Bad Medicine : Sexual Health

The “clap clinic” has moved from a Portakabin behind the hospital bins to shiny new buildings. Today sexual health is jeans wearing, eyebrow pierced, cool medicine. This is to be celebrated, but care is still regrettably concentrated in secondary care and testing is restricted. But what is concerning about sexual health is its tyranny of terror messages: these are weapons of mass destruction of relationships.⇑

Consider HIV. In the 1980s we lived in constant fear of being crushed to death by colossal falling tombstones. HIV testing was allowed only after counselling and in distant specialist centres. This policy served only to reinforce the stigma of HIV. The legacy is that today many general practitioners are still reluctant to test for HIV. And this belies the truth that HIV is rare in low risk heterosexual populations, with only 50001 people with undiagnosed infection in the UK. So for a low risk couple unaware of their HIV status, the risk of contracting HIV from one act of unprotected intercourse is more than a million to one, assuming a prevalence of 1 in 1000 and risk of transmission of 1 in 1000.1 2 This is not no risk but very low risk, and couples need proportionate advice. Also HIV is treatable: treatment reduces transmission greatly,3 and there is near normal life expectancy. HIV is no death sentence.

Other sexually transmitted infections are common but asymptomatic. Presenting genital herpes as a serious, lifelong, incurable infection misrepresents the truth. In the United States it affects perhaps 30% of the population, and the prevalence is stable.4 5 And herpes is treatable, an inconvenience but no life sentence.

As for chlamydia the message is one of increasing prevalence and increasing risk of infertility. But the epidemiology is poorly understood. Chlamydia clears itself, and the rise in prevalence is an artefact of new testing. The lifetime prevalence is perhaps 30%.6 Chlamydia is treatable, complications rare,7 pelvic inflammatory disease is declining,8 and infection does not increase risk of infertility.9

As for human papillomavirus (HPV), the lifetime prevalence is “at least 50%” of the population10; those who actually develop warts are merely unfortunate. HPV is not a stigmatising infection but almost a normal consequence of sexual activity. Yet new diagnoses of these infections are devastating in relationships, bringing suspicion and needless anxiety.

We should promote safe sex but normalise positive results and reassure more. Increasing access to testing is key, and we should encourage routine home testing.11 The vast majority of infections can easily be managed in primary care. These changes have the potential to actually destigmatise sexual health and improve infection control. A medical culture based on fear is always bad medicine.


References
↵Health Protection Agency. HIV in the United Kingdom: 2011 report. Health Protection Services. November 2011. www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131685847.
↵Centers for Disease Control and Prevention. HIV transmission risk. 14 June 2012. www.cdc.gov/hiv/law/transmission.htm.
↵Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med2011;365:493-505. CrossRefMedlineWeb of Science
↵Centers for Disease Control and Prevention. CDC analysis of national herpes prevalence. April 2010. www.cdc.gov/std/herpes/herpes-NHANES-2010.htm.
↵Scoular A, Norrie J, Gillespie G, Mir N, Carman WF. Longitudinal study of genital infection by herpes simplex virus type 1 in western Scotland over 15 years. BMJ2002;324:1366-7.FREE Full Text
↵Spence D. Bad medicine: Chlamydia. BMJ2010;340:c2547.FREE Full Text
↵van Valkengoed IG, Morré SA, van den Brule AJ, Meijer CJ, Bouter LM, Boeke AJ. Overestimation of complication rates in evaluations of Chlamydia trachomatis screening programmes—implications for cost-effectiveness analyses. Int J Epidemiol2004;33:416-25.FREE Full Text
↵Ward H, Cassell J, Williams S, Aylin P. Hospital indicators of poor sexual health. BMJ2005;330:1173.FREE Full Text
↵Wallace LA, Scoular A, Hart G, Reid M, Wilson P, Goldberg DJ. What is the excess risk of infertility in women after genital Chlamydia infection? A systematic review of the evidence. Sex Transm Inf2008;84:171-5.FREE Full Text
↵Centers for Disease Control and Prevention. Genital HPV infection—fact sheet. March 2012. www.cdc.gov/hpv.
↵ClinicalTrials.gov. Home self-testing for HIV to increase HIV testing frequency in men who have sex (the iTest study). July 2012. http://clinicaltrials.gov/ct2/show/NCT01161446.