Sexual health and sexually transmissible infections

Best practice for sexual and reproductive health in primary health care (PHC) is part of a client-centred, holistic approach to health and human rights. It includes contraception services and maternal care, and covers unsafe abortion, sexually transmissible infections and cancers related to reproduction, sexual violence, and the sexual and reproductive health needs of adolescents.1 This chapter is about improving services for the prevention and control of sexually transmissible infections (STIs).

More than 1 million STIs are acquired every day worldwide, and the majority are asymptomatic. Each year, there are an estimated 374 million new infections with one of four curable STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.2 More than 500 million people are estimated to have genital infection with herpes simplex virus, while an estimated 300 million women have a human papillomavirus (HPV) infection: the primary cause of cervical cancer and preventable with vaccination.3 STIs are associated with significant morbidity in both women and men (for example, tubal infertility, pelvic inflammatory disease, ectopic pregnancy)4 and also increase the risk of HIV transmission and acquisition.5 STIs can have other serious consequences beyond the direct effect of the infection, such as mother-to-child transmission resulting in stillbirth, neonatal death, low birth weight and prematurity, sepsis and inherited abnormalities.6

Preventive care for STIs includes counselling and behavioural interventions: education, pre- and post-test counselling, condom promotion, and interventions that target high-risk groups (for example, sex workers, men who have sex with men, people who inject drugs) and young people.7

Chlamydia, gonorrhoea, syphilis and trichomoniasis are generally curable with a single course of antibiotics, while antivirals can slow the effects of herpes, HIV and hepatitis B.
In low- and middle-income countries, diagnostic tests are often unavailable or are too expensive (except for rapid testing for syphilis and HIV). As a result, diagnosis and management are often based on recognisable signs and symptoms. This commonly leads to over-treatment and missed treatment (as a majority of STIs have no symptoms). Screening strategies are important. Treatment for the sexual partners of people with STIs is essential.8 PHC should aim to raise public awareness and reduce stigma around STIs and to prevent, diagnose and treat STIs effectively. Training PHC workers to provide these interventions is key.

Improving STI care for Aboriginal and Torres Strait Islander peoples

Chlamydia, gonorrhoea and syphilis are readily treatable STIs that continue to occur at high rates in Australia. They are notifiable STIs in Australia, along with donovanosis. High rates of STIs within Aboriginal and Torres Strait Islander communities are influenced by the social and structural determinants of health, which include access to high-quality PHC that, by definition, is culturally appropriate.9 The notification rates for chlamydia are nearly three times higher among Aboriginal and Torres Strait Islander peoples compared to non-Indigenous Australians; comparative infection rates for gonorrhoea and syphilis are higher again.10 Young people aged 15–29 years are the most affected group, with the highest incidence among 15- to 19-year-olds.11 Identified risk factors for STIs are living in a community with high STI rates; age (being sexually active when younger than 35 years old, especially younger than 25 years); having an STI within the past year, having a new sexual partner; or having more than one partner in the past six months. Drug or alcohol use can be a risk factor for multiple sexual partners or unsafe sex.12 

Aboriginal and Torres Strait Islander peoples living in remote and very remote areas experience much higher rates of STIs compared to those in urban and regional areas.13 A decade-long infectious syphilis epidemic has affected almost 4,000 mainly rural young Indigenous people in Queensland, Northern Territory, Western Australia and South Australia.14 Despite remote communities experiencing endemic rates of STIs for well over two decades,15 relatively recent estimates put annual STI testing coverage in remote communities at only 20 per cent, with lower rates in men than in women.16

The National Aboriginal Community Controlled Health Organisation and the Royal Australian College of General Practitioners guidelines for preventive health recommend annual testing for chlamydia (15- to 29-year-old age group) and gonorrhoea (15- to 39-year-old age group) among Aboriginal and Torres Strait Islander clients attending primary healthcare centres.17 Clinical guidelines for communities in the Northern Territory and central Australia recommend at least annual STI testing, prompt treatment, partner notification and testing, repeat testing after a positive result and treatment, education and positive health messages, particularly for those younger than 35 years.18 

The CARPA standard treatment manual recommends two standard STI tests a year for men and women, and for sexually active young people (with consent). Testing can be done at these times:

• as part of another consultation (opportunistic), if the client is between 15 and 35 years old
• as part of an adult health check
• as part of community-wide screening
• if symptoms and risk factors suggest STI
• if requested by the client – even if it has not been long since the last check.

