Sexual health and bloodborne viruses
Author Dr Gabrielle Hall
Expert reviewers Dr Steven Skov, Mr James Ward
Sexually transmissible infections (STIs) and bloodborne viruses (BBVs) are seldom diagnosed from symptomatic presentation. The majority of STIs in Australia are diagnosed in primary care as opposed to specialised sexual health clinics.1 In contrast to sexual health clinic settings, patients in a primary care setting infrequently present requesting a sexual health check. In this scenario it is necessary for the health worker to realise an opportunity for opportunistic screening. This guide should assist in deciding which tests to include in screening and help recognise the high risk patient and offer screening at every appropriate opportunity. Every state and territory in Australia has a public health department that can advise clinicians on current prevalence data and any increased risks in their region.
The teenage pregnancy rate (women under 20 years age) in 2006 in Australia was five times higher for Aboriginal and Torres Strait Islander women compared to non-Indigenous women.2 The peak age group for births to Aboriginal and Torres Strait Islander women was 20–24 years of age, compared to 30–34 years for non-Indigenous women. In the period 2001–04, 23% of Aboriginal and Torres Strait Islander women who gave birth were younger than 20 years of age. Only 4% of non-Indigenous women were aged under 20 years.2 This reminds us that prevention and screening for STIs and appropriate vaccination are vital for healthy pregnancies and need to start early for Aboriginal and Torres Strait Islander adolescents. Counselling during the screening process should include discussions about contraception and family planning.
There are widely varying prevalence rates for STIs within Australia and a variation from community to community within the states and territories.3 Factors such as poverty, discrimination, substance abuse, illicit drug use and recent incarceration all affect sexual behaviours. Table 8.1 highlights the common risk factors for STIs and BBVs. In Aboriginal and Torres Strait Islander populations and non-Indigenous populations, 80% of notifications occur in the 15–29 years age group. Notification rates of STIs are generally increasing in Australia, although disease incidence and prevalence have been difficult to estimate reliably. The data for Aboriginal and Torres Strait Islander populations are inconsistent, largely due to under identification of Aboriginal or Torres Strait Islander status. There have been improvements in data collection, notification systems and diagnostic techniques that make it difficult to compare trend data.4 The most current data are from the 2011 Australian Annual Surveillance for Notifiable STIs.5 National STI incidence comparing Aboriginal and Torres Strait Islander rates to that of the non-Indigenous population were:
- 1257 vs 340 per 100 000 population for chlamydia infection
- 804 vs 30 per 100 000 population for gonorrhoea
- 25 vs 6 per 100 000 population for syphilis.
Queensland defied the national trend of a decline in the rate of syphilis (notably in the Northern Territory, South Australia and Victoria) with an increase in the Aboriginal and Torres Strait Islander rate to 35 per 100 000. The incidence rates for Aboriginal and Torres Strait Islander people when compared with non-Indigenous populations for newly acquired virus were:
- stable at 5 vs 1 per 100 000 population for hepatitis B virus (HBV) infection
- 141 vs 48 per 100 000 population for hepatitis C virus (HCV) infection
- 4.2 vs 4.1 per 100 000 population for human immunodeficiency virus (HIV) infection.
The Genital Wart Surveillance Network reported a decline in diagnoses of genital warts in female Australian women eligible for the HPV vaccine (aged 12–26 years in 2007) from 10.9% of first time uses of a sexual health service in 2004 to 4.8% in 2009.6
The 2011 Bloodborne Viral and Sexually Transmissible Infections in Aboriginal and Torres Strait Islander people: Surveillance and Evaluation report shows the widely varying prevalence rates from state-to-state and between major cities, regional areas, and rural and remote regions.7 For chlamydia the rate of diagnosis was highest in Northern Territory and Western Australia and lowest in Tasmania and Victoria with South Australia rates falling between these regions. Queensland and New South Wales are not included as Aboriginal and Torres Strait Islander status is reported for less than 50% of the diagnoses. Twice as many remote and very remote diagnoses of chlamydia were made compared with major cities and outer regional areas. Inner regional areas have the lowest rate of diagnosis of chlamydia for Aboriginal and Torres Strait Islander people.7
Chlamydia trachomatis of immunotypes D–K is the most commonly diagnosed STI and there has been a significant increase in notification rates since 1997.8 Asymptomatic infection is common in both sexes. In men, chlamydia commonly causes urethritis and can also cause epidydimitis, infertility and Reiter syndrome. In women, chlamydia can cause cervicitis with the risk of developing salpingitis and pelvic inflammatory disease or chronic pelvic pain. Chlamydia is efficiently transmitted vertically at birth and can cause conjunctivitis, pneumonia and otitis media. Chlamydia is an important cause of tubal factor infertility and ectopic pregnancy, so early testing for chlamydia prior to reproductive age and during pregnancy is most important. Despite the need for early testing, a 2008 ecological study of chlamydia testing data (71 295 tests) and Victorian chlamydia notification data (7006 notifications) concluded that testing in the age groups at most risk, ie. women aged between 20 and 24 years, was low even in those living in the most advantaged quartile.9 Early treatment of infections can prevent complications and is effective. The immediate dose of azithromycin currently recommended for chlamydia treatment is highly effective.10
Gonorrhoea is a purulent infection of mucous membranes caused by Neisseria gonorrhoeae. It causes urethral symptoms in up to 50% of men and is largely asymptomatic in women. In men it causes urethritis, proctitis, epididymitis and prostatitis. In women it is a major cause of cervicitis and pelvic inflammatory disease and this can lead to chronic pelvic pain, infertility and ectopic pregnancy. Infection during pregnancy can cause adverse outcomes and perinatal transmission can cause gonococcal conjunctivitis. In adults, gonococcal septic arthritis is a known presentation and in both sexes there can be symptomatic pharyngitis. Gonococcal infection appears to increase susceptibility to, and transmission of, HIV.
