Understanding the burden of bacterial sexually transmitted infections and Trichomonas vaginalis among black Caribbeans in the United Kingdom: Findings from a systematic review.

BACKGROUND: In the UK, people of black Caribbean (BC) ethnicity continue to be disproportionately affected by bacterial sexually transmitted infections (STIs) and Trichomonas vaginalis (TV). We systematically reviewed evidence on the association between bacterial STIs/TV and ethnicity (BC compared to white/white British (WB)) accounting for other risk factors; and differences between these two ethnic groups in the prevalence of risk factors associated with these STIs, sexual healthcare seeking behaviours, and contextual factors influencing STI risk. METHODS: Studies presenting relevant evidence for participants aged ≥14 years and living in the UK were eligible for inclusion. A pre-defined search strategy informed by the inclusion criteria was developed. Eleven electronic databases were searched from the start date to September-October 2016. Two researchers independently screened articles, extracted data using a standardised proforma and resolved discrepancies in discussion with a third researcher. Descriptive summaries of evidence are presented. Meta-analyses were not conducted due to variation in study designs. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. RESULTS: Of 3815 abstracts identified, 15 articles reporting quantitative data were eligible and included in the review. No qualitative studies examining contextual drivers of STI risk among people of BC ethnicity were identified. Compared to the white/WB ethnic group, the greater STI/TV risk among BCs was partially explained by variations in socio-demographic factors, sexual behaviours, and recreational drug use. The prevalence of reporting early sexual debut (<16 years), concurrency, and multiple partners was higher among BC men compared to white/WB men; however, no such differences were observed for women. People of BC ethnicity were more likely to access sexual health services than those of white/WB ethnicity. CONCLUSIONS: Further research is needed to explore other drivers of the sustained higher STI/TV prevalence among people of BC ethnicity. Developing holistic, tailored interventions that address STI risk and target people of BC ethnicity, especially men, could enhance STI prevention.

Ethnic variations in sexual behaviours and sexual health markers: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Sexual health entails the absence of disease and the ability to lead a pleasurable and safe sex life. In Britain, ethnic inequalities in diagnoses of sexually transmitted infections (STI) persist; however, the reasons for these inequalities, and ethnic variations in other markers of sexual health, remain poorly understood. We investigated ethnic differences in hypothesised explanatory factors such as socioeconomic factors, substance use, depression, and sexual behaviours, and whether they explained ethnic variations in sexual health markers (reported STI diagnoses, attendance at sexual health clinics, use of emergency contraception, and sexual function). METHODS: We analysed probability survey data from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3; n=15 162, conducted in 2010-12). Reflecting Britain's current ethnic composition, we included in our analysis participants who identified in 2011 as belonging to one of the following seven largest ethnic groups: white British, black Caribbean, black African, Indian, Pakistani, white other, and mixed ethnicity. We calculated age-standardised estimates and age-adjusted odds ratios for all explanatory factors and sexual health markers for all these ethnic groups with white British as the reference category. We used multivariable regression to examine the extent to which adjusting for explanatory factors explained ethnic variations in sexual health markers. FINDINGS: We included 14 563 (96·0%) of the 15 162 participants surveyed in Natsal-3. Greater proportions of black Caribbean, black African, and Pakistani people lived in deprived areas than those of other ethnic groups (36·9-55·3% vs 16·4-29·4%). Recreational drug use was highest among white other and mixed ethnicity groups (25·6-27·7% in men and 10·3-12·9% in women in the white other and mixed ethnicity groups vs 4·1-15·6% in men and 1·0-11·2% in women of other ethnicities). Compared with white British men, the proportions of black Caribbean and black African men reporting being sexually competent at sexual debut were lower (32·9% for black Caribbean and 21·9% for black African vs 47·4% for white British) and the number of partners in the past 5 years was greater (median 2 [IQR 1-4] for black Caribbean and 2 [1-5] for black African vs 1 [1-2] for white British), and although black Caribbean and black African men reported greater proportions of concurrent partnerships (26·5% for black Caribbean and 38·9% for black African vs 14·8% for white British), these differences were not significant after adjusting for age. Compared with white British women, the proportions of black African and mixed ethnicity women reporting being sexually competent were lower (18·0% for black African and 35·3% for mixed ethnicity vs 47·9% for white British), and mixed ethnicity women reported larger numbers of partners in the past 5 years (median 1 [IQR 1-4] vs 1 [1-2]) and greater concurrency (14·3% vs 8·0%). Reporting STI diagnoses was higher in black Caribbean men (8·7%) and mixed ethnicity women (6·7%) than white British participants (3·6% in men and 3·2% in women). Use of emergency contraception was most commonly reported among black Caribbean women (30·7%). Low sexual function was most common among women of white other ethnicity (30·1%). Adjustment for explanatory factors only partly explained inequalities among some ethnic groups relative to white British ethnicity but did not eliminate ethnic differences in these markers. INTERPRETATION: Ethnic inequalities in sexual health markers exist, and they were not fully explained by differences in their broader determinants. Holistic interventions addressing modifiable risk factors and targeting ethnic groups at risk of poor sexual health are needed. FUNDING: Medical Research Council, the Wellcome Trust, the Economic and Social Research Council, UK Department of Health, and The National Institute for Health Research.

