq=Lyng+Edgework&ots=TrXqmE5A2Q&sig=2ud7CoVQCLvt5qRgWORhX82xLag#v=onepage&q=Lyng%20Edgework&f=false">valued masculine attribute</a>. Consequently, being seen as sexually risky and adventurous by rejecting social conformities relating to safe sex can also <a href="http://www.sciencedirect.com/science/article/pii/S027795360500211X">enhance masculine status</a>.</p>
<p>However, it is not only young men who are resistant to condom use. <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302567">Research shows</a> that young women also have preferences for condom-less heterosexual sex, often citing condoms’ impact on feelings of intimacy and trust as important factors. And while gender stereotypes and masculine expectations mean that this “romantic” rationale is not typically associated with or acknowledged by young men, it doesn’t mean that, in the privacy of an encounter with their partner, the desire to be intimate and the pleasure of this closeness is not also privileged by young men.</p>
<p>Talking more about pleasure would enable us to better promote condom use among young men. It would enable us to explore alternatives to penetrative sex, discuss the nitty gritty (such as how to manage condom use without fumbling and embarrassment) and challenge the preoccupation with sex as a performance to be mastered. </p>
<p>Putting pleasure and excitement at the heart of our discussions with young men provides us with a coherent, inclusive and meaningful starting point from which to talk about sex. It brings policy and interventions alongside the interests of young men rather than in opposition to them and offers a space in which to address the concerns relating to masculinities that trouble them.</p><img src="https://counter.theconversation.com/content/44275/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Eastham receives funding from the ESRC.</span></em></p><p class="fine-print"><em><span>Mark Limmer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Tackling men’s reluctant condom use comes down to the basics of how they view sex.Mark Limmer, Lecturer, Division of Health Research, Lancaster UniversityRachael Eastham, PhD candidate, Division of Health Research, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/443412015-07-29T10:41:11Z2015-07-29T10:41:11ZHave young people stopped fearing sexually transmitted infections?<figure><img src="https://images.theconversation.com/files/90119/original/image-20150729-30862-1mxj1z2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The good news is that rates of teenage pregnancies are at <a href="http://www.theguardian.com/lifeandstyle/2015/jul/15/teenage-pregnancies-uk-drops-lowest-level-70-years">record lows</a>. In 2014 in England and Wales they were at the <a href="http://www.ons.gov.uk/ons/rel/vsob1/birth-summary-tables--england-and-wales/2014/index.html">lowest rate</a> since 1946, with only 15.6 pregnancies per 1,000 women younger than 20.</p>
<p>Unfortunately, rates of sexually transmitted infections (STIs) are still very high. There were <a href="http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-wales/2013/stb-conceptions-in-england-and-wales-2013.html">440,000 diagnoses</a> in the UK in 2014, and the under 25s are one of the most high risk groups. STIs have a high financial cost for testing and treatment: diagnoses of chlamydia alone cost the NHS <a href="http://www.fpa.org.uk/sites/default/files/unprotected-nation-executive-summary.pdf">£620m</a> in 2011.</p>
<p>Condoms provide effective protection against STIs but many people choose not to use them – around <a href="http://bit.ly/2xMf1uD">15% of under-25s</a> reported having unprotected sex with two or more partners in the last year. So why don’t young people use condoms? The most commonly given reason is the impact on <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2496933/">sexual pleasure</a> <a href="http://bit.ly/2xM1cfM">and intimacy</a>. Pleasure is of course a very important part of sex, so anything that is perceived to interfere with it is bound to be viewed negatively.</p>
<h2>Mixed evidence</h2>
<p>Some also argue that young people don’t use condoms because they aren’t scared of <a href="http://www.yourtango.com/2014208790/sexual-health-safe-sex-why-arent-we-afraid-stds-anymore">contracting STIs</a> anymore. Today, the majority of common STIs, including <a href="http://www.nhs.uk/Conditions/Chlamydia/Pages/Treatment.aspx">chlamydia</a> and <a href="http://www.nhs.uk/Conditions/Gonorrhoea/Pages/Treatmentpg.aspx">gonorrhoea</a>, can be cured quickly with antibiotics, while HIV can be managed and those who contract it can expect to <a href="http://www.theguardian.com/global-development/2015/jul/14/people-with-hiv-aids-live-nearly-20-years-longer-than-in-2001">live 20 years longer</a> than was the case in 2000.</p>
