Intimate secrets

Although official figures do not paint an alarming picture of the prevalence of sexually transmitted diseases, it is believed that most cases remain unreported. Natalino Fenech caught up with Philip Carabot, who runs the GU clinic at Boffa Hospital, where 1,500 patients were seen last year.

The incidence of sexually transmitted diseases in Malta is not known as no proper studies have so far been carried out, Philip Carabot, the head of the genitourinary (GU) clinic at Boffa Hospital, said. Yet, all indications point to a growing problem.

Available statistics compiled by the Department of Health's disease surveillance unit show that 112 cases were reported by medical practitioners and by the GU clinic last year.

The clinic saw 1,500 patients in all, with an increased incidence of most infections being reported.

"Last year we had 43 cases of chlamydia, a bacterial infection. The numbers might seem small for our population but there was a significant increase over 2004, when 24 cases were detected," Dr Carabot said.

Cases of HIV are on the rise too, even though the number is still small. "The gut feeling is that we will experience an explosion sooner or later. This year we have seen more cases than last year, including three teenagers."

Dr Carabot said the clinic did not come across cases of syphilis when it was set up six years ago. "The incidence of syphilis has risen by 80 per cent since 2004; I saw 18 cases last year and six so far this year."

Syphilis is a very common infection in eastern Europe and its incidence has grown sharply since compulsory testing of prostitutes disappeared with the fall of the Iron Curtain, he said.

The mixing of cultures and the increasing tourism and contact with foreigners is a contributing factor to new diseases.

There is an increased risk of certain infections which have so far been non-existent in Malta but which are very common in Africa, such as chancroid. So Dr Carabot has started including exotic diseases found in Africa in his lectures to doctors.

"GPs have to be aware as they are the ones who are most likely to start seeing strange diseases," he said.

"Social norms have changed drastically. Youths are today more promiscuous and the condom unfortunately remains unused. We have a recipe for disaster. The prevention strategy has not been working and it has to be revised."

Dr Carabot said the statistics from the clinic were in no way representative of the whole country. "One can't extrapolate by using our statistics. There needs to be a national prevalence study to assess the real situation and decide on short and long term plans of action."

While the official statistics, with just over 100 cases of STDs reported, did not give the impression that there was a problem, it had to be kept in mind that although sexually transmitted diseases were declared as notifiable two years ago, the rate of reporting was still deemed to be low.

"Reporting depends on the goodwill of the practitioners," Dr Carabot said.

He suggests that blind tests should be made for STDs on blood submitted for other analysis at hospital. "In this way, one would not know whose blood it is but the results would give us a clear picture of the incidence of such diseases in Malta, and to keep tabs on the trend such tests can be repeated every two years," he said.

Dr Carabot strongly advocates more research. "The results would show us whether we are doing the right thing and whether we are spending enough.

"National prevalence studies of the major sexually transmitted infections should be urgently carried out. One cannot plan any sensible policies without this basic information."

Condom use still low

Tests conducted at the GU clinic show that the number of serious sexually transmitted diseases continues to rise, in particular syphilis and HIV.

"The HIV positives rose from three to seven cases. It is felt that this could be just a snapshot and the prevalence could be much higher."

Of particular concern is the misuse of antibiotics: some 17 per cent of the gonococcal cases were resistant not only to penicillin but also current first-line treatment.

"The old maxim, prevention is better than cure, still holds. The best way is to avoid disease by taking precautions. Some would stay people should abstain. But those who are not willing to abstain should at least take precautions," he said.

"Safer sex health promotion campaigns should be greatly intensified and sex education in schools has to be thoroughly reviewed.

"Young people aged between 13 and 25 years are a very vulnerable group and more prone to sexually transmitted infections and their complications for a variety of reasons both physiological as well as sociological," Dr Carabot said.

Of those who went to the GU clinic, 46 per cent admitted to casual sex while half claimed they had sex only with a regular partner. "But the latter figure needs careful interpretation since sexual relationships a few weeks old are considered stable and there is also a frequent turnover of partners, so the actual rate of casual sex is no doubt higher than appears at first sight," Dr Carabot explained.

"There has been very little appreciable change over the years. Consistent condom use remains low. If anything the situation seems worse with only 11.5 per cent of those visiting the clinic using condoms consistently in 2005, compared to 14 per cent in 2004 and 65.5 per cent never using one, compared with 63 per cent in 2004," Dr Carabot said."I do not want to enter into moral arguments. But from what I see, I would suggest that if people can't be good, they should at least be careful."

Although 23 per cent of the young females used contraception, the vast majority of these (89 per cent) used the pill, which does nothing to prevent sexually transmitted disease.

