Sexual health- view from the frontline
22 Feb 2019
You spent time teaching in India, Kenya, South Africa and Nepal- what did you learn while in those countries?
Wow, a big question. The main things I learned are that some people will walk days for good healthcare; that doctors are human beings and people would sometimes rather be based with their families in Nairobi or Kathmandu rather than rural locations, even if that's where the need is.
Also that nurses are better at assessing what's going on in a clinic rather than doctors who are treated to top level VIP floss and flannel. Some countries have paternalistic healthcare systems that work. I saw African clinics that process 300 patients for bloods and antiretrovirals from 7am-1pm, daily. Difficult to teach much, when we in London may struggle to see 300 in a week.
Should we be worried about Mycoplasma genitalium and what do we know about it?
Mycoplasma genitalium. I don't think we should be 'worried' as such, but do think we need to appreciate we don't test for it much, and ensure we use antibiotics judiciously to ensure we don't drive M Gen resistance. This includes in treating 'non-specific' urethritis. More rapid (and point of care) diagnostics can help here. We know it affects 2-3% young people and 7% young people attending sexual health clinics. Associated disease is usually mild, but it can increase HIV transmission.
‘Super-gonorrhoea’- what would the world look like if it did become untreatable?
Resistant gonorrhoea is a worry. So far it's been contained, but widespread resistance would be problematic, especially as we've just had a restriction on access to spectinomycin (the remaining antibiotic that works) due to production issues. People have got very accustomed to this infection being easily treated. Managing super resistant gonorrhoea could be very difficult indeed. In the UK this is where we are lucky to have a network of STI clinics and a well-established gonococcal resistance surveillance system.
What do you see in your clinic as the common issue for people returning from overseas?
The most common issue for people returning from overseas is having had sex under the influence of drugs and alcohol, rather than a specific infection. This does sometimes lead to infections, but also often leads to regret and remorse, and may also mean people have missed the window period for preventative interventions like HIV post exposure prophylaxis (PEP).
Do you agree that the HPV vaccine should be offered to young boys?
HPV vaccines should be offered to all young people regardless of gender or sexual orientation to prevent anogenital and head and neck cancers (on the rise), as well as the development of genital warts, which cause a huge amount of morbidity and inconvenience.
You recently hosted a Q+A on sexual health online- do you think there's a future in this kind of approach?
Whilst social media can be helpful for certain things, I think nothing beats face to face interactions for really understanding peoples worries and concerns about their sexual activity and the risk of infections. Since the arrival of HIV we’ve seen more open and public discourse around sexual health which I think should be maintained and not forgotten.
Your work has been focussed on HIV related neurocognitive disorders- what are the latest findings in this area?
HIV related neurocognitive impairment is a tricky one. We are now seeing cohorts of people diagnosed and started on HIV medicines much earlier, with less exposure to the virus, so I think the signal that HIV may be involved in neurocognitive abnormalities is starting to dwindle somewhat. Nonetheless, I do think these problems affect a small minority of patients living with HIV, perhaps with a genetic predisposition to different blood brain barrier viral transit and higher levels of CSF or CNS inflammation.
What are the biggest challenges to sexual health in the UK?
The biggest challenge in the UK is the fragmentation of services following the Health and Social Care Act. Sexual health services are now commissioned by Local Authorities whose budgets are not ring fenced. This sleight of hand means that services the public perceives to be ‘NHS” delivered can now be put out to tender, risking the public health advances that have been made by our specialty in recent years if cost becomes more important than quality and good public health.
Is there a particular kind of infection that fascinates you more than others? Like, do you have a 'favourite'?
The most intriguing infection is one of my least favourite. Herpes simplex, and the herpes family of viruses, cause a huge amount of disease, including affecting people’s mental health. Steps in vaccine development to prevent these infections would have a tremendous effect in improving people’s sex lives and worries about passing on infection.
Although it may seem relatively inconsequential, it really does cause tremendous problems for individuals patients as well as in counselling time, and have profound effects on some people’s ability to form intimate relationships, sometimes over a lifetime, sadly.
In your experience, do you think that young people are as knowledgeable about sexual health as they should be?
Young people know some things more than they used to, and some things far less. In general they know far less about HIV, often thinking it affects only older gay men. With social media in particular, young people can struggle to find or maintain privacy, meaning their sexual activities are often made public, shared, and commented on.
There is more gender and sexual fluidity, but there can be issues arising around consent also which can muddy the waters for young people trying to define themselves and what gives them and their partners most pleasure.
The SfAM Early Career Scientist (ECS) Research Symposium is on 13 Mar 2019 and will have special focus on sexual health.