Doing STI work in a culturally sensitive way is crucial. Experienced and respected Aboriginal and Torres Strait Islander health practitioners, health councils, and respected community members are important sources of help for non-Indigenous staff.19 

Findings: quality of STI care

Preventive health audits of 16,086 client records were conducted at 137 Aboriginal and Torres Strait Islander PHC centres between 2005–06 and 2014 (see Chapter 11). The audits involved government- and community-controlled, urban, regional and remote health centres. Testing and counselling data for sexually transmissible infections were analysed, looking for the levels of variation in testing for chlamydia, syphilis and gonorrhoea, and in discussions about sexual health. Overall, the audited preventive health records showed that there were several areas of STI care where improvement is needed:

• 68 per cent of clients had attended the PHC centres in the last six months, 49 per cent for acute care and only 8 per cent specifically for sexual health
• clients aged 20–24 and 25–29 years were more than three times more likely to be tested than clients in other age groups
• women received higher levels of testing for sexually transmitted infections compared with men (a 45 per cent greater chance of being tested)
• women having a Pap smear test were more than four times more likely to have STI testing and counselling than women attending for other types of care.20

Recent surveillance reports about STIs indicate that these findings about the quality of preventive care for sexual health are still relevant for focusing improvement efforts.21 

The CQI research found that adherence to clinical guidelines for sexual health testing and counselling varied widely between PHC centres, ranging from 0 per cent to 100 per cent in some years or cycles. Overall, service delivery for sexual health testing and counselling services improved over time, from a median of 27 per cent in 2005/06 to 54 per cent in 2014 (see Figure 18.1). There were several factors accounting for the variation:

• whether or not adult health checks were provided by the PHC centre: individuals undergoing an adult health check were three times more likely to be tested for STIs
• whether or not the centre had participated in one to two CQI cycles compared with just conducting a baseline audit (see Figure 18.1b)
• whether or not there was policy support and infrastructure for CQI. There were higher levels of service delivery in the two jurisdictions that had regional CQI facilitator networks and statewide CQI planning and governance committees.22

In the context of a syphilis outbreak among Aboriginal and Torres Strait Islander peoples in Northern Australia, CQI data from 77 PHC services (2012–14) were analysed to examine associations between PHC health centre (or clinic) factors and syphilis-testing performance.23 The study provided insights to help PHC managers respond to the syphilis outbreak, as follows:

• neither accreditation status nor governance model were associated with syphilis-testing performance
• with respect to Systems Assessment Tool24 component scores, “Delivery system design” (which refers to the design of the clinic’s infrastructure, staffing profile, allocation of roles and responsibilities, client flow and care processes) was significantly associated with syphilis-testing performance in all clinics
• within “Delivery system design”, three items were significantly associated: “Continuity of care”, “Team structure and function” and “Care planning”
• “Information systems and design support” was also linked with syphilis-testing performance.25

The STRIVE trial

The “STIs in Remote communities, ImproVed and Enhanced primary care” (STRIVE) trial was a stepped wedge cluster-randomised trial with CQI as an intervention. STRIVE was the first large-scale investigation of clinical CQI strategies for the control of STIs in remote Aboriginal community settings. The trial was conducted over three years from 2010 in 67 remote communities in three Australian jurisdictions (Northern Territory, Queensland and Western Australia).26 

STRIVE established evidence-based tools and processes to drive CQI and showed that a clinic-level sexual health CQI program supported by regional sexual health coordinators could improve care systems and STI testing rates. The trial found that simple but reproducible actions increased testing and retesting for STIs.

Context-specific CQI tools and audit reports helped teams to use data for improvement.