Trichomonas is a sexually transmissible protozoal parasite that causes vaginal discharge, however the majority of cases in high prevalence areas are asymptomatic. The consequences of trichomoniasis are potentially important in pregnant women in whom infection is associated with premature rupture of the membranes and pre-term delivery however, treatment of asymptomatic infection has not been shown to reduce these complications (see Chapter 9: Antenatal care). It has also been associated with an increase in the acquisition of HIV. It is associated with low economic status,11 injecting drug use and no Pap test screening, which probably reflects lack of access to healthcare or poor health seeking behaviours.12 It is a notifiable disease in the Northern Territory where case notification rates are similar to those for chlamydia.13 Trichomonas is not a notifiable disease elsewhere in Australia.
Syphilis is a bacterial STI caused by the spirochaete Treponema pallidum. Syphilis is spread by direct sexual contact and most cases presents as asymptomatic. Early syphilis is defined as the stages of syphilis (primary, secondary and early latent syphilis) that typically occur within the first year after acquisition of the infection. Latent syphilis is characterised by asymptomatic infection with a normal physical examination in association with a positive serology.14 Latent syphilis is categorised as ‘early’ or ‘late’ depending on the established date of infection. Early latent syphilis implies infection within 1 year. All other cases are referred to as late latent syphilis or latent syphilis of unknown duration.14 The primary stage of syphilis is usually marked by a lesion called a ‘chancre’, that appears 7–90 days after exposure. Weeks to a few months later, approximately 25% of individuals with untreated infection will develop a systemic illness that represents secondary syphilis, which commonly presents as a maculopapular rash on the palms of the hands and the soles of the feet. The secondary stage typically resolves spontaneously in 2–6 weeks but can recur repeatedly during the first 2 years. Following the secondary phase there is an asymptomatic latent stage that can be diagnosed by a positive specific treponemal antibody test. In the early latent syphilis phase the disease is considered contagious. In late latent syphilis it is not considered contagious. Tertiary or late syphilis occurs in an uncertain proportion of patients infected by T. pallidum and refers to symptomatic manifestations of the disease involving the central nervous system, the cardiovascular system, or the skin and subcutaneous tissues (gummas).14
Treatment of syphilis in pregnant women is important to prevent congenital syphilis of the newborn. The rate of diagnosis of infectious syphilis was on a decline to 25 per 100 000 in Aboriginal and Torres Strait Islander populations in 2009, whereas the rate in the non-Indigenous population rose to 6 per 100 000 in 2009.15 Despite the decline, Aboriginal and Torres Strait Islander rates are many times higher than other Indigenous and non-Indigenous populations in high income countries.15 In Queensland, syphilis persists in Aboriginal and Torres Strait Islander populations at high levels of up to 52 cases per 100 000 population compared to non-Indigenous rate of 2 cases per 100 000 population.16 The decrease in infectious syphilis has not yet been seen in a complementary reduction of congenital syphilis where there have been 12 cases notified in Queensland since 2001. The majority of these were acquired in remote areas.16 Syphilis in pregnancy, long recognised as a significant cause of pregnancy loss and perinatal death in northern Queensland,17 is associated with a high population prevalence of infection.
