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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 14: Sexual health and blood-borne viruses
☰ Table of contents


Recommendations: General prevention advice

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

All sexually active people aged ≤30 years
People with risk factors for sexually transmitted infections (STIs) and blood borne viruses (BBVs) (Box 1)
Screen for chlamydia, gonorrhoea and, if a high prevalence area, trichomoniasis (refer below)

Offer screening for human immunodeficiency virus (HIV), syphilis and hepatitis B virus (HBV) (refer below)
Annually GPP

I
46

14, 47
  Consider offering females a human papillomavirus (HPV) test for cervical cancer screening (refer to Chapter 15: Prevention and early detection of cancer) Opportunistic GPP 48
People diagnosed with an STI Review STI risk factors and, if not already done, screen for other STIs according to local prevalence guidelines
Screen for BBVs if risk factors present
(refer below and Box 1)
Upon diagnosis, and re-test for all three months posttreatment GPP 46
Sexual partners of a person with an STI Ensure contact tracing is undertaken at time of diagnosis

Contact should be offered screening for STIs, HIV, syphilis and HBV, and be offered immediate treatment for the STI the index case had
Options include ‘partner referral’, possibly including patient-delivered partner therapy; or ‘provider referral’ in consultation with the local sexual health team*
Every new diagnosis of an ST GPP 49
All sexually active patients Provide sexual health counselling, including proactive discussion of issues of sexuality (Box 2) Opportunistic II 50, 51

Behavioural

All sexually active patients Patients should be advised to use condoms in new relationships until both partners have had an STI check Opportunistic GPP 34
People at higher risk of hepatitis B or C infection (Box 1) Provide counselling on harm minimisation and promote peer education strategies around safer sex and injecting drug use Opportunistic and as part of annual health check GPP 52
People with substance use Conduct brief motivational interviewing to reduce use of illicit drugs, harm with injection of drugs, risky alcohol use and risk of BBV infection and STIs, particularly for those unlikely to attend specialist treatment Opportunistic GPP 53
People with exposure to HIV, occupational or nonoccupational Assess post-exposure risk using national guidelines17 and provide post-exposure prophylaxis (PEP) within 72 hours of the risk exposure when indicated (refer to ‘Resources’) Opportunistic GPP 37

Chemo-prophylaxis

People at high risk of nonoccupational HIV exposure, including men who have sex with men, intravenous drug users, and partners of HIVpositive people Consider eligibility for pre-exposure prophylaxis (PreP) (refer to ‘Resources’) Opportunistic III 36
Condom access Ensure access to condoms (preferably free, private and available at all hours) Opportunistic GPP 54, 34

Environmental

People with opioid dependence Refer to an opioid substitution therapy program for all interested individuals, including those in prison, rehabilitation and detention centres As early as possible in dependence situation III 40
People who inject drugs Needle and syringe programs should be made available to all populations, including prison populations Opportunistic IIA 55
*With patient referral, the index case contacts their own sexual contacts. In this circumstance, the health provider gives guidance on the advice to be translated to partners. This may also include ‘patient-delivered partner therapy’ (such as azithromycin for chlamydia). Another form of contact tracing is through provider referral, whereby the patient provides the healthcare provider with the contact details for their sexual partners. This allows for confidential contact tracing and is the method of choice for serious infections such as HIV.

Recommendations: Sexually transmitted infections

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening – chlamydia

All people aged 15–30 years if sexually active

All people aged >30 years if sexually active and at high risk (Box 1)
Recommend nucleic acid amplification tests (NAAT) via:
  • (for women) endocervical swab if having a concurrent speculum examination, or selfadministered vaginal swab, or first void urine
  • (for men) first void urine
Annually GPP (to age 25 years) GPP (25–29 years) 56, 57
All pregnant women First visit
Pregnant women at high risk of STI (Box 1) First visit and again in third trimester
Women having a termination of pregnancy Opportunistic
Men who have sex with men in the presence of other risk factors (Box 1) Recommend first void urine, throat and anal swab for chlamydia NAAT Annually or 3–6-monthly if high risk (Box 1) GPP 58

Screening – gonorrhoea

All people aged 15–30 years if sexually active

Pregnant women who are at risk

All people aged >30 years if sexually active and at high risk (Box 1)
Recommend gonorrhoea NAAT via samples as for chlamydia

Include screening for chlamydia infection (as above)
Annually GPP 57, 59, 60
Men who have sex with men Recommend gonorrhoea NAAT using first void urine

Include throat swab NAAT and culture, plus anal swab NAAT and culture
Annually or 3–6-monthly if high risk (refer to Box 1) GPP 61

