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Literature searches completed on 28.6.99

Chapter 5: Sexually transmitted infections

This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.
Sexually transmitted infections (STIs) affect people of all ages in Wales. Incidence is greatest among people under 25, but older men and women are also at risk, particularly those who are entering new partnerships following the break up of a long-term relationship. These infections are an important source of reproductive ill health, but can be prevented by encouragement of safer sex practices. Many of the interventions aimed at reducing sexually transmitted infections also contribute to reducing unintended teenage pregnancy.
Prior to the advent of HIV, STI prevention received relatively little attention, and in recent years research has tended to focus on STIs in the context of HIV. In the absence of appropriate evidence relating to prevention of STIs other than HIV, and given the similarity of the behavioural interventions advocated both for HIV and general STI prevention, the HIV literature has been used to identify relevant evidence-based statements on risk reduction interventions.
The Statements The Evidence
5.1. Background
5.1a. Sexually transmitted infections (STIs) are an increasing cause of morbidity among young adults in England and Wales, and rising rates among teenagers give particular cause for concerni. i. Nicoll A, Catchpole M, Cliffe S et al. Sexual health of teenagers in England and Wales: analysis of national data. British Medical Journal 1999; 318: 1321-2. http://www.bmj.com/cgi/content/full/318/7194/1321
(Type IV evidence – statistics)
5.1b. Genital Chlamydia trachomatis infection is the commonest curable bacterial STI in England and Wales. Reported rates in Wales are highest among 20 to 24 year olds (212 per 100,000 men and 323 per 100,00 women), but rates are also high among 16-19 year old women (306 per 100,000 in 1997) i,ii. Levels of awareness of chlamydia are low with estimates of only 26% in 16-24 year olds in the general populationiii and only 60% in one high-risk groupiv. i. Communicable Disease Surveillance Centre. Sexually transmitted diseases quarterly report: genital Chlamydia trachomatis infection in England and Wales. Communicable Disease Report 1998; 8(44): 390-391.
(Type IV evidence – statistics)
ii. Communicable Disease Surveillance Centre (Wales). KC60 data.
(Type IV evidence – statistics)
iii. Health Education Authority. Chlamydia: Why You Should Know About It. London: Health Education Authority, 1999
(Type V evidence – citing a survey carried out in 1997)
iv. Kellock DJ, Piercy H, Rogstad KE. Knowledge of Chlamydia trachomatis infection in genitourinary medicine clinic attenders. Sexually Transmitted Infections 1999; 75: 36-40
(Type IV evidence – Questionnaire study of 500 consecutive patients (96.4% response rate = 482 completed questionnaires) attending a genitourinary medicine clinic for the first time)

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5.1c. New cases of genital warts have increased substantially since 1971, making this condition the commonest STI in England and Wales in 1997. The highest rates in Wales are among 20 to 24 year olds (693 per 100,000 men and 703 per 100,000 women in 1997). Rates are also high in women aged 16-19 years (645 per 100,000 in 1997), and among 25-34 year old men (279 per 100,000 in 1997) i,ii. i. Communicable Disease Surveillance Centre. Sexually transmitted diseases quarterly report: genital warts and genital herpes simplex virus infection in England and Wales. Communicable Disease Report 1998; 8(31): 274-276
(Type IV evidence – statistics)
ii. Communicable Disease Surveillance Centre (Wales). KC60 data.
(Type IV evidence – statistics)
5.1d. The numbers of reported cases of genital herpes in Wales have increased substantially between 1990 and 1997. Rates are highest among women aged 20–24 (105 per 100,000 in 1997), followed by women aged 16-19 (95 per 100,000 in 1997). Rates among men are highest for 20-24 year olds (45 per 100,000 in 1997) and 25-34 year olds (37 per 100,000) i,ii. i. Communicable Disease Surveillance Centre. Sexually transmitted diseases quarterly report: genital warts and genital herpes simplex virus infection in England and Wales. Communicable Disease Report 1998; 8(31): 274-276
(Type IV evidence – statistics)
ii. Communicable Disease Surveillance Centre (Wales). KC60 data.
(Type IV evidence – statistics)
5.1e. The incidence of gonorrhoea in England and Wales has decreased for both men and women since 1981. However, between 1995 and 1997 the number of cases appeared to be rising, in particular among men. In Wales the rates are highest among men in the 20-25 year old age group (up from 36 per 100,000 in 1995 to 66 per 100,000 in 1997). Cases among women in Wales have remained fairly constant, with the exception of a slight increase among 16-19 year olds: 32 per 100,000 in 1995 to 37 per 100,000 in 1997i,ii. i. Communicable Disease Surveillance Centre (1998c). Sexually transmitted diseases quarterly report: gonorrhoea in England and Wales. Communicable Disease Report 1998; 8(22): 194-196.
(Type IV evidence – statistics)
ii. Communicable Disease Surveillance Centre (Wales). KC60 data.
(Type IV evidence – statistics)

