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We Need To Take A Public Health Approach To STI Prevention

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A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it.

The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed "apps": "We believe this is due to use of social media to set up sexual encounters," she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters. While I agree with her follow-up statement -- that anonymous encounters make it difficult to contact people for testing and treatment -- I cannot join her in blaming a social media platform for a complex social issue.

Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication.

After discussing the increase on CBC's "The Current" , I decided to expand my thoughts.

Unprotected sexual activity

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what's going to happen -- and how -- whether you meet in a bar; or whether you meet online through a dating site or app.

Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking. Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication. Consent -- ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated. Should.

And yet, communication and negotiation are not always straightforward. The result is risky behaviour.

The social determinants of health influence risk-taking. Poverty, for example, is associated with increased risk-taking. In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods. Internalized homophobia, current or previous abuse may also prevent a person's ability to be assertive about safer sex because of low self-worth.

Of course, comprehensive sexual health education and the availability of sexual health clinics also play a crucial role. Awareness and testing go hand in hand.

One, two, three testing

Why get tested? Here are the basics.

Most STIs show no symptoms. To be blunt, if you have had unprotected sexual activity, you need to be tested. But you will not necessarily get an HIV test, for example, unless you specifically ask for it. That means you have to actually disclose your unsafe sexual practices. Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body. The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests. But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs. Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; but clinics generally do a urine test.

There is no test for HPV or a screening test for herpes. You have to show your bump or sore to a doctor. You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex. One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection. If someone has a history of cold sores, for example (caused by herpes simplex virus - 1), they should tell their partner before offering unprotected oral sex. (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with "Plenty of syph" received a lot of attention, much of it negative. The site has since been revised. But it still refers, as do most educational materials, to "sex" rather than higher and lower risk sexual activities. Moreover, the assumption is that "sex" means penis in vagina intercourse. Skin-to-skin contact in the "boxer short area" is enough to spread HPV and HSV -1 and -2.

There is no point encouraging unrealistic, unattainable goals.

Since we're not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic. Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:
- no unprotected sex
- abstinence
- mutual monogamy
- condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals. In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers. So when I used to talk with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured. This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion touched on seniors and safer sex. The statistics for seniors are becoming alarming. Statistics show increases in incidents of syphilis, chlamydia and gonorrhoea in adults 45-64. Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is "staggeringly low".

Older people may be even less able to communicate about STIs than teenagers or young adults. Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs. They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship. They may also be learning the dating game the "hard" way. A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vagina may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV. Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria. Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

True prevention

Rather than app bashing or unrealistic expectations, let's just apply good old public health policy.

Here is my short wish list to prevent STIs:
• ensure comprehensive sexual health education across the country
• eliminate poverty, sexism, sexual abuse, homophobia and transphobia
• adopt harm reduction as a national strategy
• establish sexual health clinics from sea to sea to sea

That's not a lot to ask, is it?

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