What factors are associated with reporting lacking interest in sex and how do these vary by gender? Findings from the third British national survey of sexual attitudes and lifestyles.

OBJECTIVES: To investigate factors associated with reporting lacking interest in sex and how these vary by gender. SETTING: British general population. DESIGN: Complex survey analyses of data collected for a cross-sectional probability sample survey, undertaken 2010-2012, specifically logistic regression to calculate age-adjusted OR (AOR) to identify associated factors. PARTICIPANTS: 4839 men and 6669 women aged 16-74 years who reported ≥1 sexual partner (opposite-sex or same-sex) in the past year for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). MAIN OUTCOME MEASURE: Lacking interest in sex for ≥3 months in the past year. RESULTS: Overall, 15.0% (13.9-16.2) of men and 34.2% (32.8-35.5) of women reported lacking interest in sex. This was associated with age and physical and mental health for both men and women, including self-reported general health and current depression. Lacking interest in sex was more prevalent among men and women reporting sexually transmitted infection diagnoses (ever), non-volitional sex (ever) and holding sexual attitudes related to normative expectations about sex. Some gender similarities in associated relationship and family-related factors were evident, including partner having had sexual difficulties in the last year (men: AOR 1.41 (1.07-1.86); women: AOR 1.60 (1.32-1.94)), not feeling emotionally close to partner during sex (men: 3.74 (1.76-7.93); women: 4.80 (2.99-7.69) and ease of talking about sex (men: 1.53 (1.23-1.90);women: 2.06 (1.77-2.39)). Among women only, lack of interest in sex was higher among those in a relationship of >1 year in duration and those not sharing the same level of interest (4.57 (3.87-5.38)) or preferences (2.91 (2.22-3.83)) with a partner. CONCLUSIONS: Both gender similarities and differences were found in factors associated with lacking interest in sex, with the most marked differences in relation to some relationship variables. Findings highlight the need to assess, and if appropriate, treat lacking interest in sex in a holistic and relationship-specific way.

Illicit drug use and its association with key sexual risk behaviours and outcomes: Findings from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

OBJECTIVES: We explore the hypothesis that using illicit drugs other than, or in addition to, cannabis is associated with sexual risk behaviour and sexual health outcomes in the British population. METHODS: We analysed data, separately by gender, reported by sexually-active participants (those reporting > = 1 partners/past year) aged 16-44 years (3,395 men, 4,980 women) in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability survey undertaken 2010-12 involving computer-assisted personal-interview and computer-assisted self-interview. Analyses accounted for the stratification, clustering and weighting of the data. Multivariable logistic regression was used to calculate adjusted odds ratios. RESULTS: Use of illicit drugs other than, or in addition to, cannabis in the past year was reported by 11.5% (95%CI:10.4%-12.8%) of men and 5.5% (4.8%-6.3%) of women. Use of these types of drugs was more common among those <35 years, those who reported poor general and/or sexual health behaviours, e.g. binge drinking > = weekly (age-adjusted ORs, aAORs, 10.91 (6.27-18.97) men; 9.95 (6.11-16.19) women); having > = 2 condomless partners in the past year (aAOR:5.50 (3.61-8.39) men; 5.24 (3.07-8.94) women). Participants reporting illicit drug use were more likely (than those who did not) to report sexual health clinic attendance (ORs after adjusting for age, sexual identity and partner numbers: 1.79 (1.28-2.51) men; 1.99 (1.34-2.95) women), chlamydia testing (1.42 (1.06-1.92) men; 1.94 (1.40-2.70) women), unplanned pregnancy (2.93 (1.39-6.17) women), and among men only, sexually transmitted infection diagnoses (3.10 (1.63-5.89)). CONCLUSIONS: In Britain, those reporting recent illicit drug use were more likely to report other markers of poor general and sexual health. They were also more likely to attend sexual health clinics so these should be considered appropriate settings to implement holistic interventions to maximise health gain.

