STIs: New Threats or Old Foes?

Peter Russell

Disclosures

September 18, 2018

"STI that causes flesh-eating ulcers found in UK for first time," declared a headline in the press last month. The article referred to a necrotic type of donovanosis (granuloma inguinale) that could 'erupt' onto the genitals, it was reported.

Other articles have described 'the STI you have probably never heard of', called MGen, caused by a bacterium called Mycoplasma genitalium.

Are these really new? How rare are they?  Do they pose a threat to our sexual health? And how do they fit in to the pattern of increasing demand for sexual health services in the UK?

Also, are our sexual health services keeping up with demand?

   

Dr Mark Lawton

We seek the expert opinion of Dr Mark Lawton, media chair of the British Association for Sexual Health and HIV (BASHH) and sexual health & HIV consultant in Liverpool.

Q&A

Medscape UK: Should we be concerned that donovanosis has been recorded in the UK?

Dr Lawton: The recent report of a first UK case of donovanosis was both not the first new case of donovanosis but also not a case of donovanosis at all. It was a coding error.

But there is a number of cases reported each year. It's a tropical STI so we don't usually see it in the UK, but obviously we do see people who've travelled from the tropics. So, it's something we have in the back of our mind, but probably would get overlooked in some places because it's not common.

If you think about the 100,000 cases that we see of things like chlamydia, the numbers of cases that we see reported are in single figures for things like donovanosis.

Medscape UK: What are the symptoms of donovanosis, and how is it diagnosed?

Dr Lawton: It causes ulceration in the genital area, and there are characteristic features of that ulcer.

But what the text book says it should look like and what it looks like in real life are often quite different.

It's diagnosed either with some special stain on microscopy, or some more complex molecular techniques, looking for the organism that causes donovanosis.

It's an infection that we would probably need a specialist laboratory to test for to make a firm diagnosis.

Medscape UK: How easily treatable is it?

Once diagnosed – and that's probably the main problem – it would be through antibiotics, and I would expect it to respond to antibiotics.

So, I think the headlines we saw about the 'flesh-eating bacteria' are perhaps a little bit dramatic. While it might cause ulcers that look scary if they're on your genitals, it should respond to antibiotics and resolve – but it can take a little while, so 3 weeks might be required in terms of treatment.

Medscape UK: We've heard recently about another STI, Mycoplasma genitalium (Mgen). Would it be fair to say this is quite rare but becoming more common in the UK?

Dr Lawton: I wouldn't say it's that rare. It's probably [seen in] about 1% of the population between the ages of 16 and 44. That's not dissimilar to gonorrhoea. But the main challenge with MGen is that we don't have routine testing available, so it's not something that people would get routinely tested for like they might do for chlamydia and gonorrhoea.

The people who present with symptoms – and that might be pain when you pee, or discharge from the penis, for example – would often be treated with antibiotics that would cover mycoplasma, without necessarily diagnosing it.

So, the standard treatment regimens would be first line antibiotics that cover chlamydia, for example, or, if not getting better, then second line treatments that would then cover things like mycoplasma.

It's only very recently that a commercial test has become available to clinicians to test for it. And, at the moment, not many hospitals have that machine, or assay, in them. So, we have to treat based on clinical suspicion perhaps rather than necessarily actual diagnosis.

Medscape UK: MGen has been referred to in news reports as a potentially dangerous 'superbug'. Is that overstating the situation, even if antibiotic resistance is to become a major factor?

Dr Lawton: I think the issue is 'what is a superbug?' It can cause harm, so it has been associated with pelvic inflammatory disease, which could lead to fertility problems in women, so it does have a potential for harm.

With regard to antibiotic resistance, the treatment that's been first line for chlamydia for a number of years is not sufficient to treat mycoplasma, in most cases, but will drive resistance to antibiotics in mycoplasma.

One of the things that BASHH is suggesting is a change in the routine treatment for chlamydia to an antibiotic that won't cover mycoplasma but also won't drive resistance in it.

What worries us is that 'out there' are a lot of people who potentially have mycoplasma, who've already got resistant mycoplasma, because of the antibiotics they've perhaps had in the past to treat chlamydia.

So, I think the danger is that because we've not been able to routinely test for it, and that this antibiotic that we've used to treat chlamydia, which is azithromycin, has been used in a group of people that probably have got mycoplasma, we've actually been driving this problem of antibiotic resistance.

Medscape UK: We've focused on two STIs. STIs in general are becoming more prevalent. What is behind this increase, and which ones are particular threats, or more common?

Dr Lawton: We've seen significant increases in gonorrhoea and syphilis. Public Health England's latest data shows a 22% increase in gonorrhoea and a 20% increase in syphilis over 12 months. They're up to levels that we haven't seen since World War II, just to put it into context.

Gonorrhoea is also displaying quite a lot of antibiotic resistance. We've had the first case of gonorrhoea that was not treatable by standard antibiotics earlier this year, and that was reported on quite heavily.

So, why? Well, I think there are a couple of things. One, people are probably having more sex with more people and not using condoms for that sex, and this is likely to have been facilitated to an extent by the popularity of dating apps/websites.

But also, just changes in attitudes towards sex in society. I think 'one night stands', casual sex, even not many years ago, was seen to have been perhaps a bad thing, or something that you were a bit embarrassed and shy about. And perhaps these days [it] is something that people are more proud of, and talk about quite openly.

So, those changes in attitudes are leading to more people wanting to, or engaging in, casual sexual encounters, but then fuelled by the ease of access and ease of availability that the dating apps provide.

Medscape UK: Is the budget for sexual health services keeping pace with this extra demand?

Dr Lawton: I think 'struggling' would be a word to use.

The Government has cut funding for public health, of which sexual health is part, significantly over the last few years. That funding cut has been, in many areas, passed on to the sexual health clinics, which is having an impact on access to people getting tested.

Let's take gonorrhoea. Gonorrhoea, in a lot of people, will cause symptoms, and those symptoms may come on a week after your sexual encounter. Well, if you can't get into your clinic and get treatment, but you still end up having sex with people, you're going to be passing that infection on.

So, yes, we could change society's attitudes towards sex – I'm not sure that's going to happen, I think that's just where we're at now; we could make condoms available, which we do, and encourage people to use them, as we do – but that doesn't seem to have made a huge difference.

I think the main thing we can do is encourage people to get tested regularly, and make it easy for them to get tested, so we identify these infections before they get passed on to people. And obviously access to specialist sexual health services, so that people feel comfortable going and getting tested, is going to be a key part of that.

So, at a time when we're seeing increases in these STIs, it really is the worst time to be cutting funding.

Public health is all about prevention. So, you cut money from public health, and it doesn't take much of a leap to realise that's going to have an impact on the health of people in years to come.

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