<p>While this idea makes sense, the evidence supporting it is mixed. Research has shown people’s <a href="http://journals.lww.com/stdjournal/Abstract/2006/03000/Incidence_of_Sexually_Transmitted_Diseases_and_HIV.13.aspx">beliefs about the seriousness of non-HIV STIs are not</a> related to their behaviour, suggesting that it doesn’t make any difference whether people think STIs are serious or not: they’re still likely to put themselves at risk. This is despite the fact that, if left untreated, they can cause complications such as infertility.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Joint decision.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Fear of HIV, on the other hand, may well influence behaviour. The problem is that many people may not feel at risk of catching it, particularly non-black-African heterosexual people, who are statistically at <a href="https://www.gov.uk/government/statistics/hiv-data-tables">lower risk of HIV</a>. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22404427">One study</a> showed heterosexual people who were at high risk of STIs and HIV underestimated that risk and many didn’t use condoms. This suggests that young people’s decision to use a condom or not may depend on whether they think they are at risk of an STI rather than how severe they think the consequences are.</p>
<p>We should also be aware that the decision to wear a condom isn’t always made by one person. Their partners may also be involved, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2496933/">expectations</a> about their reaction (or a <a href="http://www.ncbi.nlm.nih.gov/pubmed/18725548">lack of discussion</a> altogether) may influence the choice. Getting caught in the “<a href="http://www.researchprotocols.org/2015/3/e82/">heat of the moment</a>” is a commonly cited barrier to condom use and experiments have shown that sexual arousal in men <a href="http://people.duke.edu/%7Edandan/Papers/PI/Heat_of_Moment.pdf">reduces their ability</a> to make decisions. </p>
<h2>Sex-positive approach needed</h2>
<p>So what can we do to change this situation? Previous educational programmes have often focused on the “<a href="http://pps.sagepub.com/content/9/5/455.short">dangers</a>” of unprotected sex. But <a href="http://www.tandfonline.com/doi/abs/10.1080/17437199.2012.703527#.VZu2uflVhBc">evidence suggests</a> that scaring people, in particular those who feel unable to change their behaviour, can just cause them to become defensive.</p>
<p>The fact that perceived loss of sexual pleasure appears to be the fundamental reason most people don’t use condoms highlights how important it is to address the positive aspects of sex, rather than solely focusing on the negative consequences. Finding a way to enhance sexual pleasure with condoms, or at least change beliefs about pleasure, is important. This could be as simple as improving actual sensation with condoms, from recommending thinner designs to revolutionary new materials such as <a href="http://www.newscientist.com/article/mg22429920.400-the-futures-flat-the-wondrous-world-of-2d-materials.html#.VZu6QPlVhBc">graphene</a>. Alternatively, it could involve persuading people that <a href="http://www.researchprotocols.org/2015/3/e82/">safe sex can be good sex</a>. </p>
<p>This sex-positive approach attempts to target an important driver of behaviour: motivation. We are primarily driven by our <a href="http://www.primetheory.com/">wants and needs</a> in any particular moment. Therefore, we need to make people want to use condoms, rather than making them feel that they should. To do this, we should focus on outcomes that are <a href="https://books.google.co.uk/books?hl=en&lr=&id=CoGNDeVdjoQC&oi=fnd&pg=PR1&dq=Self-Regulation+in+Health+Behavior&ots=ZpIV0qGSb2&sig=ZWdPGvVBnJL0bztN8z5a8cNQH6E#v=onepage&q&f=false">important to people</a> –- things that we know they want.</p>
<p>For example, when targeting smoking, focusing on appearance-related consequences may be more effective than focusing on health-related consequences, for people who value being attractive. Interventions to increase condom use should therefore focus on more immediate goals that young people care about, such as enjoying good sex or gaining social approval.</p>
<p>We certainly haven’t cracked the problem of getting people to use condoms yet. However, focusing on goals that are important to young people create an exciting new area for future investigation.</p><img src="https://counter.theconversation.com/content/44341/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rosie Webster receives funding from UK National Institute for Health Research, Health Technology Assessment Program, 10/131/01.
