This is the second national STI strategy to be adopted in Australia. It builds on the first National Sexually Transmissible Infections Strategy 2005–20081, which was developed in recognition of the:
- rising rates of STIs, particularly chlamydia
- causal relationship between STIs and reproductive and sexual health consequences, such as pelvic inflammatory disease and infertility
- relationship between STIs and HIV.
This strategy addresses the health needs caused by STIs in Australia. It provides a framework for promoting the health of priority populations at risk of the negative health impacts of STIs, thus improving public health. This section details the health needs resulting from STIs for priority populations.
Infections caused by sexually transmitted pathogens other than HIV impose a burden of morbidity and mortality in the community both directly (through their impact on quality of life, reproductive health and child health) and indirectly, through their role in facilitating the sexual transmission of HIV and their economic impact.2 STIs are also easily preventable and as such are a cost-effective focus for health promotion activities.
STIs are the main cause of infertility, particularly in women. Between 10% and 40% of women with untreated chlamydial infection develop symptomatic pelvic inflammatory disease. Post-infection tubal damage is responsible for 30% to 40% of cases of female infertility. Furthermore, women who have had pelvic inflammatory disease are six to 10 times more likely to develop an ectopic (tubal) pregnancy than those who have not, and 40% to 50% of ectopic pregnancies can be attributed to previous pelvic inflammatory disease.3
Chlamydia was the most frequently reported infection notified in Australia in 20084, with nearly 60 000 cases. In men, the rate nearly doubled between 2004 and 2008 from 125 for every 100 000 to 220 for every 100 000. In women, rates increased from 180 for every 100 000 to 325 for every 100 000 for the same period. Rates were greatest in the 20 to 24 and 25 to 29-yearold age groups.5
The trends in gonorrhoea notifications were different. There was a 5% decline in men over the period 2004–08 but a 16% increase in women. These trends varied across Australia’s states and territories. Notifications of rectal isolates of gonorrhoea in men decreased in New South Wales and Victoria in 2008.6
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Nationally, rates of diagnosis of infectious syphilis more than doubled, from three for every 100 000 in 2004 to seven for every 100 000 in 2007. This increase was most pronounced in the 40 to 49–year–old age group. Diagnoses were almost completely confined to gay men and other men who have sex with men in New South Wales, Victoria and Queensland. In the Northern Territory, diagnoses decreased to 49 for every 100 000 in 2007, with the vast majority of cases being diagnosed affecting Aboriginal and Torres Strait Islander peoples.7
In Aboriginal and Torres Strait Islander peoples, chlamydia rates generally increased between 2004 and 2008, with the exception of South Australia where they decreased. There was also an increase in rates of gonorrhoea in 2008, which are 36 times that for the non-Indigenous population.8 Infectious syphilis increased in the period 2004–08, although jurisdiction trends vary and in 2008 remain up to 15 times higher (Northern Territory, 105 for every 100 000) than the rest of the Australian population (seven for every 100 000).9 The continuing decline in the number of diagnoses of donovanosis, from 10 in 2004 to two in 2008, may be a consequence of a coordinated response around improved diagnosis and treatment.
Genital herpes infections caused by herpes simplex virus type 2 (HSV2) are estimated to affect 12% of adult Australians and can cause significant psychological morbidity and some physical morbidity. Transmission to neonates is rare, but potentially fatal. Infection with HSV2 also increases the risk of acquiring HIV several-fold, but efforts to treat HSV2 to prevent HIV infection have so far proved ineffective. A vaccine against HSV2 is not yet licensed in Australia, but may be during the course of this strategy.
The above data show that epidemics of STIs continue in Australia. Notification data show upward trends for most STIs in most priority populations. This data must be carefully interpreted because notifications and trends may not reflect true population prevalence or change and may be influenced by testing practices. Sentinel and enhanced surveillance and research findings provide a more comprehensive picture, particularly on priority populations. The notification data do not provide information on psychological, reproductive or sexual consequences of STIs.
Australia has a network of publicly funded sexual health clinics, but the majority of STIs are diagnosed and treated in general practice as a result of symptom recognition or identification of risk.10 The importance of training in this area of medicine needs to be emphasised in undergraduate as well as continuing education. As many programs or campaigns will continue to rely heavily on the continued participation of general practice, practitioner-initiated testing and treatment and partner notification initiated in the general practice setting will continue to be important.
The first national STI strategy successfully addressed the priority areas of chlamydia surveillance and service models and the response to syphilis in gay men. It also delivered national STI campaigns targeting gay men and young people. During the life of the first strategy, human papillomavirus (HPV) vaccination, which has significant benefits for morbidity arising from genital warts as well as HPV-related cancers, was incorporated into Australia’s National Immunisation Program.
Some data suggest that trichomonal infection is endemic in Aboriginal and Torres Strait Islander populations. In the Northern Territory in 2008, for example, there were 2218 cases of this infection of which 2140 were in the Aboriginal and Torres Strait Islander population.
This second National Sexually Transmissible Infections Strategy 2010–2013 continues and expands the work of the first. Within the priority populations, this strategy concentrates primarily on bacterial STIs, specifically chlamydia, gonorrhoea and syphilis, because this focus will likely produce the most significant public health benefits over the life of the strategy. There is an additional and new focus on the issues of trichomonal infection11and HPV prevention.
In common with the first strategy, the focus of this strategy is on preventing and managing STIs. Sexual and reproductive health, while linked to the strategic management of STIs, is outside the scope of this strategy. Unless specifically referring to HIV, this strategy deals with STIs other than HIV (which is the focus of another national strategy).
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1 Australian Department of Health and Ageing, 2005, ‘National Sexually Transmissible Disease Strategy 2005–2008’.
2 World Health Organization, 2006, ‘Global strategy for the prevention and control of sexually transmitted infection 2006–2015’, ISBN 978 92 4 156347 5.
4 National Centre for HIV Epidemiology and Clinical Research, 2009, Annual Surveillance Report, University of New South Wales.
6 Communicable Diseases Intelligence Volume 33 No3, September 2009, Annual Report of the Australian Gonococcal Surveillance Programme, 2008
7 National Notifiable Diseases Surveillance System, 2008, Communicable Diseases Intelligence Annual Report, viewed 13 September 2009, <http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi3202-pdf-cnt.htm/$FILE/cdi3202a.pdf>.
8 National Centre for HIV Epidemiology and Clinical Research, 2009, Bloodborne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander people: surveillance and evaluation report, University of New South Wales.
9 National Centre for HIV Epidemiology and Clinical Research, 2009, Annual Surveillance Report, University of New South Wales.
10 Donovan B, Knight V, McNulty A, Wynne-Markham & Kidd M, 2001, ‘Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates’, Medical Journal of Australia 175: pp. 412–414.
11 Northern Territory Health, 2002 ‘Trichomonas vaginalis: Consideration of the issues that underpin testing: which way to go?’, Background paper prepared by the Northern Territory AIDS/STD program, Disease Control, Darwin, March 2002.