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Lack of sexual health services: a ticking sexual health time bomb

I called the GU clinic for a sexual health screening and was told to call again in a fortnight. By then, clinicians hope that they will be given the go-ahead to see more than the imposed limit of 12 patients a day. This has and looks like will be the case for another two months. With medical laboratories at Mater Dei Hospital repurposed to focus on testing for SARS-COV2 fully, PCR tests for sexually transmitted infections are only conducted on patients who present symptoms. A ticking time bomb scenario.

During the COVID19 pandemic, health care services across the globe have seen an increase in demand and strain on their services. Resources had to be rerouted and the provision of some services was reduced. One of the services which were hit hard was the provision of sexual health testing and screening.

In Malta, the GU clinic has been operating on reduced services, scheduling appointments to only those who are symptomatic or are worried that they may have acquired a sexually transmitted infection (STI) since March 2020. 

In fact, the total number of tests conducted in the first six months of this year has gone down dramatically (chart 1). For both Chlamydia and Gonorrhoea, tests were down by over 50 per cent and for HIV and Syphilis by around 32 per cent.

Last month, the Times of Malta reported how new cases of sexually transmitted infections have “plummeted” since the start of the pandemic. The number of new cases has gone down, yes, but not for HIV and we certainly cannot only look at the number of diagnoses alone.

The number of Chlamydia diagnoses between January and June of this year totals 87; last year, in the same period, we had 178 diagnoses, but testing between the same period went down by 43%. We had 59 fewer new cases of Gonorrhoea for the same period, but testing was also down by 50%. These STIs and others may increase the risk of acquiring HIV for which there is currently no cure though Anti-Retroviral Therapy controls the virus.  

Over the last few years, we have seen an increase in the number of new HIV cases Between January and April 2020 alone, there were 23 new HIV cases, 10 more than the same period last year. This increase is even more worrying when you see that there were 1000 fewer HIV tests compared to the same period last year and that in 2018, Malta had the second-highest rate of new cases in the EU/EEA region.

The current policy of 12 patients a day is a barrier for sexual health tests and screening and a cause for concern. Sexually transmitted infections are often asymptomatic and can lead to complications if left untreated. Before the number of patients was capped for COVID times, the GU clinic was already struggling to meet the demand on their services. 

Waiting lists at the GU clinic are not something new. For years, sexual health services were underfunded with a small number of staff members. While this has been improving, not enough is being done to secure that we do not have to deal with an STI epidemic later this year. We must find innovative ways to prevent this and look into both interim and long-term measures. 

COVID 19 has taught us that a centralised system is not practical. Home testing kits and point of care tests (POCTs) are the way forward but these require investment and innovative technology. In recent years, we have seen the development of effective POCTs for both HIV and Syphilis which can be used by lay health workers. Between 2010 and 2017, Malta reported an increase of 123 per cent in the number of Syphilis cases, and in 2017, Malta had the second-highest rate of Syphilis in Europe. 

The availability of these tests could be a game-changer but would only be effective as wide educational campaigns and community testing are introduced. In most European countries, self-testing kits are available for purchase or for free from the national health services or NGOs working in sexual health. These would ramp up testing and provide for timely diagnosis and treatment. 

Sensitive and low-cost POCTs for STIs are still being developed, and therefore tests for Gonorrhoea and Chlamydia still need to be processed in medical laboratories, This means that even if, similar to the UK, we offered to send patients an STI testing kit to their home, these would still need to be sent to the Medical laboratory at Mater Dei to be processed. This implies that investment in sexual health cannot be only limited to increasing resources to the GU clinic, though that would not do not any harm. 

The government can still invest in PrEP which prevents the acquisition of HIV substantially reduces the risk of acquiring HIV by over 99%. Earlier this month we sent questions to the Ministry for Health on when and how PrEP will be introduced on the National Health Services; Deputy Prime Minister and Minister for Health, Chris Fearne, said late last year. that he is adamant about introducing PrEP. At the time of writing, the questions remain unanswered. 

At the moment PrEP is available in some pharmacies at €56.70 per box consisting of 30 tablets, a hefty price for some of the people who are at high risk and would likely benefit most from taking PrEP. This includes students in full-time education, the unemployed or those who do not have a regular income.

While it is appreciated that we are living unprecedented times, we must quickly restart acting on controlling other public health threats. Failure to do so will only lead to increased health care issues which could have been easily prevented with the right collaborations and strategies. 

*Data used in this article was obtained from the Infectious Disease Prevention & Control Unit, Health Promotion and Disease Prevention Directorate.

**I would like to thank Andre Micallef and Joseph Xuereb for their invaluable help with the design of graphs



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