Views are entirely of the author and do not reflect the views of the funder or of UCL eHealth unit.</span></em></p>STIs might be easier to treat or manage but unprotected sex still comes with potentially serious risks.Rosie Webster, Research Associate in Digital Health and Sexual Health, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/445972015-07-16T19:29:14Z2015-07-16T19:29:14ZNorthern Australia syphilis outbreak is about government neglect, not child abuse<figure><img src="https://images.theconversation.com/files/88624/original/image-20150716-5089-6swco6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Syphilis outbreaks tend to occur in marginalised populations where there is a lack of affordable, appropriate and culturally acceptable health care.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/barkochre/251902177/in/photolist-og4JZ-8vqDsw-2fNt7j-8vqBMG-4WSQh7-48CoBM-89pxEr-8vnzLt-4vaApc-7ftPxg-8txe3a-2e8zVU-9kkH4p-fcgQvz-4Hj3nA-DgDTk-7eJZ2v-fySHVY-g8iTu3-2h3bX5-7WbEhf-4rL3MY-4rSvo4-ama5St-ah434f-5jgr9p-4SMCTZ-qLKpf">yaruman5/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The <a href="http://www.abc.net.au/news/2015-07-12/syphilis-outbreak-nt-indigenous-youth-prompts-fears-for-unborn/6613514">recent syphilis outbreak</a> in Central Australia highlights the urgent need for investment in sexual health services for young Aboriginal Australians living in remote regions.</p>
<p>Since July last year, 134 cases of the sexually transmitted disease have been reported in the Barkly and Katherine regions. This is up from 15 reported cases in the 2013-14 financial year. </p>
<p>There’s a serious risk the outbreak will extend into other parts of remote Australia. But suggestions that the recent rise in syphilis cases has something to do with child sexual abuse in Aboriginal communities are an irresponsible distraction from the issue at hand. </p>
<p>What both the territory and federal governments need to do is acknowledge that investment in primary health-care delivery in remote Aboriginal communities is inadequate. That’s why outbreaks of sexually transmitted diseases are confined to these regions, while being a rarity in mainstream Australia.</p>
<p>Globally, syphilis outbreaks have been reported in many <a href="http://khn.org/morning-breakout/dr00002167/">marginalised populations</a>, including <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5906a2.htm">Native Americans,</a> <a href="http://gov.nu.ca/health/information/syphilis-outbreak-nunavut">First Nations</a> peoples and African Americans. All these groups share a common problem: lack of access to affordable, appropriate and culturally acceptable health care.</p>
<h2>Outbreaks of syphilis</h2>
<p>Syphilis is a sexually transmitted bacterial infection. In Australia, it mainly affects urban gay men and heterosexual people in remote Aboriginal communities. It’s extremely uncommon in the general population. </p>
<p>The <a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/syphilis#clinical-presentation">symptoms are often mild and transient</a>, making it easy for infectious people to unknowingly transmit the infection to their sexual partners. But if left untreated, syphilis can affect multiple organs, including the heart, brain, bones and joints.</p>
<p>Most concerning is that the infection <a href="http://www.health.vic.gov.au/neonatalhandbook/infections/syphilis.htm">crosses the placenta</a>, which accounts for high rates of stillbirth or permanent disabilities in children, including blindness and even perinatal death.</p>
<p>Exactly why syphilis outbreaks occur is not fully understood. Until recently <a href="http://www.nature.com/nature/links/050127/050127-1.html">the prevailing theory</a> was that due to acquired partial immunity in the population, syphilis rates fluctuate naturally in cycles of about ten years. But more recent evidence has discounted this theory and suggested changes in sexual behaviour and the vigour of <a href="http://precedings.nature.com/documents/1373/version/1">public health control programs</a> are the main factors driving syphilis rates at the population level.</p>
<p>Another factor - and one that plays into the current outbreak - is the recent realisation that <a href="http://aac.asm.org/content/54/2/583.full">syphilis is becoming resistant to common antibiotics</a> such as azithromycin, which is used widely to treat other infections. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sexual behaviours of Aboriginal young people are broadly the same as those of other young Australians.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/211626852/in/photolist-7nh9ar-nRLt3t-9nf73B-5rCNrP-avg5ks-7nhQbV-8KDJvT-gQbdwt-pvnJb7-8CY6xV-8AJXMC-8PHh2Z-f6hTM5-edcjfR-8xnMuU-gxA95-aEiAVv-3N1wYY-8wRTrV-8ByV3k-gLpBpo-jGDhQ-9hvFDL-7EGLC-acUNrr-e2rqeM-8Sod4U-7nmnYy-4MCW82-3i22L-mJXr9j-qKy8Wh-4PgEvk-qrwYuv-gxzyn-ehW3ha-gvRRsj-aAua5C-oXk9pc-4UJqk8-7DHPQT-dHMKrW-jVW2AF-kaU8m7-72DcVz-y8n2D-6JegTp-78P1zb-78P2Lo-5dW9i">Thomas Hawk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Syphilis in children</h2>
