What are the most common sexually transmitted infections (STIs) in Malta?

We see a bit of everything, with all infections becoming more and more common. We are no different to other countries in this respect. Chlamydia, gonorrhea, HIV and warts are frequently diagnosed. Syphilis has also increased tremendously these last few years. In general, all sexually transmitted infections (STIs) are on the rise.

 

Why are STIs on the rise?

These infections do not appear out of nowhere, they come from an infected person. People who have multiple partners or different partners and do not use protection, in particular condoms, are at much greater risk. The consistent use of condoms, in my experience, remains very low, especially among Maltese patients.

The use of condoms does not entirely eliminate the risk of contracting STIs. It is equally important to limit the number of partners.

 

What is HPV?

HPV is short for human papillomavirus, but the name itself is misleading since it implies a single virus. In fact, HPV is actually a group of over 150 different subtypes, with each HPV sub-type given a different number.

Out of these 150-plus types, some 30 per cent are sexually acquired, infecting the anogenital area as well as the mouth, head and neck.

HPV is extremely common, with up to 80 per cent of those who are sexually active encountering one of these viruses at some stage in their lives. However, most people who have these viruses are blissfully unaware, since only two types, (mainly) types 6 and 11, actually cause visible warts. Warts are a nuisance and can be distressing as they can recur but they can be treated.

A minority of the HPV sub-types are considered to be high risk for cancer of the cervix, penis, anus, head and neck. However, it does not mean that if someone has these high-risk viruses they will necessarily get cancer. The progression from infection to cancer is very slow.

 

How does HPV cause cancer?

The virus enters the skin and stays there and in most cases does nothing at all. The ones which are considered to be high risk for cancer have a different structure and can change the cell into a cancerous one. It is a very slow, prolonged process in most cases.

Because HPV is so widespread, all women should have regular smear tests. This allows early changes to be treated in time and thus avoid late complications.

The smear test will tell you if the HPV is present and whether it is affecting the cells.

Almost invariably, cervical cancer is caused by HPV. As already mentioned, it is also associated with other cancers in the genital areas like the vagina, vulva, penis and anus. It can also cause some types of cancer of the mouth and throat.

 

What if HPV is detected in the smear test?

Since the process is so slow, if regular smear tests are done, there is a lot of time to treat it. This is why it is important for women to be up to date with their smear test.

Doing a smear test once every year is more than enough in most instances.

Is HPV tested during a sexual health checkup?

No, it is not routine to test for HPV during a sexual health checkup.

It is also not routine in a smear test; however, if abnormal cells are found during a smear test, then one would carry out an HPV DNA test. That would guide the practitioner as to how seriously to take the changes. Having abnormal cells does not necessarily mean you have cancer or the beginnings of it. We need to keep in mind that most changes disappear spontaneously, especially in the young.

A routine HPV DNA test will probably become the norm in the future as a means to triage women, meaning those found to be positive for a high-risk type will be screened more frequently than those found to be negative.

 

Can HPV be prevented?

Vaccines for certain types of HPV are available and all boys and girls should take it before they are sexually active.

The vaccines were originally just for girls but have now been extended to boys as well. It should ideally be given before they are sexually active with a catch-up period till the age of 18. After that, because HPV is so common, it is thought not to be worth taking the vaccine as chances are the virus has already been encountered.

In gay men, however, the vaccine is even given up to the age of 45, as they have higher chances of contracting HPV.

In Malta, the bivalent vaccine is given as part of the National Immunisation Schedule and protects against types 6 and 18. These types are responsible for 70 per cent of cancers. However, the quadrivalent vaccine is also available, protecting against types 6 and 18 as well as types 6 and 11, which are the types that cause most warts.

The ideal vaccine that young people should receive is the quadrivalent one. In Australia, genital warts have practically disappeared with the early use of the quadrivalent HPV vaccine.

There is also another vaccine available that protects against the four types mentioned as well as an additional five. This will protect against some 90% of cancer as well as warts.

 

Why do gay men have higher chances of contracting HPV?

Gay men have a higher risk of getting cancer of the anus because anal sex in itself is riskier. This is due to the fact that the lining of the anus is much more delicate than, for example, that of the vagina, with more possible bruising and bleeding. This makes the entry of bacteria and viruses much easier.