Dr Carabot said 28 per cent of those who went to the GU clinic said they practised anal sex, which is a known high-risk act. The rate of such sex within the teenage group stood at 30 per cent.

An interesting aspect that emerged from those attending the GU clinic was that some 13 per cent of the bisexuals were married. When they had extra-marital sex, they always seemed to do so with another male.

Chlamydia

Chlamydia is a common sexually transmitted disease caused by bacteria which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur before a woman ever recognises a problem.

Chlamydia also can infect men.

It can be transmitted through sexual contact between men and women as well as in same-sex contact. It can also be passed from an infected mother to her baby during natural childbirth.

Any sexually active person can be infected with chlamydia and the greater the number of sex partners, the greater the risk of infection. Teenage girls and young women are at particularly high risk for infection if sexually active because the cervix is not fully matured.

Chlamydia is known as a silent disease because some three quarters of infected women and about half of infected men have no symptoms. If symptoms do occur, they usually appear within one to three weeks after exposure. When the infection spreads up to the fallopian tubes, the tubes that carry eggs from the ovaries to the uterus, some women still have no signs or symptoms.

Chlamydial infection increases HIV infectiousness and susceptibility.

Gonorrhoea

Gonorrhoea is a venereal disease caused by bacteria. The disease most frequently affects 15- to 25-year-olds and is mainly transmitted through sexual contact. However, mothers infected with gonorrhoea can also transfer the disease to their children during delivery. If untreated, such children may develop a serious inflammation of the eyes, which can result in blindness.

One can protect oneself from gonorrhoea by using a condom.

There were 23 cases of gonorrhoea diagnosed at the GU clinic last year; 20 in males and three in females. Although the number is small there has been an increase of 28 per cent over 2004.

The number almost certainly does not reflect the national prevalence. Many, if not most, patients with acute symptoms, both male and female, are treated by other practitioners with broad-spectrum antibiotics and without investigations. Many patients attend the clinic having already had different antibiotics often prescribed but also bought over the counter.

Syphilis

Syphilis is a sexually transmitted disease (STD) caused by bacteria. It has often been called "the great imitator" because so many of the signs and symptoms are indistinguishable from those of other diseases.

Syphilis is passed from person to person through direct contact. Like most other STDs, pregnant women with the disease can pass it to the babies they are carrying.

"At first sight, the number of cases in Malta appears small but it must be remembered that only a handful of cases were reported in the 25 years before 2000. The rise is therefore significant and consistent with what is happening in the rest of Europe,' Dr Carabot said.

HIV

HIV stands for Human Immunodeficiency Virus. It is also referred to as the AIDS virus. HIV lives in blood and other body fluids that contain blood or white blood cells. People can contract HIV through: unprotected sexual intercourse or oral sex with an HIV-infected person, sharing drug needles or being accidentally stuck by needles or sharp objects contaminated with infected blood and being given infected blood in transfusions.

HIV and AIDS are not transmitted through casual contact where no blood or body fluids are involved. HIV is what gets passed from person to person. People don't "catch AIDS"; they "become infected with HIV".

There were seven cases of HIV diagnosed in 2005, significantly more than in previous years. The ages of those infected ranged from 17 to 49. Four of these patients were male and three female. Four were heterosexual and the other three were gay.

"It is generally held that HIV disease is still uncommon in Malta, but this is mere speculation. It is the clinical impression of medical colleagues that the number of positive patients are about to increase significantly, a view I fully agree with," Dr Carabot said.

"We need to find out the true national prevalence and plan accordingly. A sudden unexpected increase in HIV positive patients requiring expensive ant-retroviral therapy, even if relatively small, could easily overwhelm our limited resources," he said.

Notifiable Disease	Total	Males	Females
AIDS	3	2	1
Chlamydia	47	21	26
Gonorrhoea	20	15	5
Herpes Simplex	12	5	7
HIV	11	6	5
Syphilis	19	15	4
Table Notifiable Diseases reported to the Health Department in 2005

Awareness

A total of 78 per cent of patients who visited the GU clinic last year went of their own accord. Referrals by Caritas accounted for 4.6 per cent and doctor referrals remained low at 16.8 per cent, the same percentage as in 2004.

A total of 89 per cent of patients were heterosexual, eight per cent were men who have sex with men and three per cent bisexual. Only one patient admitted to being lesbian. The young, defined as those aged between 13 and 25, are a significant group of patients, accounting for 48 per cent. The youngest patient was 13 years old and the oldest 78.

A total of 70 per cent of those who sought the services of the clinic were single. The highest percentage of patients were skilled manual workers, followed by professional and managerial staff.

Forty one per cent of the patients were symptom free and their motivation for the visit was worry about casual sex or not using condoms.