<p>Syphilis is a notifiable disease, which means that doctors who make a diagnosis have a legal obligation to report the case to their jurisdictional health department. The majority of the current outbreak’s notified syphilis cases have been among Indigenous people aged 15 to 19. But the disease has affected children as young as 12. </p>
<p>The legal age of sexual consent in the Territory, and many other jurisdictions, is 16. But the median age of sexual debut in Australia is 15. This is the same everywhere - in mainstream Australia and among Aboriginal people in the Northern Territory.</p>
<p>Indeed, <a href="https://www.sahmri.com/our-research/themes/infection-immunity/research/list/sexual-health-and-relationships-survey-2">survey data has shown</a> that the sexual behaviours of Aboriginal young people in the Northern Territory and other remote areas are broadly the same as those of other young Australians. There are similar numbers of sexual partners, for instance, and similar rates of condom use, as well as same-aged sexual partners. </p>
<p>Of course, sexually transmitted infections in children are a major concern. But it’s important to remember that most sexually transmitted infections in the Northern Territory in adolescents below the age of 16 (that is, below the age of consent) occur among 14 and 15-year-olds. And these rates are <a href="http://kirby.unsw.edu.au/surveillance/2014-aboriginal-surveillance-report-hiv-viral-hepatitis-stis">similar to non-Indigenous young Australians</a>. These notifications – both in mainstream and Aboriginal Australia - predominantly arise because of early sexual debut.</p>
<p>In recent days, the Northern Territory’s health minister, John Elferink, <a href="http://www.abc.net.au/news/2015-07-12/syphilis-outbreak-nt-indigenous-youth-prompts-fears-for-unborn/6613514">has alluded</a> to the increasing rates of syphilis being caused by sexual abuse in Territory communities. However well-intentioned, comments linking high rates of sexually transmissible infections among children to child sexual abuse carries a risk of further pushing young people away from services we so desperately need them to engage with.</p>
<h2>Successful programs</h2>
<p>Outbreaks of sexually transmitted infections like this one are related to the inappropriately low level of investment in sexual health in remote areas. They highlight the lack of high-quality education, primary health care and specialist outreach programs, all of which could stop these high rates of infections. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/22697136">Several programs</a> have been successful in bringing rates under control through consistent delivery of primary care, appropriate sexual health education and specific testing and treatment programs. But not all Aboriginal people living in remote areas have access to these programs. </p>
<p>To deal appropriately with the current outbreak, we are using what we have learnt from <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870166/">past syphilis outbreaks</a> and have instigated an intense and sustained public health response. More specifically, we are <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-syphilis.htm">focusing on raising awareness</a> of the issue among people at risk, increasing the rate of condom use, and ensuring both early detection and treatment of people infected, as well as their sexual partners, occurs in a timely manner. </p>
<p>What’s urgently required in remote Australia is a significant investment in sexual health to be integrated into existing primary health care services, alongside education.</p>
<p>We need to ensure that young Aboriginal Australians’ sexual debut is a positive and pleasurable experience - not an embarrassing, shameful one because it went hand-in-hand with a sexually transmitted infection.</p>
<p><em>Ms Amanda Sibosado, Sexual Health Coordinator at Kimberley Aboriginal Medical Services, co-authored this article.</em></p>
<p><em>This article was originally published with the headline “Northern Territory syphilis outbreak is about medical neglect, not child abuse”. It has been amended at the authors’ request.</em></p><img src="https://counter.theconversation.com/content/44597/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The syphilis outbreak in Central Australia is not about child abuse. But it highlights the urgent need for investment in sexual health services for Aboriginal Australians living in remote areas.James Ward, Associate Professor, Infectious Diseases Research Aboriginal and Torres Strait Islander Health, South Australian Health & Medical Research InstituteDonna B Mak, Professor, Head of Population and Preventive Health, University of Notre Dame AustraliaJohanna Dups, Masters of Applied Epidemiology (MAE) Scholar, National Centre for Epidemiology and Population Health, Australian National Univeristy (ANU), Australian National UniversityNathan Ryder, Conjoint Senior Lecturer, School of Medicine and Public Health, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.