Advice and guidance on the health needs of migrant patients for healthcare practitioners.
A sexual history is an important part of an overall health assessment.
Although sexually transmitted infections (STIs) can be asymptomatic, they can have serious health consequences.
A high rate of human immunodeficiency virus (HIV) in a country can be taken as an indicator of likely high rates of other STIs. Offer a full sexual health screen to all sexually active people who are from countries with an HIV rate of >1%.
Offer sexual health screening as appropriate for their sexual history to sexually active people who are from countries with a HIV prevalence of ≤1%.
Investigate all people with symptoms of an STI promptly; give a full sexual health screen, and manage appropriately.
Where more specialist STI services are required, refer patients to the local GUM clinic.
Screen all sexually active women under the age of 25 for chlamydia annually, and/or whenever they change sexual partners, irrespective of symptoms or country of origin.
Address sexual health promotion with all sexually active people, providing:
- advice about safer sex and contraception for both men and women
- information about cervical screening for women
Include sexual health promotion as part of a pre-travel health consultation for all sexually active travellers.
Prevention and control of STIs helps reduce the spread of HIV.
Under the National Health Service (Charges to Overseas Visitors) Regulations 2015 the following are exempt from charge:
- diagnosis and treatment for STIs
- testing for HIV and associated pre-and post-test counselling
- HIV treatment
STIs are infections that are spread primarily through person-to-person sexual contact. There are more than 30 different sexually transmissible bacteria, viruses and parasites. Many STIs can also be transmitted from mother to child during pregnancy and childbirth.
According to the World Health Organization, throughout the world:
- more than 1 million people acquire an STI every day
- 376 million new cases of curable STIs (syphilis, gonorrhoea, chlamydia and trichomoniasis) occur annually
STIs can have serious health consequences beyond the immediate impact of the infection itself.
Prevention and control of STIs help reduce the spread of HIV.
The range of STIs that occur commonly varies between different countries. Non-UK born patients may present in the UK with STIs that are less commonly seen here.
Acquisition of STIs may occur prior to arrival in the UK, but may also occur after arrival. Sexual health promotion is important to address with all sexually active people, and should include both safer sex and contraceptive advice. See the ‘Health promotion for sexual and reproductive health and HIV strategic action plan, 2016 to 2019’ and guidance based on applying All Our Health.
The most common sexually transmissible bacteria are:
Neisseria gonorrhoeae: causes gonorrhoea or gonococcal infection
Chlamydia trachomatis: causes chlamydial infections, including lymphogranuloma venereum
Treponema pallidum: causes syphilis
Haemophilus ducreyi: causes chancroid
Klebsiella granulomatis (previously known as Calymmatobacterium granulomatis): causes granuloma inguinale or donovanosis
The most common sexually transmissible viruses are:
Human immunodeficiency virus (HIV): causes AIDS
Herpes simplex virus types 1 and 2: cause genital herpes
Human papillomavirus: causes genital warts and certain subtypes lead to cervical cancer in women
Hepatitis B virus: causes hepatitis and chronic cases may lead to cancer of the liver
Cytomegalovirus: causes inflammation in a number of organs including the brain, the eye, and the bowel
Human T-cell lymphotropic virus types 1 and 2 (HTLV-1 and HTLV-2): approximately 5-10% of people with HTLV-1 will develop a recognised associated clinical condition such as adult T-cell leukaemia/lymphoma or HTLV-1 associated myelopathy (also known as tropical spastic paraparesis)
The most common sexually transmissible parasite is Trichomonas vaginalis, which causes vaginal trichomoniasis.
Diagnosis and treatment for STIs is exempt from charge under the National Health Service (Charges to Overseas Visitors) Regulations 2015.
Testing for HIV, associated pre-and post- test counselling and treatment are also exempt under these regulations.
The main symptoms associated with STIs are:
- urethral discharge
- genital ulcers, blisters or sores
- vaginal discharge or bleeding
- lower abdominal pain
- neonatal eye infections (conjunctivitis of the newborn)
- pain when urinating
Sexually transmitted infections can often be present without symptoms. For example, up to 50% of women and 10% of men don’t experience any symptoms of gonorrhoea. Most people do not experience symptoms of chlamydia. Even asymptomatic infections can however lead to the development of serious complications.
Complications include chronic infection, and serious delayed consequences such as:
- ectopic pregnancy
- cervical cancer in women
- pelvic inflammatory disease (PID) in women
- congenital infections (for example, syphilis)
- adverse pregnancy outcomes
- the untimely death of infants and adults
Testing and treatment
In the UK, STIs are typically diagnosed and treated through genito-urinary medicine (GUM) services, which are able to offer comprehensive screening and treatment for a wide range of diseases, partner notification, and sexual health promotion services.
An increasing number of services offering STI diagnosis and care are being commissioned in other community-based settings, including general practice and contraceptive services. This includes services offering access to chlamydia testing through the National Chlamydia Screening Programme (NCSP).
All services offering STI management are expected to follow Standards for the management of sexually transmitted infections (STIs) developed by British Association for Sexual Health and HIV (BASHH). Further guidance from Public Health England is also available
However, where more specialist STI services are required, referral to the local GUM clinic is the preferred option.
Primary care practitioners should be aware that:
- a sexual history is an important part of an overall health assessment
- a high HIV rate in a country can be taken as an indicator of likely high rates of other STIs as well - all sexually active people who are from countries with an HIV rate of >1% should be offered a full sexual health screen
- sexually active people who are from countries with an HIV rate of ≤1% should be offered sexual health screening as appropriate for their sexual history
- people from countries where HTLV-1/-2 is endemic should be considered for HTLV testing
- all sexually active people under the age of 25 should be screened for chlamydia on an annual basis and/or whenever they change sexual partners, irrespective of country of origin
- symptomatic patients should be promptly investigated, treated and managed
Find your local GUM clinics by postcode.
Guidelines on testing and management of a range of sexually transmitted infections, and other sexual health issues, are available from BASHH.
Prevention and control
Prevention and control of STIs rely on:
- safer sexual practices
- prompt diagnosis and treatment of disease
- partner notification
Sexual health promotion is important to address with all sexually active people and primary care practitioners have an important role to play in conveying appropriate sexual health messages to different at risk groups.
Investigate and treat symptomatic patients promptly. Partner notification is a routine part of GUM clinic practice to limit further spread of disease.
For further information on STIs, see Sexually transmitted infections (STIs): surveillance, data, screening and management, which includes statistics on new diagnosis of STIs in England by world region of birth.
The National Chlamydia Screening Programme has produced a patient information leaflet titled: ‘You may not know you have it’, which is available in Arabic, Bengali, Chinese Mandarin, Lithuanian, Nepalese, Polish, Somali, Spanish, and Urdu.
NaTHNaC has produced advice on:sexually transmitted infections and travel.
The Family Planning Association’s Sexual health, asylum seekers and refugees leaflet is a handbook for people working with refugees and asylum seekers in England.
The Zanzu website provides simple information on contraception, sexually transmitted infections, pregnancy, relationships and sexuality in Albanian, Arabic, Bulgarian, Dutch, English, French, German, Polish, Romanian, Russian, Spanish, Turkish.
Country-level data on contraception use is available from the World Health Organization.