Human papilloma virus
Human papilloma virus (HPV) infects the cutaneous and mucosal epithelial tissues, most commonly involving the skin or anogenital tract. Persistent infection is the leading cause of cervical cancer and is associated with other cancers of the vagina, vulva, penis and anus. HPV genotypes 16 and 18 are the causative agents in 70–80% of all cervical cancers. HPV genotypes 6 and 11 are among the HPV genotypes designated as low risk (for cancer), and are associated with 90% of genital warts. HPV infection is acquired soon after the first sexual encounter with an infected individual. Like all STIs, peak prevalence of HPV infection occurs within the first decade after sexual debut, typically between 15–25 years of age in most Western countries.
In Australia, a national HPV vaccine program began in 2006 using Gardasil®. This quadrivalent vaccine is effective against high risk HPV types 16 and 18 to prevent cervical cancer and low risk HPV types 6 and 11 for prevention of external genital warts. HPV vaccination is currently given to girls via a school based vaccination program in Year 7, at 12 years of age. The Australian Immunisation Handbook recommends HPV for females aged 9–26 years.18 Population based preventive measures include dissemination of general information about HPV.19 Health professionals should include in their sexual health counselling discussions that cover abstinence and the importance of using condoms ‘from start to finish’ with no unprotected genital contact. This can also be an opportunity to discuss smoking as a risk factor, due to its association with an increased risk of genital cancer.19
Hepatitis B and C
The rate of diagnosis of HBV infection in the Aboriginal and Torres Strait Islander population resident in the Northern Territory, South Australia, and Tasmania was 237 cases per 100 000 in 2006 declining to 120 cases per 100 000 in 2009. The rate of diagnosis of newly acquired HBV in the same group was 5 cases per 100 000 in 2005–09.15 The estimated prevalence of chronic HBV in the Aboriginal and Torres Strait Islander population ranges from 2% in some urban communities and up to 8% in some rural communities.15 The population rate of diagnosis of HCV infection in Aboriginal and Torres Strait Islander residents in the Northern Territory, South Australia and Western Australia was 131 cases per 100 000. The rate was substantially higher for Aboriginal and Torres Strait Islander people in South Australia and Western Australia compared to the non-Indigenous population, yet it was lower for Aboriginal and Torres Strait Islander people in the Northern Territory compared to non-Indigenous residents.15 This may be related to different rates of injecting drug use.
Chronic HBV and HCV infections cause significant morbidity and mortality through sequelae such as liver fibrosis, cirrhosis and hepatocellular carcinoma. Together, they are the most common indication for adult liver transplantation in Australia. Antiviral therapy is the standard treatment for HBV and HCV infection in adults. It is currently not listed as approved for the treatment of children in Australia.20 Chronic HBV causes cirrhosis in around 25% of adults over a 20-year period and is a precursor to hepatocellular carcinoma. The lifetime risk of cirrhosis is 20–30% in perinatal and childhood infections. Studies in the Northern Territory in the 1980s and 1990s found prevalence rates for HBsAg of 8.2% among urban and rural Aboriginal school children.21 Prevalence studies have shown that HBsAg is highest among Aboriginal and Torres Strait Islander prison inmates, at 12%.22 HCV transmission occurs predominately among people with a recent history of injecting drug use. It is the underlying cause of liver disease in 28% of liver transplants in Australia.5
Human immunodeficiency virus
The per capita rate of HIV diagnosis in the Aboriginal and Torres Strait Islander population was similar to that in the non-Indigenous population. In the Aboriginal and Torres Strait Islander population, the rate declined from 4.7 cases per 100 000 in 2000–04 to around 3.9 cases per 100 000 in 2005–09 but this is based on small, localised numbers and may not reflect a national pattern. Higher proportions of Aboriginal and Torres Strait Islander cases of HIV infection were attributed to heterosexual contact (21% compared with 15%) and injecting drug use (20% compared with 3%) than in non-Indigenous cases.5
HIV prevalence in Australia is lower than in most comparable high income countries. One of the significant factors for this is the early adoption of needle syringe programs, another was effective early education though peer groups and community organisations. The rate of HIV notification in Aboriginal and Torres Strait Islander people has remained relatively stable over the past 6 years and disease incidence rates are similar in Aboriginal and Torres Strait Islander populations and non-Indigenous populations.5 Among Aboriginal and Torres Strait Islander people, HIV is seen more in women and heterosexual couples and the rate is seven times greater for those who inject drugs, when compared to subgroups of non-Indigenous people. The reason for this trend is thought to be due to less access to appropriate health services and harm reduction activities and increased rates of STIs.23 Co-infection with chlamydia, gonorrhoea and/or trichomonas are significant risk factors for HIV infection, highlighting the importance of a comprehensive and systematic management of a person’s overall sexual health as a key strategy in reducing the risk of HIV infection.24