Screening – trichomoniasis

All sexually active people aged ≤30 years in regional/remote areas or where local prevalence rates are high Recommend NAAT for women (as above) and first void urine NAAT for men Annually GPP 59

Screening – syphilis

All pregnant women Recommend syphilis serology (refer to Chapter 2: Antenatal care) At first visit

Repeat at 28 weeks’ gestation if in a high prevalence area, or if risk factors for STIs are present
II–IV 62
Men who have sex with men
Others at high risk of STI (Box 1)
Recommend syphilis serology Annually or 3–6-monthly if high risk (Box 1) IB 56

 

 

Recommendations: Blood-borne viruses

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation – hepatitis B virus (HBV)

 

 

 

 

 

Neonates Recommend hepatitis B vaccination as per National Immunisation Program Schedule (NIPS) At birth prior to leaving hospital, and at two, four and six months I
GPP
63, 64
Babies born to mothers who are hepatitis B virus surface antigen (HBsAg) positive Recommend HBV immunoglobulin and vaccination at birth

Complete primary course of vaccination, followed by testing for antiHBs and HBsAg at age 3–12 months after completing vaccination
Hepatitis B immunoglobulin (HBIG) ideally within 12 hours and certainly within 48 hours of birth. HBV vaccine preferably within 24 hours and certainly within seven days of birth I 25, 65
Adults who have not previously been vaccinated against hepatitis B and are non-immune Recommend hepatitis B vaccination Three doses – refer to The Australian immunisation handbook IB 63
Healthcare workers, sex workers, those at risk of severe or complicated disease, haemodialysis patients, sexual partners and household contacts of people recently identified as hepatitis B carriers Test for seroconversion 4–8 weeks after the last dose GPP  
Individuals exposed to a person who is HBsAg positive or who is at high risk of HBV infection and is unable to be identified and tested rapidly Offer HBV postexposure prophylaxis (PEP) (HBIG and primary course of vaccination) for nonimmune people Initiate within 72 hours (or 14 days for sexual contact) IIC 25
People with hepatitis C virus (HCV) infection or chronic liver disease who are non-immune to hepatitis B Recommend hepatitis B vaccination Three doses – refer to The Australian immunisation handbook IIC 25,66–68

Immunisation – human papillomavirus (HPV)

Young people prior to first sexual activity

Females who are sexually active and have not yet been vaccinated
Recommendations vary with age, sexual orientation and gender (consult The Australian immunisation handbook, chapter 4.6 for more information) Children aged 9–18 years – refer to The Australian immunisation handbook GPP 25, 50, 69, 70

Immunisation – hepatitis A virus (HAV)

Men who have sex with men
Injecting drug users
People with chronic HBV or HCV infection
Recommend testing for hepatitis A immunity and offer hepatitis A vaccination if non-immune Two doses – refer to The Australian immunisation handbook GPP 25,. 71

Screening – HBV

Non-vaccinated or vaccine status unknown

People at high risk for BBVs (Box 1)

Healthcare workers
Offer HBV screening with:
  • HBsAg (a marker of acute or chronic infection)
  • hepatitis B surface antibody (HBsAb) (marker of immunity either from vaccine or infection)
If non-immune, offer hepatitis B vaccination as above
Opportunistic and as part of an annual health assessment GPP 72–74
All pregnant women Recommend HBV screening to allow timely HBV vaccination and HBIG for infant at birth (if necessary), and offer antiviral treatment for mother during pregnancy if HBsAg positive and HBV DNA >106 copies/ ml75 (refer to Chapter 2: Antenatal care) At first antenatal visit I–III 75, 76

Screening – HCV

People at high risk for contracting hepatitis C infection (Box 1) Offer HCV serology testing Opportunistic and as part of annual health assessment IIIA 71
Infants born to HCV-infected mothers Offer HCV serology testing Age 18 months (repeat if positive) IIIA 71, 77

Screening – human immunodeficiency virus (HIV)

Pregnant women Offer HIV serology testing At first antenatal visit III–IV 62
Men who have sex with men, and others at high risk of BBVs (Box 1) As part of annual health assessment and 3–6-monthly

Box 1. Risk factors for sexually transmitted infections and blood-borne viruses6

Risk factors for sexually transmitted infections (STIs)

Risk factors for blood-borne viruses (BBVs)

