The burden, risk factors, and preventive practices of sexually transmissible infections among travellers in Australia

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Introduction: The relationship between travel and the acquisition of sexually transmissible infections (STIs) has been well documented. Australia’s Fourth National STIs Strategic Plan identified travellers as a priority population due to increased international mobility to and from high-prevalence settings. To curb the transmission and acquisition of STIs, targeted measures are required to achieve meaningful prevention outcomes. However, there is little evidence on the burden of travel-related STIs and associated changes in sexual behaviours among travellers to support development of targeted interventions. Therefore, the aim of my thesis was to determine the burden of STIs and the sexual behaviours of Australian travellers across the continuum of travel to generate evidence for targeted intervention. The specific objectives were: 1) to estimate the post-travel burden of STIs and/or blood-borne viruses (BBVs) among travellers; 2) to assess travellers’ risk perceptions and attitudes about STIs, and their use of preventive practices during travel; and 3) to explore awareness and barriers to the uptake of sexual health advice during pre-travel consultations. Methods: To assess post-travel burden (Objective 1), a systematic review and meta-analysis, and a cross-sectional study using data from the Australian National Notifiable Disease Surveillance System (NNDSS) were conducted. Attitudes and activities during travel (Objective 2) were examined through a cross-sectional survey among Australian travellers attending the Travel Medicine Alliance network and a sexual health clinic. Pre-travel uptake of sexual health advice (Objective 3) was investigated through a qualitative study among newly arrived international students. Results: The post-travel prevalence of STIs and/or BBVs varied by traveller type. The highest post-travel prevalence was observed for syphilis (1.7%) among visiting friends or relatives (VFRs), chlamydia (6.6%) among backpackers, and human immunodeficiency virus (HIV) (2.5%) and gonorrhoea (4.17%) among men who have sex with men (MSM) travellers. Lack of pre-travel consultations (OR: 1.50; 95%CI: 1.20-1.87), absence of hepatitis B virus (HBV) vaccination (OR: 2.23; 95% CI:1.61-3.41), and short travel duration (OR: 1.25; 95% CI:1.01-1.56) were identified as factors associated with STIs/BBVs among travellers. Findings from a cross-sectional study using the NNDSS dataset revealed that 11,782 cases of overseas‑acquired STIs were reported in Australia from 2017 to 2023. Among these cases, 63% occurred among men and 24.6% among young adults aged 20-24 years. The burden of overseas-acquired STIs sharply declined during the COVID-19 pandemic in 2020. Nearly half (45%) of overseas-acquired STIs occurred in Southeast Asia. Findings from a cross-sectional survey of Australian travellers attending Travel Medicine Alliance network and a sexual health clinic identified that nearly a quarter of travellers (23%) intended to engage in casual sex with a new partner during-travel. Of these, over 72% had a low perception of the risk of acquiring STIs. Most respondents reported intending to engage in sexual behaviours that increase their risk of STIs, such as having sex without a condom (28%), using illicit drugs (7%) or alcohol (48%), and having sex with sex workers (24%). Findings from the qualitative study among international students indicated that most had no awareness of pre-travel sexual health advice and services. Barriers to the uptake of these services were lack of awareness/knowledge, socio-cultural barriers, psychological barriers, and challenges in navigating the Australian healthcare system. These barriers were present during both pre-departure from their home countries and post-arrival in Australia. The students suggested strategies to enhance sexual health advice and services, such as orientation sessions, incorporating the sexual health education into the school curriculum in their home countries, integration with other services (e.g., mental health or general check-ups), and mandatory sexual health courses post-arrival in Australia. Conclusions: These findings highlighted that the travel-related burden of STIs among travellers varied by gender, age, type of traveller, and travel itinerary (e.g., region of destination). These variations were largely attributed to changes in sexual behaviour during-travel and a low perception of the risk of STI acquisition. Therefore, sexual health strategies should be tailored across the travel continuum–these include providing pre-travel sexual health advice, safe sex practices and the use of prophylaxis for those at risk; giving travellers risk-awareness information during-travel; and ensuring that individuals who were sexually active overseas receive post-travel STI screening. These interventions should be delivered based on personal risk profiles, travel itineraries, and other contextual factors. Furthermore, policymakers and clinicians should support the integration of sexual health services into travel medicine to enhance prevention and mitigate the acquisition of travel-associated STIs.

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