HPV vaccine has been developed to prevent cervical cancer and the National Immunisation Program provides vaccination for girls aged 12–13 years, ideally before their first sexual contact. Systematic review of the efficacy of HPV vaccination for young girls show seroconversion rates over 99.5% after vaccination and studies are ongoing to ascertain whether a booster dose of HPV will be required.25,26 The age standardised rate for death from cervical cancer in Aboriginal women in Queensland, Western Australia, the Northern Territory and South Australia from 1997 to 2000 was five times that for non-Indigenous women (11.3 vs 2.1 per 100 000 women).27,28 It is too early to see evidence of a reduction in rates of cervical cancer after HPV vaccination, as cancers can occur decades after infection, but there has been a decline in high grade abnormalities on cervical lesions, particularly in women naïve to HPV types 16 or 18.29
A systematic review of HBV vaccination in people with no previous exposure or unknown exposure status showed that vaccination reduces the risk of developing HBV infection by 88% for HBV surface antigen marker and 62% for anti-core antibody marker.30 To reduce perinatal transmission of HBV in newborn infants of HBsAg positive mothers, a systematic review concluded that HBV immunoglobulin plus vaccine was required.31 Neonatal HBV vaccination was introduced in the late 1980s to at risk groups in Australia. This was offered to Aboriginal children in the Northern Territory in 1988 and in 1990, universal infant vaccination commenced in the Northern Territory.21 The National Universal Infant HBV Vaccination Program began in 2000. The Australian Immunisation Handbook recommends universal neonatal HBV vaccination, ideally in the first 24 hours of life, followed by a primary course of vaccination at 2, 4 and 6 or 12 months age.18 This includes vaccination of all adolescents aged 10–13 years who have not yet had a primary course of vaccination. Individuals vaccinated at birth are only just reaching 23 years of age in the Northern Territory and 11 years of age in the rest of Australia, therefore there will be a need for prevention and management of chronic HBV among Aboriginal and Torres Strait Islander people for decades into the future. The current Australian Immunisation Handbook also recommends HBV vaccine for high risk individuals who are injecting drug users, household and sexual contacts of HBV carriers, incarcerated individuals and men who have sex with men.18 It does not specifically recommend HBV vaccine for Aboriginal and Torres Strait Islander people who are outside the ages eligible for the National Immunisation Program or who are not in a high risk group. This is in contrast to the Gastroenterological Society of Australia and New Zealand recommendations that all Aboriginal and Torres Strait Islander people are in a higher risk group and should be screened and vaccinated if non-immune.32 HBV vaccination for Aboriginal and Torres Strait Islander children and young adults up to the age of 20 years are funded through some state/territory immunisation programs. HBV vaccine for Aboriginal and Torres Strait Islander adults over 20 years is state government funded in New South Wales and South Australia only. In the Northern Territory, Western Australia and Tasmania, HBV vaccines are funded for catch-up immunisation for Aboriginal and Torres Strait Islander school-aged children only. In Victoria, HBV vaccines are only funded for household contacts and seronegative injecting drug users. In Queensland, HBV vaccines are only funded for school vaccination programs.
The Australian Immunisation Handbook recommends hepatitis A vaccine for people who have chronic HBV and/or HCV, for injecting drug users and for men who have sex with men. There is a vaccination program for all Aboriginal and Torres Strait children residing in the Northern Territory, Queensland, South Australia and Western Australia.18
Screening is designed to detect disease in people without signs or symptoms of that disease and should be followed by confirmatory testing and treatment in the event of a positive diagnostic test. If health services do not have the capacity to respond to a positive screening test then the test should not be undertaken in the first place.
With the introduction of nucleic acid amplification tests (NAATs) in the 1990s, screening for chlamydia, gonorrhoea and trichomonas is now simple. This has had a dramatic impact on the way we screen for STIs but has resulted in a decrease in the number of swabs sent for culture and sensitivity.33 NAATs for chlamydia, as well as gonorrhoea and trichomonas, can be conducted on swab specimens obtained from the endocervix (chlamydia and gonorrhoea) or high vagina (chlamydia and trichomonas), or self administered low vaginal swabs (SOLVS) and first void urines (FVU). Self collected samples increase ease of screening.34 When collecting an FVU, patients should be advised that an ideal specimen is collected 2 hours after last void; earlier specimens will lose some sensitivity. An NAAT can be performed on a few millilitres of urine but 25 mL is better, and refrigeration is recommended if there is a time delay beyond 24 hours before getting the sample to the laboratory. The specimen should be frozen if it will be longer than 4 days before processing.34 The choice of chlamydia, gonorrhoea and trichomonas testing from FVU, SOLVS or ECS/HVS in women should take into account patient preference. Endocervix and high vagina swabs are the routinely collected screening tests when performing a speculum examination.35 For men, FVU is the only screening option. The promotion of the same method of screening (ie. FVU) for women as for men may suit some regions. At each primary healthcare encounter that results in consideration of STI screening, it is important to provide pretest counselling and education about other STIs as well as safe sex advice including the use of condoms for prevention of STIs.