The health and well-being of men who have sex with men (MSM) in Britain: Evidence from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: To date, research on men who have sex with men (MSM) has largely focused on their sexual health needs and on men recruited from gay-orientated venues. National probability survey data provide a rare opportunity to examine the broader sociodemographic, behavioural, and health profiles of MSM, defined as men who reported ≥1 male sexual partner(s) in the past 5 years, and thus regardless of their sexual identity, in comparison to men reporting sex exclusively with women (MSEW) during this time, and also the extent that health inequalities cluster. METHODS: Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability sample survey, interviewed 15,162 people aged 16-74 years (6,293 men) during 2010-2012 using computer-assisted personal-interviewing with a computer-assisted self-interview. We used multivariable regression to compare MSM relative to MSEW in their reporting of variables, individually and collectively, corresponding to three domains: physical, mental, and sexual health. RESULTS: Among all men, 2.6 % (n = 190) were defined as MSM, of whom 52.5 % (95 % CI: 43.6 %-61.2 %) identified as gay. MSM were as likely as MSEW (n = 5,069) to perceive their health was 'bad'/'very bad', despite MSM being more likely to report a long-standing illness/disability/infirmity (adjusted odds ratio, AOR: 1.46, 95 % CI:1.02-2.09), treatment for depression/past year (2.75, 1.69-4.47), and substance use (e.g., recreational drug use/past year: 3.46, 2.22-5.40). MSM were more likely to report harmful sexual health behaviours, e.g., condomless sex with ≥2 partners/past year (3.52, 2.13-5.83), and poor sexual health outcomes, including STI diagnosis/es (5.67, 2.67-12.04), poorer sexual function (2.28, 1.57-3.33), both past year, and ever-experience of attempted non-volitional sex (6.51, 4.22-10.06). MSM were also more likely than MSEW to report poor health behaviours and outcomes both within and across the three health domains considered. Of all MSM, 8.4 % had experienced poor health outcomes in all three domains - physical, mental, and sexual health - in contrast to 1.5 % of all MSEW. CONCLUSIONS: MSM are disproportionately affected by a broad range of harmful health behaviours and poor health outcomes. Although often observed for a minority of MSM, many health inequalities were seen in combination such that policies and practices aimed at improving the health and well-being of MSM require a holistic approach, regardless of clinical specialty.

Forming new sex partnerships while overseas: findings from the third British National Survey of Sexual Attitudes & Lifestyles (Natsal-3).

OBJECTIVES: Travelling away from home presents opportunities for new sexual partnerships, which may be associated with sexually transmitted infection (STI) risk. We examined the prevalence of, and factors associated with, reporting new sexual partner(s) while overseas, and whether this differed by partners' region of residence. METHODS: We analysed data from 12 530 men and women aged 16-74 years reporting ≥1 sexual partner(s) in the past 5 years in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability survey undertaken 2010-2012. RESULTS: 9.2% (95% CI 8.3% to 10.1%) of men and 5.3% (4.8% to 5.8%) of women reported new sexual partner(s) while overseas in the past 5 years. This was strongly associated with higher partner numbers and other sexual and health risk behaviours. Among those with new partners while overseas, 72% of men and 58% of women reported partner(s) who were not UK residents. Compared with those having only UK partners while abroad, these people were more likely to identify as 'White Other' or 'Non-White' (vs White British ethnicity), report higher partner numbers, new partners from outside the UK while in the UK and paying for sex (men only) all in the past 5 years. There was no difference in reporting STI diagnosis/es during this time period. CONCLUSIONS: Reporting new partners while overseas was associated with a range of sexual risk behaviours. Advice on sexual health should be included as part of holistic health advice for all travellers, regardless of age, destination or reason for travel.

Sexual behaviour.

Sexual health is not merely the absence of disease, but the ability to have informed, consensual, safe, respectful, and pleasurable sexual relationships. The majority of the population are sexually active, most with someone of the opposite sex. The frequency and range of sexual practices that people engage in declines with age, but for many, sexual activity continues well into later life. Different aspects of sexual health affect people at different times throughout their lives. As people in the UK tend to first have sex around the age of 16, but do not start living with a partner until much later, the avoidance of sexually transmitted infections and unplanned pregnancy is necessary for many for a number of years. As people get older, their sexual health needs change and they become more concerned with the impact of their general health on their ability to have sex. Some people experience non-volitional sex (sex against their will); although this occurs typically in late teenage it may affect women and men at any age and so requires consideration throughout life. As many people find it difficult to talk about sex and sexual health matters, health professionals should make sexual health enquiry a component of their holistic healthcare.

Effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections: observational study, systematic reviews and mathematical modelling.