However, it is anal sex which is the problem, not the sexual orientation. Many gay men do not have anal sex, whereas heterosexuals increasingly do. So if one leads a high-risk lifestyle (different partners, no condoms, recreational drug use), then the risk of contracting an STI is that much higher. But again, this is not dependent on sexual orientation.

At the moment, there is cervical testing for HPV but there is no test widely used as an anal smear test. These tests are only available in research settings. The only way to know if HPV is present is if warts are visible. There is as yet no licensed, reliable HPV DNA test for men.

 

Are you checked for STIs during a smear test?

There is the misconception that a smear test tells you all there is to know about a woman’s health. A smear test does not check for STIs, but is there for one thing: to check for changes which could be cancerous or pre-cancerous. Sometimes it can highlight some minor infection like candida, but this is not considered an STI.

A smear test is not a substitute for a proper sexual health checkup.

 

Are women more susceptible to STIs?

There are some infections were the transmission of an STI is more efficient in women. Gonorrhea is one such example. Women’s anatomy makes the transmission of the infection easier.

 

Does circumcision provide protection against STIs?

Yes. The foreskin is full of glands which are thought to be targeted by bacteria and viruses including HIV. If the penis is circumcised, there is a reduced risk of STIs.

Circumcision as a means of prevention of STIs, especially HIV, is used in some countries in Africa, where the prevalence is high. I don’t think that in Malta we have the numbers to justify circumcision as a preventive measure.

 

When should one be tested for STIs?

It is important to note that the vast majority of STIs are asymptomatic. Chlamydia, for example, is asymptomatic in 80 per cent of women and 60 per cent of men. The absence of signs and symptoms does not mean one does not have an STI.

Of course, people with symptoms need to be tested, but even asymptomatic people should be tested. Anybody who has had unprotected sex with somebody they do not really know or do not trust should get checked out.

Unlike a smear test, which is a regular checkup, the frequency of a sexual health checkup depends on the lifestyle of the individual. It is always a good idea to get a checkup at the start of any relationship so, hopefully, both can start off the relationship with a clean bill of health with no further immediate worries.

So, of course, the more partners one has, and the fewer condoms one uses, the more frequent the sexual health checkup should be.

 

What should one look out for?

In males, the common symptoms include discharge from the penis and/or burning in passing urine. Pain in the testicles is also a sign to look out for.

In women, keeping in mind that most are asymptomatic, if there is any change in discharge, bleeding after sex or abnormal bleeding in between periods or pain during sex, one should get checked out, not by getting just a smear test but by having a sexual health checkup.

Common to both males and females, one should look out for any sores, ulcers or rashes which could be sexually acquired.

 

What is the process of getting tested?

First of all, it is important to emphasise that everything is confidential. The doctor will take a detailed sexual history, which is important to see which tests need to be done. Although there are some tests which are considered basic, no one set of tests is suitable for everyone; they should be tailored to the patient’s history, individual needs and sexuality. Some will need more than others.

The patient’s genital area is examined and anywhere else that is relevant. A woman would need vaginal swabs taken — a urine test is not enough in a woman, unlike in a male where it is sufficient. A urine test in females would miss out on a significant number of infections.

Blood tests will also be carried out, with the number depending on the individual’s history.

 

What happens if STIs go undetected?

If untreated, in women these infections can cause chronic pelvic pain, abnormal periods, bleeding, and infertility. In males, it can also cause infertility as well as swelling and pain in the testicles.

STIs are also associated with arthritis. The presence of one STI will make one more susceptible to the acquisition of other STIs, including HIV.

 

How are STIs generally treated?

Most STIs can be treated with antibiotics. However, because of the gross abuse of antibiotics over years, bacteria have found ways to change and become resistant to antibiotics.

This is a huge problem with gonorrhea worldwide. In some countries, it has become resistant to all antibiotics. We are now facing a similar problem with a ‘new’ STI called mycoplasma.

 

Can STIs be passed on to newborns?

Yes, all STIs can be passed on to newborns. A sexual health checkup is very important for a pregnant woman, especially if there are any symptoms.

STIs can cause problems while the baby is still in the uterus. For example, if a pregnant woman has early syphilis, it can lead to a miscarriage or the baby being born with severe malformations. Most others can be transmitted during labour.

Syphilis, HIV and hepatitis are routinely checked for in ante-natal visits.