NAAT is recommended for gonorrhoea screening.11 N. gonorrhoeae can be sensitive or resistant to penicillin and resistance patterns vary. Therefore a positive NAAT result often needs further information about the susceptibility of the particular strain to penicillin.36 It is recommended, therefore that for NAAT positive gonorrhoea, a swab for culture is collected within 1 week to gather important information on sensitivities for the local population.37 While it is recommended that women presenting with a vaginal discharge are tested for trichomonas,11 it is not recommended as a screening test for asymptomatic women. Local prevalence data should be used to guide the need to screen, as the prevalence rate has been found to be high in the Northern Territory, northern Queensland and the Kimberley region of Western Australia,38 but low in southern urban sexual health clinic settings. A study in Sydney reported a higher prevalence of trichomonas in an urban STI clinic population when testing using NAATs than previously reported.17 As NAAT for trichomonas becomes more widely available there may be updated prevalence data and recommendations for screening.
Syphilis and HIV screening is not recommended for routine screening of asymptomatic individuals but should be considered if the patient reports risk factors that promote STI or BBV transmission (Table 8.1) and where local prevalence rates are high.10 A low threshold for testing is recommended, as some people are reluctant to disclose risk behaviours or identify their own risk taking activities. Local prevalence data can assist in decisions to include syphilis and HIV routinely in screening. Syphilis infection is of particular concern during pregnancy because of the risk of transplacental infection to the fetus. Congenital syphilis infection of the fetus is associated with several adverse outcomes including perinatal death, pre-term birth, low birthweight, congenital abnormalities, active congenital syphilis of the newborn and long term sequelae such as deafness and neurological impairment.39 It is for this reason that syphilis screening is recommended early in antenatal care. Vertical syphilis transmission usually occurs after 4 months gestation, so early screening and treatment should prevent most cases. Individual antenatal patients who remain at high risk for STIs should be re-screened for relevant STIs again in the third trimester.39
Screening for STIs provides the opportunity to offer prevention and health promotion advice. Condom use for vaginal and anal sex will significantly reduce the risk of STIs.10 It is the most effective method of preventing HIV transmission. When discussing safe sex practices, it is important to recommend the use of condoms with water based lubricant for all genital contact during vaginal and anal intercourse. It is also important to discuss the barriers to condom use and how they might be overcome and to recommend an STI check with new partners before couples in a monogamous relationship stop using condoms. Discussion of issues around personal safety, self respect and respect of others can also promote healthy and more stable relationships.40
The Queensland Sexual Health Clinical Management Guidelines has comprehensive chapters that cover history taking and risk assessment including a health worker’s legal obligations.41 It is important to be familiar with the legislation in your state or territory regarding sexual activity in persons under the age of 18 years as there are mandatory reporting requirements in some jurisdictions.42 Pretest discussions should also include talking about what a positive test result would mean and explaining the notification requirements for STIs while reassuring the patient that their privacy will be respected.43
Health promotion interventions to provide information on STI transmission and prevention as well as skill development, can have a positive effect on sexual risk reduction for up to 3 months after intervention, measured by increased use of condoms for vaginal intercourse.44
Contact tracing is a voluntary process where sexual contacts of index cases are notified of their exposure to an infection. Contact tracing can be broadly used to cover both partner notification (patient referral) and provider referral. Partner notification involves the index case contacting his or her own sexual contacts and the health provider advising on the information to be given to the partner. It may also include patient delivered partner therapy (such as azithromycin for chlamydia). Provider referral involves the healthcare worker directly advising the contact or using their local sexual health team to perform this task. Provider referral allows for confidential contact tracing and is the method of choice for infections such as HIV. It is important to have access to the Australian Contact Tracing Manual (see Resources) as this has the necessary information on how far back to trace for individual diseases. There are very limited data to comment on the effectiveness of contact tracing; a Cochrane review in 2001 found that health worker notification to a contact was a more effective way to treat contacts than patient notification.45 The strategy of contact tracing varies between states and regions. Most states have a sexual health unit that will oversee GP notifications of HIV, syphilis and gonorrhoea, but chlamydia partner notification is usually followed up by the GP and their clinic health team. There is limited evidence based information regarding contact tracing effectiveness for Aboriginal and Torres Strait Islander people. A literature review by the Burnet Institute suggests that health worker referral or patient delivered partner therapy is appropriate and that Aboriginal and Torres Strait Islander health worker involvement should be offered sooner rather than later.1 It should be noted, however, that patient delivered partner therapy is not recommended in several Australian jurisdictions. Although the review noted that avoiding the use of letters or the telephone to notify may be important, these strategies could still be appropriate, depending on local circumstances and protocols.