Over the trial period, testing coverage improved by almost 40 per cent overall, and aspects of the CQI program became normalised in clinical practice. There was no change in prevalence of STIs over the three-year time frame. This was mainly because baseline testing was so low.30

Sexual health (STI/BBV) clinical audit tool

The above findings about quality of care for STI testing resulted from the use a preventive health audit tool. A sexual health audit tool31 was developed, piloted and refined by service providers in four Australian jurisdictions. Released by Menzies School of Health Research in 2014, the tool is intended to be used in conjunction with the Systems Assessment Tool and the preventive health and youth health audit tools (see Chapters 5, 11 and 14).

The purpose of the sexual health audit is to determine the management of a sexually transmissible infection (STI) or bloodborne virus (BBV) episode from the time the client first presents to the health centre for assessment of symptoms and diagnosis through to laboratory investigations, treatment and follow-up care.

Improving STI care in Aboriginal and Torres Strait Islander PHC

Improving knowledge and awareness of STIs among communities and health professionals is essential for improving sexual health care and reducing the rate and consequences of STIs. While common STIs are easily detected and easily treated, a high proportion of STIs are asymptomatic. Therefore, diagnosis rates depend on testing that mainly occurs in PHC services.32 This requires PHC staff to be aware of the STI risk factors and the current guidelines on testing and treatment, and skilled in communicating with clients and providing culturally safe care. This in turn highlights the need for these elements:

• a stable workforce that includes Aboriginal and Torres Strait Islander practitioners
• training in cultural safety for non-Indigenous staff
• a team mix that enables culturally appropriate care (for example, male practitioners providing care for men)
• measures that ensure privacy and confidentiality, particularly in smaller communities (for example, family members may work in the health centre).33 

Our findings showed that a high proportion of the variation in quality of care was explained by health centre factors rather than client factors, suggesting that structural and organisational developments are needed to provide high-quality sexual health care. In addition to the measure suggested above, organisational-level strategies such as multidisciplinary clinical teams, refined professional roles and structural changes (for example, changes in clinic hours, outreach services) could increase the capacity of PHC staff to provide high-quality care and ensure that STI prevention and management services are always available. Barriers such as workload pressures and competing work priorities should also be considered.34

There have been a number of interventions to improve the quality of sexual health care for Aboriginal and Torres Strait Islander clients attending PHC services. In addition to the ABCD program (the source of our audit findings) and the STRIVE project they include, for example, the Sexual Health Quality Improvement program (SHIMMER) in New South Wales.35 Across these interventions, the use of CQI was shown to increase STI testing rates. Findings supported the integration of STI testing into general medical consultations and adult health checks, and health promotion programs that encourage people to present more frequently to PHC services and request STI testing.36

Community health promotion for STIs should include knowledge of risk factors and the important role of condoms, the need for timely testing and treatment, and the potential long-term consequences of STIs. Client and community approaches must be culturally safe, and gender and age appropriate. This may involve, for example, peer-based approaches and outreach services in places where young people meet. Resources should present an Aboriginal and Torres Strait Islander perspective and any approach used should aim to counter shame and STI-related stigma. Resources for PHC staff doing STI work with different groups are available through the Australian Indigenous HealthInfoNet.37

CQI research findings about the positive association between cervical screening test and STI testing in female clients highlights the value of integrating STI testing and counselling with other aspects of care. Cervical screening among Aboriginal and Torres Strait Islander women is important given that the incidence of and mortality from cervical cancer is higher compared to non-Aboriginal women,38 but also because cervical screening provides an opportunity for STI testing.39 From 2017, CQI activities have needed to monitor the possible effect of changes in Australia’s cervical cancer screening program on STI testing rates among women, as the introduction of a primary human papillomavirus (HPV) test every five years has replaced the requirement for Pap tests every two years.40

A national surveillance and research network for STIs and bloodborne viruses in Aboriginal and Torres Strait Islander PHC services (ATLAS) has been established to augment the Australian National Notifiable Diseases Surveillance System. The ATLAS network analyses de-identified client records to help improve understanding of patterns of infection, testing and care, risk and protective behaviours, and returns data to participating health services every six months for use in CQI processes.41 

References