**12. STIs among travelers and immigrants from the tropics**

Travel is known to be a major factor in the spread of STIs around the world, particularly in developing countries where STIs are endemic and very high rates are encountered in commercial sex workers. The rapid spread of antibiotic resistance around the world for a number of STIs and the spread of HIV infection are cases in point. It is difficult to assess the risk of acquiring STIs during travel in which sexual acts occur. Poverty and lack of legal enforcement certainly facilitate access to sexually compliant individuals in the developing world. In addition, risk-taking behavior increases when on vacation and often vacations involve higher risk activities than the traveler typically encounters at home. Studies have shown that engaging in sexual activity is the specific reason for travel, i.e. 'sex vacations', in some travelers. Reports of lower condom rate usage and higher rates of engagement in anonymous sex by travelers support a conclusion of increased risk. Travel clinics and physicians advising overseas travelers should counsel travelers about the risks and proper prophylactic regimens available. Travelers should also be strongly encouraged to be tested for STIs upon return if they have engaged in sexual activity. There are high rates of asymptomatic infection for many STIs and long incubation periods can also occur before there is an onset of symptoms. Immigrants and refugees pose a problem to the health care system in developed countries as well. STIs uncommon in the developed world such as chancroid, LGV, and donovanosis present a diagnostic challenge to the physician unfamiliar with these diseases. Incorrect diagnosis and subsequent incorrect treatment can delay resolution of the disease and increase the risk to the patient and sex partners, even permitting local mini-epidemics of new STIs. Health care providers should be aware of uncommon STIs present in their patient's country of origin when evaluating symptoms of genital infection in this population.