Post-exposure prophylaxis (PEP), which is the provision of a course of treatment to someone exposed to HIV or HBV, reduces the risk of infection with the virus and prevents disease. The exposure could be in the healthcare workplace, exposure through sex with an infected individual or through needle sharing. For HIV, it is recommended to start PEP within 72 hours after exposure; this involves the prescription of antiretroviral drugs over a course of 28 days. This is administered via a S100 prescriber for HIV drugs. It is estimated that receptive anal intercourse and sharing injecting drug equipment with an HIV positive individual constitutes the highest risk of transmission of HIV and concurrent STIs are one of the cofactors that significantly increase the risk of sexual transmission. The evidence for this secondary prevention strategy mostly comes from observational studies on animals and mother-to-child transmission.46
Harm minimisation is the principle underlying Australia’s National Drug Strategy since 1985. It encompasses a wide range of approaches involving supply reduction, demand reduction and harm reduction. Using clean injecting equipment is the most effective method of preventing transmission of HIV and HCV among injecting drug users.10 Needle and syringe exchange programs provide sterile injecting equipment and are an effective, safe and cost effective component of harm reduction strategies. It was found that between 1991 and 2000, needle and syringe exchange programs cost Australian governments $130 million dollars but saved $7.8 billion by preventing 25 000 cases of HIV and 21 000 cases of HCV.47 International research has shown that there is a reduction of spread HIV and HCV in prisons that operate needle syringe exchange programs and evaluation of these prison programs found that more people access drug treatment.48 Data collected from the 2005–09 National Needle and Syringe Exchange Programs Survey show that among those participating in their annual survey who reported recent incarceration, approximately 1 in 3 reported injecting in prison.49 Patients in contact with needle syringe exchanges or in primary care settings should opportunistically be delivered brief interventions focused on motivation to assist with cessation of drug use.50 Motivation to change behaviour can be enhanced by discussions and feedback that explore patient perspectives and treatment options for drug use in a non-judgemental manner. Two sessions, each lasting 10–45 minutes, are recommended, with the primary focus on harm minimisation. In this setting, harm minimisation involves education to reduce risky behaviours, the consideration of abstinence, access to needle and syringe exchange programs and opioid substitution therapy and, ideally, access to peer group educators.
There is healthy debate in Australia about current and future harm minimisation strategies. The prohibitionist activities enacted at the level of law enforcement include lack of access to needle and syringe exchange programs in prisons, increasing use of drug sniffer-dogs, and lack of political support for medically supervised injecting drug rooms versus the harm reduction approach of health and alcohol and other drug specialists.51
Injecting drug use has been strongly linked with HIV and HCV infections and unsafe injecting practices have led to the epidemic of HCV infections. Although several illicit drugs can be injected (eg. opioids, methamphetamine, cocaine), the majority of evidence on environmental interventions relates to opioid use. Opioid dependent individuals have been found to have an annual mortality of 2–4%, or 13 times that of their peers.52 This increased mortality is primarily due to overdoses, violence, suicide, and smoking and alcohol related causes. Injecting drug users have a reduced quality of life due to time spent intoxicated or seeking drugs as well as an increased rate of psychiatric comorbidity. Opioid dependence places a significant economic burden on society through increased healthcare costs, the criminal justice system and unemployment. Treating opioid dependence is aimed at reducing harm and improving quality of life. Opioid substitution therapy consists of daily administration of an opioid agonist such as methadone or an opioid partial agonist such as buprenorphine. The aim of opioid substitution therapy is to reduce the use of illicit opioids, reduce injection of drugs and its risk of BBV infection, reduce criminal activity, reduce the risk of overdose and improve psychological and physical health.52 It is a minimum standard recommendation by the World Health Organization (WHO) that opioid agonist maintenance treatment is an option and that this treatment is accessible to disadvantaged populations.52 WHO also recommends the availability of a range of structured psychosocial interventions such as counselling and assistance with housing, education, employment and legal problems. Patients with psychiatric comorbidity should have access to psychiatric treatment. Opioid agonist maintenance treatment has been shown to reduce the seroconversion to HIV.53 This correlates with measured reductions in drug related and sex related risk.