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5.1f. The cumulative number of AIDS cases in the UK to the end of 1998 was 16,028 of which 227 were in Wales. The equivalent figures for HIV infection were 33,764 for the UK of which 519 were in Wales. Although the proportion of cases acquired through heterosexual intercourse is increasing in Wales, the main transmission route for HIV infection continues to be sex between meni. i. Communicable Disease Surveillance Centre (Wales). KC60 data.
(Type IV evidence – statistics)
5.2. Adverse health effects
5.2a. Important sequelae of inadequately treated STIs include pelvic inflammatory disease and infertilityi.ii, cervical canceriii, and increased susceptibility to HIV infectioniv. i. Adler MW. Sexually transmitted diseases and their effect upon fertility and pregnancy outcome. British Journal of Family Planning 1991; 16 (Suppl): 46-50
(Type V evidence – expert opinion)
ii. Healy DL, Trounson AO, Andersen AN. Female infertility: causes and treatment. The Lancet 1994; 343: 1539-1544
(Type V evidence – expert opinion)
iii. Bosch FX, Manos MM, Munoz N et al. Prevalence of human papillomavirus in cervical cancer: a worldwide perspective. Journal of the National Cancer Institute 1995; 87(11): 796-802
(Type IV evidence – histological analysis of 1000 specimens from patients with invasive cervical cancer)
iv. Laga M, Manoka A, Kivuvu M et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 1993; 7: 95-102
(Type IV evidence – prospective case-control study in a cohort of 431 initially HIV-negative female prostitutes in Zaire)
5.2b. Chlamydia in particular represents a largely preventable source of reproductive morbidityi. After effects of Chlamydia infection can be severe, particularly in women, in whom it may lead to pelvic inflammatory disease, ectopic pregnancy (which ma y be fatal), tubal-factor infertility and chronic abdominal painii. i. Department of Health. Summary and Conclusions of CMO’s Expert Advisory Group on Chlamydia Trachomatis. London: Department of Health, 1998
(Type V evidence – expert opinion)
ii. Anonymous. Sexually transmitted diseases quarterly report: genital chlamydial infection, ectopic pregnancy, and syphilis in England and Wales. Communicable Disease Report 2000; 10(13): 116-118
(Type IV evidence – statistics)
5.2c. HIV infection is usually latent for several years and many infections are undiagnosed until the onset of illness. As yet there is no effective vaccine or cure for HIV. Development of combined antiretroviral treatments have been successful in reducing proliferation of HIV and destruction of the immune system in people already infected. However, these treatments are expensive and may be complicated by side effects and poor compliancei. i. Mortimer JY, Evans BG, Goldberg DJ. The surveillance of HIV infection and AIDS in the United Kingdom. Communicable Disease Report 1997; 7 (9): R118-120.
(Type V evidence – expert opinion)

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5.3. Educational interventions: young people
5.3a. It is possible to modify sexual behaviour through education, provided that attention is paid to programme design and implementationi,ii,iii.
(Health gain notation - 2 "likely to be beneficial")
i. Grunseit A, Kippax S, Aggleton P, Baldo M, Slutkin G. Sexuality education and young people’s sexual behaviour: a review of studies. Journal of Adolescent Research 1997; 12(4): 421-453
(Type I evidence - systematic review of 47 intervention studies including 11 randomised controlled trials)
ii. Grunseit AC, Aggleton P. Lessons learned: an update on the published literature concerning the impact of HIV and sexuality education for young people. Health Education March 1998; 2: 45-54
iii. Kirby D, Short L, Collins J et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994: 109(3): 339-360
(Type I evidence – systematic review of 23 studies including 16 intervention studies)
5.3b. The impact of educational strategies is in the direction of postponed initiation of sexual intercourse and/or safer practices. There is little support for the contention that sex education encourages experimentation or increased sexual activityi,ii.
(Health gain notation - 2 "likely to be beneficial")

 

i. Grunseit A, Kippax S, Aggleton P, Baldo M, Slutkin G. Sexuality education and young people’s sexual behaviour: a review of studies. Journal of Adolescent Research 1997; 12(4): 421-453
(Type I evidence - systematic review of 47 intervention studies including 11 randomised controlled trials)
ii. Kirby D, Short L, Collins J et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994: 109(3): 339-360
(Type I evidence – systematic review of 23 studies including 16 intervention studies)
5.3c. School sex education that includes specific targeted methods with the direct use of medical staff and peers can produce behavioural changes that lead to health benefiti.
(Health gain notation -2 "likely to be beneficial")
i. Mellanby AR, Phelps FA, Crichton NJ, Tripp JH. School sex education: an experimental programme with educational and medical benefit. British Medical Journal 1995; 311: 414-417 http://www.bmj.com/cgi/content/full/311/7002/414 [accessed 10.3.00]
(Type III evidence – matched control experiment of a sex education intervention vs standard education over 3 years – questionnaire evaluation. 1175 students in programme vs 1373 local and 4025 distant controls)

