The provision of sexual and reproductive health information and services to travellers: an exploratory survey of Australian travel medicine clinicians

Background

International travel has vastly increased the opportunity for individuals to develop new professional, social, and sexual networks.¹ However, overseas travel can also increase risk of exposure to infectious diseases.² Pre-travel consultation provides an opportunity for travel-related health risk assessments, advice and/or vaccinations,^3,4 typically administered by general practitioners or specialist travel clinics. An awareness of potential health risks (e.g. sexually transmitted infections, STI) may increase the likelihood travellers will engage in preventative behaviours.⁵ However, it is estimated that only a third of travellers seek pre-travel healthcare advice.⁶

International travel can contribute to short-term changes in sexual practices and has been associated with the global spread of STIs and blood-borne viruses (BBV).^1,7–9 STI risk among travellers engaging in casual sex can be three times higher compared to casual sex within their home country, with purpose and destination of travel influencing risk behaviours and risk of acquisition (e.g. if planning to engage in casual sex and/or travelling to a high STI/HIV prevalence setting).^10–15 Additionally, self-reported rates of condom use among long- and short-term travellers engaging in casual sex is low,^10,16–18 increasing the risk of onward STI/BBV transmission and presenting significant public health challenges within origin and destination countries.

Despite limited information regarding the efficacy of pre-travel sexual health interventions, the inclusion of sexual health in pre-travel consultations can be effective in mitigating sexual risk behaviours and risk of STI/BBV acquisition.^13,14 Under current Australian prescribing guidelines, for people intending to have sex while travelling, pre-exposure prophylaxis (PrEP) for HIV can be appropriately prescribed by a clinician as either daily or on-demand dosing to align with their travel schedule.¹⁹ This capacity optimises the role of practitioners acting as a ‘front-line’ in delivering sexual and reproductive health (SRH) to travellers and should be considered an important component of any holistic travel healthcare.

Previous studies have found that STI/BBV counselling and condom information were included in less than half of pre-travel consults.^14,20–22 Nonetheless, data on the extent to which health practitioners are providing clients with sufficient information about SRH, STI/BBV and protective behaviours is limited, as is evidence on strategies to increase clinicians’ capacity to provide pre-travel advice and health promotion related to SRH. Increasing the capacity and capability to deliver these critical health promotion services therefore requires a timely assessment of current clinical practice. This work aims to understand four key gaps in understanding: (1) how clinicians determine SRH risk; (2) their approaches to STI testing; (3) what content they include in SRH consultations; and (4) what areas of interest are important for future training.

Materials and methods

Results

A total of 78 responses were collected, of which 67 were eligible for inclusion based on occupation relevant to travel medicine and practice in Australia. Twenty-three eligible respondents were recruited via email (from a total of 71 members of the Travel Medicine Alliance), while the remaining 44 eligible surveys (from a total population of 75 attendees to a Travel Medicine conference in Brisbane, Queensland) were completed as hard copies.

Most respondents were aged between 40 and 69 years (n, 56; 83.6%), identified as female (n, 41; 61.2%), were doctors (n, 50; 74.6%), or reported working in general practice (n, 41; 61.2%). Most (n, 51; 76.1%) had a postgraduate qualification relevant to travel medicine and more than half were members of the International Society of Travel Medicine (ISTM) (n, 39; 58.2%) and had worked in travel medicine for over 10 years (n, 37; 55.2%). Participant demographics are in Table 1.

Discussion

Australia has recognised the impact of travel on STI/BBV risk and transmission by including ‘travellers’ as a priority population in current national STI and HIV strategies.^25,26 However, current practice within travel medicine clinics do not appear to be reflecting the recommendation provided in these national strategies. Our findings indicated the inclusion of SRH interventions mainly occurred when patients raised the issue themselves or self-disclosed their behavioural risk. Similarly, a systematic review by Crawford et al. demonstrated that less than half of participants do not receive SRH information in travel consultations.¹⁴ Given the significant benefits of including STI/BBV information in travel medicine consultations, it is important that future research explores barriers to its integration. Such barriers can include clinician discomfort, reduced confidence, and lack of training in discussing sexual health with clients, and/or fear of embarrassing and or inadvertently stigmatising clients.^27,28 There are also barriers to patients requesting this information which can be exacerbated by stigma, embarrassment, cultural attitudes/norms and risk perceptions among people from higher endemic countries.²⁹ Future research is needed to explore the barriers that travel medicine clinicians face when providing sexual health advice to travelling clients. Such understanding can be used to inform the development of strategies that equip clinicians with the capability, resources, and confidence to engage in sexual health related conversations with clients.²⁷

When SRH is integrated into consultations, many clinicians reported opening dialogue around safer sex practices and testing, but only one in four reported directing patients to resources to learn more. The provision of pre-travel STI/BBV information through physical or online platforms (e.g. brochures, websites) can be useful in the promotion of safe sexual practices, such as consistent condom use among travellers,^11,30 and inclusion of additional resources for travellers could aid in reducing STI/BBV risk. Given only 16.4% of respondents reported providing condoms and/or lubricant at their clinic, practical tools and strategies, such as provision of condoms during travel consults may increase the use of condoms during travel. Croughs and colleagues, for example, found condom provision could increase use by up to five-times while travelling.³¹ However, cost implications for travel clinics could act as a barrier to providing condoms and lubricants.