General practitioners often have patients who present with requests that hint at opioid addiction such as escalating opioid doses for chronic pain, ‘lost’ prescriptions and injection related morbidity. These are opportunities to discuss harm minimisation strategies, including treatment options such as opioid substitution therapy. It is important to be familiar with the opioid pharmacotherapy prescribers in your region and referral pathways for patients who demonstrate a willingness to change. Patients can also present in a crisis when their level of motivation for change is high. The more readily available the treatment program, the more likely we can take advantage of the motivational high. Each jurisdiction in Australia has its own requirements for training of opioid prescribers. The training is free and usually involves a half or 1 day workshop. GPs working with Aboriginal and Torres Strait Islander people should consider undertaking this training so that their service is able to provide fully comprehensive primary healthcare to this vulnerable and marginalised group of people. There are already many GP prescribers and experienced alcohol and other drug health workers and counsellors in Aboriginal Community Controlled Health Services in Australia who can be consulted for advice and support in this regard.
Recommendations: General preventive advice
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||All people with risk factors for STIs or BBVs (see Table 8.1)
||Screen for STIs according to local prevalence guidelines and screen for BBVs if risk factors are present (see specific recommendations below)
||Annually and re-screen 3 months after positive test
|People diagnosed with an STI
||Review STI risk factors and screen for other STIs according to local prevalence guidelines
Consider also screening for BBVs if risk factors are present (see Table 8.1)
|On diagnosis and re-screen in 3 months
|Sexual partners of a person with an STI
||Ensure contact tracing is undertaken at time of diagnosis and appropriate testing and treatment is offered to contacts, as per Australasian Contact Tracing Manual (see Resources54)
||Every positive screen
||All sexually active people
||Provide sexual health counselling including proactive discussion of issues of sexuality
||Recommend condom use with all sexual activity
|People at higher risk of HBV or HCV infection (see Table 8.1)
||Provide counselling on harm minimisation and promote peer education strategies around safer sex and injecting drug use
||Opportunistic and as part of an annual health assessment
|People with opioid dependence
||Conduct brief motivational interviewing to reduce use of illicit drugs, harm with injecting drugs, risky alcohol use and risk of BBV infection and STIs, particularly for those unlikely to attend specialist treatment (see Resources57,58)
||Exposure to HIV both occupational and non-occupational
||Assess post-exposure risk using national guidelines (see Resources)59 and provide post-exposure prophylaxis (PEP) within 72 hours of the risk exposure when indicated
Refer to local jurisdictions to source PEP starter packs and recommendations regarding specialist access (see Resources)60
Follow up PEP requires an authorised prescriber (under Section 100 Special Access Scheme)
|People with opioid dependence
||Opioid substitution therapy should be made accessible to all populations, including those in prison populations and other closed settings
||As early as possible in dependence situation
||Injecting drug users
||Needle and syringe programs should be made available to all populations including prison populations
Recommendations: Sexually transmissible infections
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||All people aged 15–29 years of age if sexually active
All people aged ≥30 years and at high risk (see Table 8.1)
|Recommend nucleic acid amplification tests (NAAT) via:
- endocervical swab if having a speculum examination, or
- first void urine, or
- self administered low vaginal swab
||IA (to age 25 years)35,41
GPP (25–29 years)
|All pregnant women
|Pregnant women at high risk of STI (see Table 8.1)
||First visit and again in third trimester
|Women having a termination of pregnancy
|Men who have sex with men
||Recommend first void urine NAAT and anal swab NAAT
||Sexually active people aged 15–39 years and pregnant women where local prevalence rates are high (see reference 7)
||Recommend NAAT (as above)
||IIB (age <25 years)11,41
GPP (age 25–39 years and pregnant women)
|Men who have sex with men
||Recommend throat swab NAAT and culture, plus anal swab NAAT and culture
||Annually or 3–6 monthly if high risk (see Table 8.1)
|Screening: Trichomonas vaginalis
||All sexually active people aged <35 years where local prevalence rates are high (see Resources)
||Recommend NAAT for women (as above) and first void urine NAAT for men
||Opportunistic if symptomatic
||All pregnant women
||Recommend testing with specific treponemal tests (EIA or TPPA or FTA-Abs) and non-specific treponemal tests (RPR). Liaise with local pathology providers to determine which tests are available for screening
||At first visit
Repeat at 28 weeks if positive, in a high prevalence area or if risk factors for STIs are present
Men who have sex with men
Others at high risk of STIs
Syphilis testing as above
Recommendations: Bloodborne viruses
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||Recommend HBV vaccination