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5.3d. To promote sexual health among young people in respect of sexually transmitted infections, it is necessary not only to advocate specific preventive behaviour such as condom use, but also to address wider cultural issues notably the taboos around the discussion of sex and the empowerment of women. Traditional gendered norms of sexual behaviour undermine young women’s ability to choose safer sexual practices or to refuse unsafe sexual activityi,ii.
(Health gain notation - 2 "likely to be beneficial")
The design of evaluations in sexual health intervention needs to be improved so that more reliable evidence of the effectiveness of different approaches to promoting young people’s sexual health may be generatediii,iv.
i. Wight D. Impediments to safer heterosexual sex: a review of research with young people. AIDS Care 1992; 4(1): 11-21
(Type IV evidence – review of 17 observational studies carried out in Britain)
ii. Holland J, Ramazanoglu C, Sharp S, Thomson R. The Male in the Head: Young People, Heterosexuality and Power. London: Tufnell Press, 1998.
(Type IV evidence – in-depth interviews carried out with purposive samples of 148 young women and 46 young men)
iii. Grunseit A, Kippax S, Aggleton P, Baldo M, Slutkin G. Sexuality education and young people’s sexual behaviour: a review of studies. Journal of Adolescent Research 1997; 12(4): 421-453
(Type I evidence - systematic review of 47 intervention studies including 11 randomised controlled trials)
iv. Oakley A, Fullerton D, Holland J et al. Sexual health education interventions for young people: a methodological review. British Medical Journal 1995; 310: 158-162
http://www.bmj.com/cgi/content/full/310/6973/158 [accessed 10.3.00]
(Type I evidence - systematic review studying the methodological quality of 270 research papers)
5.4. Effectiveness of condoms in preventing sexually transmitted infection
5.4a. Condoms provide substantial protection against HIV and other sexually transmitted infectionsi,ii. When used consistently, they are 90 to 95 per cent effective against HIVii.
(Health gain notation - 1 "beneficial")
i. Shaw EJ, Rienzo BA. Permeability of latex condoms: do latex condoms prevent HIV transmission? Journal of Health Education 1995; 26(6): 372-376
(Type IV evidence – review of observational and laboratory studies)
ii. Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission. Social Science & Medicine 1997; 44(9): 1303-1312
(Type IV evidence - systematic review, Medline only, of observational studies including 11 studies of consistent vs inconsistent condom use)

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5.5. Risk reduction interventions
5.5a. Individuals at elevated risk for sexually transmitted infections can be helped to achieve short-term change in their risk behaviours through multiple-session interventions whichi,ii,iii,iv:
  • involve face-to-face small group work with peer support;
  • are based on theories of behaviour change;
  • are sensitive to local culture and context;
  • address cognitive and attitudinal factors;
  • build motivation;
  • address gender issues;
  • focus on development of risk reduction skills such as sexual assertiveness and discussing and negotiating condom use.

(Health gain notation - 2 "likely to be beneficial")

i. Wingood GM, DiClemente RJ. HIV sexual risk reduction interventions for women: a review. American Journal of Preventive Medicine. 1996; 12(3): 209-217
(Type I evidence - systematic review of 7 studies, 1152 women in total)
ii. Kim N, Stanton B, Li X, Dickersin K, Galbraith J. Effectiveness of the 40 adolescent AIDS-risk reduction interventions: a quantitative review. Journal of Adolescent Health. 1997; 20(3): 204-215
(Type I evidence - systematic review of 40 studies, including 14 randomised controlled trials)
iii. Kelly JA, Murphy DA, Washington CD et al. The effects of HIV/AIDS intervention groups for high-risk women in urban clinics. American Journal of Public Health. 1994; 84(12): 1918-1922
(Type II evidence - randomised controlled trial of 197 women at high risk for HIV infection)
iv. Kelly JA. Sexually transmitted disease prevention approaches that work. Sexually Transmitted Diseases. 1994; 21(2) (Supplement): S73-S75
(Type II evidence – description of two studies: one randomised controlled trial of 197 women (see iii. above) and one randomised community study with homosexual men in 8 cities)
5.6. Partner notification
5.6a. Partner notification leads to identification and treatment of cases of STIi,ii,iii.
(Health gain notation – 2 "likely to be beneficial")
Research is required to establish the direct effects that this has on the incidence/prevalence of STIs within the community, and comparative efficacy and cost effectiveness of different strategies
i. Oxman AD, Scott EAF, Sellors JW et al. Partner notification for sexually transmitted diseases: an overview of the evidence. Canadian Journal of Public Health 1994; Suppl 1: S41-S47.
(Type I evidence – systematic review of 15 trials: 12 published, 2 unpublished and 1 trial in progress, of which 8 were randomised controlled trials)
ii. Cowan FM, French R, Johnson AM. The role and effectiveness of partner notification in STD control: a review. Genitourinary Medicine 1996; 72(4): 247-252
(Type IV evidence – influential reports and studies)
iii. Clarke J. Contact tracing for chlamydia: data on effectiveness. International Journal of STD & AIDS 1998; 9(4): 187-191
(Type IV evidence – influential reports and studies)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk