Remote Practice – The Context -

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STI diagnosis rates for Aboriginal and Torres Strait Islander people living in regional and remote areas of Australia are disproportionate to rates among non-Indigenous Australians. An ongoing syphilis outbreak occurring in remote areas of far north Queensland, all of the Northern Territory, the Kimberley region in Western Australia and South Australia’s Far North, Eyre and Western regions is an example of the disparity in STI diagnosis rates.

Rates of hepatitis B are disproportionately high in remote Aboriginal communities. Hepatitis C is increasing in remote areas but endemic in regional areas, and there is a risk that HIV will escalate.

The pictogram below highlights the complexity of issues that sustain high rates of STI in remote and regional communities.

There are many factors to be taken into account when working with communities to up the ante on testing young people in remote communities for STIs and BBVs:

Most STIs occur in people over the age of 16 who are in most jurisdictions legally allowed to have sex.
STIs mostly affect young people and adults (aged 16–34) who are contracting these infections from having sex.
This sexual activity is no more or less a part of Aboriginal young people’s life than for non-Indigenous people, but the prevalence of STIs in remote communities means that the risk of acquiring an STI is significantly higher for people living in these communities.
STIs, including HIV, are mostly asymptomatic and for most people they will not know they have an STI or HIV.

Young people/adults (16–34) access health services less frequently than older people, especially young men, contributing to delayed diagnoses.
Not only do young men access health services less than young women STI testing rates are also lower than for young women.
If left untreated, STIs can cause long-term health consequences. STIs can affect reproductive health in both men and women including infertility; and cause complications in pregnancy, including stillbirths and congenital syphilis.
Six Aboriginal babies born with congenital syphilis have died since the current outbreak of syphilis in northern Australia commenced in 2011.
Failure to address endemic STI rates in Aboriginal communities means that HIV is a continuous risk factor.
High prevalences of STIs and increasing rates of injecting drug use, mean that escalation in HIV rates could occur at any time.
Lower levels of health literacy contributes to high prevalences. The challenge is building sexual health education into clinical practice and in communities across disciplines, and normalising sexual health as part of overall health monitoring and care.

STIs, including HIV, can be a source of shame and stigma in any community especially in Aboriginal communities.
Providing practical support and assistance to young people to enable contact tracing is crucial for limiting onward infection and reinfection.
There is a need for enhanced testing for hepatitis C for young people in remote Aboriginal communities, to ensure early diagnosis and equitable access to new hepatitis C treatments.
Ongoing monitoring of people living with hepatitis B in remote areas is required to ensure people are healthy as can be.

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Access to health services — is important to prevent and reduce STIs and BBVs. Finding ways to increase access is an important aspect of remote clinical practice, providing services that are friendly, non-stigmatising and accessible is important, either within the clinic or in the community. Young men access health services much less than young women so strategies that increase access to clinical care for this group are an important aspect of STI control.

Appropriate STI Testing — An important aspect of STI control is to focus efforts on testing the right age group, i.e., sexually active young people aged 15–34 years, or other sexually active people who have recently had sex with a new partner. People outside of this age group should be offered testing if symptoms are present or if they report sex with a new partner.

Testing frequency — is also an important aspect of STI control. Young people who are sexually active should have at least one STI test per year. Tests should be a minimum of three months apart*.

Retesting after a positive diagnosis — retesting should be conducted at 3 months after treatment to ensure infection has been cleared and reinfection has not occurred. *People who test positive for chlamydia trachomatis (CT) neisseria gonorrhoeae (NG) or trichomonas vaginalis (TV), should be tested for syphilis and HIV within 30 days if they were not tested on the same day.

Contact tracing — is also an important aspect of STI control. Testing and treating all sex partners once someone is diagnosed is important for ensuring reinfection does not reoccur in a client who has been treated for STIs.

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In Australia STIs are mostly diagnosed in primary health care services. It is therefore important that STI testing occurs in the following contexts:

Offer STI testing opportunistically – offer testing whenever young people in the recommended age group present at the health service. Current STI testing rates for appropriate age groups range between 15% and 40%. This is well below rates proposed in STI testing guidelines, which state that to have an impact on community prevalence 60–80% of patients in appropriate age groups should be tested.

Normalise testing – explain to young people that STI testing is offered to all young people in their age group because this is the age group predominantly affected by STIs.

Offer STI testing to all antenatal clients according to guidelines – explain to pregnant women that STI testing during antenatal care is important to reduce harms to both mother and baby.

Offer STI testing during Aboriginal and Torres Strait Islander Adult Health Assessments (MBS Item 715) – these assessments provide an ideal opportunity to screen people in target age groups for STIs and BBVs.

Offer STI testing in outreach settings – outreach testing should be considered for groups in the community who do not access clinics frequently, including young men.

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Information on all newly diagnosed cases of notifiable STIs and BBVs is collected on standard forms which include questions which ask about the probable mode of transmission, country of birth, and Indigenous status. This information is forwarded to state/territory health departments.

Annual STI and BBV reports: Surveillance data are sent to the Kirby Institute, which produces annual surveillance reports, including the Blood-borne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander people: Annual Surveillance Report. These annual reports show the number of new diagnoses in the previous calendar year for various Australian populations ([simple_tooltip content=’In epidemiology incidence means the number of new diagnoses of a particular medical condition in a population during a specific period of time. Incidence data conveys information about the risk of people in that population contracting the disease.’]incidence data[/simple_tooltip]), statistics on modes of transmission for these new diagnoses (e.g., anal sex, heterosexual sex, sharing of injecting drug equipment), and rates of STIs and BBVs among Aboriginal and Torres Strait people ([simple_tooltip content=’In epidemiology prevalence means the percentage of people in a population with a particular medical condition at a given time. Prevalence data indicates how widespread the disease is in that population.’]prevalence data[/simple_tooltip]).

Syphilis data and commentary: The Multijurisdictional Syphilis Outbreak Group (MJSO) produces communiques which provide updates on epidemiological data for the syphilis outbreak, and the Group’s activities.

HIV data and commentary: For an overview of the 2017 data on HIV rates among Aboriginal & Torres Strait Islander people and a discussion of the growing divergence between rates for Indigenous and non-Indigenous Australians, see HIV and Aboriginal & Torres Strait Islander Communities in 2017 [PDF:7.2MB], a booklet produced by the South Australian Health and Medical Research Institute.

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Here are links to a selection of peer-reviewed research publications on:

Incidence and prevalence of STIs/BBVs among Aboriginal people
HIV — risk of a concentrated epidemic
Risk behaviours / social determinants
Testing and treatment — service issues and Torres Strait Islander STI and BBV incidence and prevalence data.