BACKGROUND: Partner notification is essential to the comprehensive case management of sexually transmitted infections. Systematic reviews and mathematical modelling can be used to synthesise information about the effects of new interventions to enhance the outcomes of partner notification. OBJECTIVE: To study the effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections (STIs). DESIGN: Secondary data analysis of clinical audit data; systematic reviews of randomised controlled trials (MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials) published from 1 January 1966 to 31 August 2012 and of studies of health-related quality of life (HRQL) [MEDLINE, EMBASE, ISI Web of Knowledge, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA)] published from 1 January 1980 to 31 December 2011; static models of clinical effectiveness and cost-effectiveness; and dynamic modelling studies to improve parameter estimation and examine effectiveness. SETTING: General population and genitourinary medicine clinic attenders. PARTICIPANTS: Heterosexual women and men. INTERVENTIONS: Traditional partner notification by patient or provider referral, and new partner notification by expedited partner therapy (EPT) or its UK equivalent, accelerated partner therapy (APT). MAIN OUTCOME MEASURES: Population prevalence; index case reinfection; and partners treated per index case. RESULTS: Enhanced partner therapy reduced reinfection in index cases with curable STIs more than simple patient referral [risk ratio (RR) 0.71; 95% confidence interval (CI) 0.56 to 0.89]. There are no randomised trials of APT. The median number of partners treated for chlamydia per index case in UK clinics was 0.60. The number of partners needed to treat to interrupt transmission of chlamydia was lower for casual than for regular partners. In dynamic model simulations, >10% of partners are chlamydia positive with look-back periods of up to 18 months. In the presence of a chlamydia screening programme that reduces population prevalence, treatment of current partners achieves most of the additional reduction in prevalence attributable to partner notification. Dynamic model simulations show that cotesting and treatment for chlamydia and gonorrhoea reduce the prevalence of both STIs. APT has a limited additional effect on prevalence but reduces the rate of index case reinfection. Published quality-adjusted life-year (QALY) weights were of insufficient quality to be used in a cost-effectiveness study of partner notification in this project. Using an intermediate outcome of cost per infection diagnosed, doubling the efficacy of partner notification from 0.4 to 0.8 partners treated per index case was more cost-effective than increasing chlamydia screening coverage. CONCLUSIONS: There is evidence to support the improved clinical effectiveness of EPT in reducing index case reinfection. In a general heterosexual population, partner notification identifies new infected cases but the impact on chlamydia prevalence is limited. Partner notification to notify casual partners might have a greater impact than for regular partners in genitourinary clinic populations. Recommendations for future research are (1) to conduct randomised controlled trials using biological outcomes of the effectiveness of APT and of methods to increase testing for human immunodeficiency virus (HIV) and STIs after APT; (2) collection of HRQL data should be a priority to determine QALYs associated with the sequelae of curable STIs; and (3) standardised parameter sets for curable STIs should be developed for mathematical models of STI transmission that are used for policy-making. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Physical and mental health could greatly affect sexual activity and fulfilment, but the nature of associations at a population level is poorly understood. We used data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) to explore associations between health and sexual lifestyles in Britain (England, Scotland, and Wales). METHODS: Men and women aged 16-74 years who were resident in households in Britain were interviewed between Sept 6, 2010, and Aug 31, 2012. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data for self-reported health status, chronic conditions, and sexual lifestyles, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures. FINDINGS: Interviews were done with 15,162 participants (6293 men, 8869 women). The proportion reporting recent sexual activity (one or more occasion of vaginal, oral, or anal sex with a partner of the opposite sex, or oral or anal sex or genital contact with a partner of the same sex in the past 4 weeks) decreased with age after the age of 45 years in men and after the age of 35 years in women, while the proportion in poorer health categories increased with age. Recent sexual activity was less common in participants reporting bad or very bad health than in those reporting very good health (men: 35·7% [95% CI 28·6-43·5] vs 74·8% [72·7-76·7]; women: 34·0% [28·6-39·9] vs 67·4% [65·4-69·3]), and this association remained after adjusting for age and relationship status (men: adjusted odds ratio [AOR] 0·29 [95% CI 0·19-0·44]; women: 0·43 [0·31-0·61]). Sexual satisfaction generally decreased with age, and was significantly lower in those reporting bad or very bad health than in those reporting very good health (men: 45·4% [38·4-52·7] vs 69·5% [67·3-71·6], AOR 0·51 [0·36-0·72]; women: 48·6% [42·9-54·3] vs 65·6% [63·6-67·4], AOR 0·69 [0·53-0·91]). In both sexes, reduced sexual activity and reduced satisfaction were associated with limiting disability and depressive symptoms, and reduced sexual activity was associated with chronic airways disease and difficulty walking up the stairs because of a health problem. 16·6% (95% CI 15·4-17·7) of men and 17·2% (16·3-18·2) of women reported that their health had affected their sex life in the past year, increasing to about 60% in those reporting bad or very bad health. 23·5% (20·3-26·9) of men and 18·4% (16·0-20·9) of women who reported that their health affected their sex life reported that they had sought clinical help (>80% from general practitioners; <10% from specialist services). INTERPRETATION: Poor health is independently associated with decreased sexual activity and satisfaction at all ages in Britain. Many people in poor health report an effect on their sex life, but few seek clinical help. Sexual lifestyle advice should be a component of holistic health care for patients with chronic ill health. FUNDING: Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and Department of Health.