||Once at birth prior to leaving hospital
|Babies born to mothers who are HBsAg positive
||Recommend HBV immunoglobulin and vaccination at birth
Complete primary course of vaccination, followed by testing for anti-HBs and HBsAg at 3–12 months after completing vaccination (see Australian Immunisation Handbook)
|Immunoglobulin (HBIG) ideally within 12 hours and vaccination (HBV) preferably within 24 hours (definitely within 7 days) of birth
|Unvaccinated people at high risk of STI/ BBV infection (see Table 8.1)
||Recommend HBV vaccination Test healthcare workers, those at risk of severe or complicated disease, haemodialysis patients, sexual partners and household contacts of recently notified HBV carrier for seroconversion
||3 doses at 1 and
4–8 weeks after the last dose
|Individuals exposed to HBsAg positive individuals or unable to be identified and tested rapidly
||Offer HBV post-exposure prophylaxis (HBIG and primary course of vaccination) for non-immune people
||Initiate within 72 hours (or 14 days for sexual contact)
|People with HCV infection or chronic liver disease not immune to HBV
||Recommend HBV vaccination
||3 doses at 0, 1 and 6 months*
||Girls/women prior to first sexual activity
Females who are sexually active
|Recommend HPV vaccination (see Chapter 15, recommendations for cervical cancer prevention)
||10–13 years of age: school-based
14–26 years of age at cost to the patient
||Men who have sex with men
Injecting drug users
People with chronic HBV and HCV infection
|Recommend hepatitis A vaccination if serology is negative (see Australian Immunisation Handbook)
||Non-vaccinated or vaccine status unknown
People at high risk for BBVs
|Offer individual HBV screening including:
See Resources for guidelines on interpreting HBV tests
- HBsAg ( a marker of acute or chronic infection)
- HBsAb (a marker of immunity)
- HBcAb (a marker of recent or past infection)
If serology is negative, offer HBV vaccination as above*
|All pregnant women
||Recommend HBV screening to allow timely HBV vaccination and HBIG for infant at birth
(see Chapter 9: Antenatal health)
|At first antenatal visit
||People at high risk of contracting HVC infection (see Table 8.1)
||Offer HCV serology testing
||As part of an annual health assessment
|Infants born to HCV infected mothers
||Offer HCV serology testing
||18 months of age (repeated if positive)
||Offer HIV serology testing
||At first antenatal visit
|Men who have sex with men and others at high risk of BBVs (see Table 8.1)
||As part of an annual health assessment
|* Not subsidised on the National Immunisation Schedule but check relevant state/territory immunisation programs
Table 8.1. Risk factors for STIs and bloodborne viruses
|Risk factors for STIs||Risk factors for BBVs|
- Age <30 years
- Age <35 years and sexual network relates to a remote community
- Multiple current partners
- Engaging in group sex
- New partner
- Using condoms inconsistently
- Living in an area with a high incidence of STIs
- Having sex while under the influence of drugs and alcohol
- Having sex in exchange for money or drugs
- Prison incarceration
- Victim of sexual assault
- Men who have sex with men where any of the above risk factors are also present
- Prison incarceration: current or past
- Blood transfusion prior to 1990
- Tattoos or piercings not performed in a sterile professional setting
- Cultural practices (ie. initiation ceremonies)
- Current or past injecting drug use
- Household member with HBV, HCV or HIV
- Sexual partner with HBV, HCV or HIV
- Infants of mothers infected with HCV, HBV or HIV
|Source: Bradford D, Hoy J, Matthews G 200810
Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: surveillance and evaluation report 2011 (The Kirby Institute)
www.med.unsw.edu.au/ NCHECRweb.nsf/resources/2011/ $file/KIRBY_ATSIP2011.pdf
Sexual health clinical management guidelines (Queensland Government)
Clinical guidelines for the management of sexually transmissible infections among priority populations (RACGP)
Guidelines for managing sexually transmissible infections
Management of genital Chlamydia trachomatis infection: a national clinical guideline (Scottish Intercollegiate Guidelines Network)
Sexually transmissible infections: UK national screening and testing guidelines
Drug misuse: psychosocial interventions, national clinical practice guideline number 51 (National Collaborating Centre for Mental Health)
Australasian contact tracing manual (ASHM)
http://ctm.ashm.org.au/ Default.asp?PublicationID=6&Parent SectionID=P6&SectionID=733
HIV, viral hepatitis and STIs: a guide for primary care (ASHM)
www.ashm.org.au/ images/publications/monographs/HIV_viral_ hepatitis_and_STIs_a_guide_for_primary_care/ hiv_viral_hepatitis_and_stis_whole.pdf
Hepatitis B virus testing and interpreting results (ASHM)
www.ashm.org.au/ images/publications/monographs /b%20positive/b_positive-chapter_3.pdf.
Drug use resources
Counsellor’s guide to working with alcohol and drug users
www.dao.health.wa.gov.au/ InformationandResources/Publicationsandresources/ Healthprofessionals.aspx
Drug and alcohol psychosocial interventions professional practice guidelines (New South Wales Department of Health)
Drug misuse: psychosocial interventions, national clinical practice guideline number 51 (National Collaborating Centre for Mental Health)
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (World Health Organization)
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