Advice and provision of PrEP and PEP can provide important opportunities for HIV prevention among travellers. However, our study indicated that only a third of clinicians included PrEP and PEP in their travel consultations. As male-to-male sexual contact is the predominant route of transmission of HIV in Australia,³² men expressing such intentions prompted further discussion among some clinicians; however, it was still only discussed by approximately half of our sample. Despite men whom have sex with men (MSM) being the predominant group at risk in Australia, surveillance data indicates that among heterosexually acquired HIV in Australian-born persons, a higher proportion (38%) was likely to be acquired overseas compared to the proportion among Australian-born MSM (3%).^32,33 A similar trend has been seen in the United Kingdom where higher proportions of notification among heterosexually transmitted HIV infections were acquired overseas.³⁴

These findings indicate a need to engage heterosexual travellers in pre-travel conversations about HIV prevention. Additionally, there is a need to develop HIV prevention resources targeted towards heterosexual people, that can be used to help patients and clinicians initiate conversations about SRH. Providing pre-travel HIV education has been found to result in increased condom usage among travellers.³⁰ Thus, PrEP and PEP need to be appropriately included in consultations for travellers where potential risk is identified, (particularly those travelling to high prevalence settings), beyond those who disclose male-to-male-sexual intent. Travel medicine practitioners should be encouraged to initiate conversations with travellers rather than relying only on patient self-disclosure. Interest in further training in PrEP and PEP was highlighted as an area of interest among our sample of clinicians that could help guide proactive inclusion in pre-travel consultations. Previous research suggests that barriers to PrEP prescribing can result from difficulties integrating it with other services, discordance on who should prescribe it, health care provider knowledge, and consultation time constraints.^35–37 Therefore, future training opportunities may need to provide more than just knowledge surrounding specific conditions or medications, but how to effectively enmesh it with other services.

Additionally, participants expressed an interest in learning more about treating STIs, conducting a sexual history and providing advice and information on safe sex. Global research has indicated that many primary care and travel medicine physicians do not feel adequately trained to provide SRH or know where to find relevant information.^27,38,39 Therefore it is important to ensure health care providers engaged in providing travel medicine services are equipped to provide not only appropriate information and testing for STI prevention and detection but also appropriate treatment and management including antimicrobial stewardship. This is of particular importance due to the global threat of antimicrobial resistance associated with STIs such as gonorrhoea, syphilis and chlamydia^40–43 and the link between international travel and the global spread of drug-resistant STIs.⁴⁰ Additionally, travel medicine provides an opportunity for improving coverage of vaccinations for infections linked to sexual behaviour such as Hepatitis A and B, which are found to be suboptimal among travellers.^44,45 Therefore, while PrEP and PEP might be notable areas for up-skilling, there is a need to provide wider STI/BBV and SRH training. Consideration needs to be given on how to best achieve effective education and dissemination of sexual health information and the development of consistent, clear tools that allow for streamlined access to up-to-date clinical guidelines and important information about emerging changes in STI trends, such as the current ongoing increases in infectious syphilis occurring in Australia and other high income countries to help improve service delivery.^46–51

Strengths and limitations

While considerable efforts were undertaken to ensure the reach of our survey to members of a professional travel medicine network, including attendees at a national conference, the sample size obtained does limit the representativeness of the data. The length of the survey, contributing to ‘survey fatigue’, may have compounded the limited response rate. To assist with survey fatigue, we relied mostly on yes/no responses, which provided limited opportunity for participants to provide details (for example, on items such as purpose of travel) limiting contextual insight. The ‘typical’ composition of patients seen by the clinicians was not determined which may influence patterns and interpretation of findings and may not be representative of all travel medicine patient cohorts, nor was it possible to sample subgroup patterns/differences (e.g. international students, ethnicity, language/s spoken), which may represent a useful target for future research/investigation. The inclusion of a control group, that is a sample of general practitioners not involved in travel medicine, would have improved our capability to determine whether rates of SRH inclusion and practices compare to other professionals in primary care contexts and elucidate barriers unique to the travel medicine context. Nonetheless, our results do provide indicators of where service delivery could be strengthened.

Conclusion

Our findings have highlighted gaps in the provision of pre-travel consultation and training needs for SRH among travel medicine clinicians. There is a potential capacity in pre-travel consultation for the promotion of sexual health among travellers providing important public health benefits for individuals and the wider community. Travel medicine clinicians are ideally placed to provide proactive and opportunistic health promoting advice and services, yet these opportunities are only partially realised in the short-term. Training, particularly in the provision of PEP and PrEP, and greater distribution of condoms and printed information, may assist clinicians to take a more proactive approach to SRH consultations and STI/BBV testing. Further research is needed to explore models of care that will allow comprehensive SRH service to be integrated into standard pre- and post-travel care and address the current ad hoc delivery of services.

Supplementary material

Supplementary material is available online.