  • Age <30 years
  • Age <39 years and sexual network relates to a remote community
  • Multiple current partners
  • High rate of partner change
  • Engaging in group sex
  • New partner
  • Using condoms inconsistently
  • Live in and have sex with people from areas 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
  • Victims 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 professionally
  • Cultural practices
  • Current or past injecting drug use
  • Household member with HBV
  • Sexual partner with HBV, HCV or HIV
  • Infants of mothers infected with HBV, HCV or HIV
  • Persons born in regions with a ≥2% prevalence of chronic HBV infection
  • Candidates for immunosuppressive therapy

HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus

Box 2. Strategies and questions for asking about sexually transmitted infection risk 6

  • Ask a health worker of the same gender to help
  • Ask someone experienced in your clinic for ideas
  • Use simple explanations before asking screening risk questions – for example:
    • In our region there are a lot of infections you can get from sex. Some can stop you having kids. Most people don’t know they have them, but there are good medicines to fix them. So, I’m going to ask you some questions now about sex, to see whether it’s a good idea to check you for them with a simple pee and blood test.
    • Questions: Do you have a regular partner? Any other partners? Were your partner(s) male or female? Where was he/she from? How many partners have you had in the last six months? Did you use condoms? What kind of sex did you have?

Background


There are widely varying prevalence rates for sexually transmitted infections (STIs) and blood-borne viruses (BBVs) within Aboriginal and Torres Strait Islander populations,1 reflecting different transmission risks from lack of condom use, use of needle exchange programs, sexual partner promiscuity, understanding of safe sex, cultural values and poor access to healthcare.2 The majority of STI notifications (80%) for both the general population and Aboriginal and Torres Strait Islander peoples are in the age group 15–29 years. STI rates are higher in remote areas where the proportion of Aboriginal and Torres Strait Islander people is higher. Owing to under-identification of Aboriginal or Torres Strait Islander status, disease prevalence and incidence are difficult to reliably estimate; however, notification rates do appear to be increasing. Comparisons of STI rates between non-Indigenous people and Aboriginal and Torres Strait Islander peoples shows a significant difference between the two groups (Table 1). Syphilis notifications have increased four-fold in young Aboriginal and Torres Strait Islander people over the years 2010–15. This increase has been driven largely by the current syphilis outbreak across northern Australia.3
BBV notification rates are also higher in Aboriginal and Torres Strait Islander populations compared with rates in other Australians, particularly hepatitis C related to injecting drug use (Table 1). There are significant risks for increased rates of human immunodeficiency virus (HIV) in Aboriginal and Torres Strait Islander Australians due mainly to high rates of intravenous drug use and STIs, and often less access to condoms and pre-exposure prophylaxis (PrEP). For example, HIV infection rates in males have risen two-fold over the period 2011–15.1

Poverty, discrimination, substance abuse and incarceration all affect sexual behaviours and are associated with an increased risk of STIs and BBVs4 (Box 1).
 

Table 1. National incidence of selected sexually transmitted infections and blood-borne viruses, per 100,000 population, and rate ratio of Aboriginal and Torres Strait Islander to non-Indigenous notifications in 20151

 

Aboriginal and Torres Strait Islander notifications/100,000 population

Non-Indigenous notifications/100,000 population

Rate ratio

Chlamydia

1,325

391

3.4

Gonorrhoea

626

62

10

Syphilis

61

10

6

Human immunodeficiency virus (HIV)

6.8

3.1

2.2

New case hepatitis C

167

36

4.6

New case hepatitis B

66

22

3


STIs and BBVs can cause significant complications, especially in pregnancy, which is why antenatal care, including comprehensive testing for STIs and BBVs, is so important. Antenatal engagement and screening should commence at earlier ages for Aboriginal and Torres Strait Islander mothers, as they tend to be younger and have higher fertility rates in the younger age groups than non-Indigenous mothers5 (refer to Chapter 2: Antenatal care).

STIs and BBVs are often asymptomatic. Diagnosis and management are dependent on accurate risk assessment, screening and education. The majority of STIs in Australia are diagnosed in primary care rather than in specialist sexual health clinics.6 Therefore, primary care staff need adequate skills to make a comprehensive sexual health and BBV assessment in a non-judgemental way. Empathy, sensitivity to the patient’s feelings and needs, accessibility, a stated commitment to confidentiality, and sufficient medical knowledge on diagnosis and management of STIs are all important. A short explanation for questions can minimise embarrassment for both patient and clinician, obtain a true assessment of STI and BBV risk and increase engagement, management and education. This is particularly true of younger age groups (eg teenagers) and remote communities where STI and BBV risks are higher (Box 2).

Those with symptoms require encouragement to attend the clinic for testing and treatment. This involves a focus on patient education and making the health service acceptable to people via empathy, flexible care delivery, presence of both male and female practitioners and non-judgemental approaches. Outreach work is invaluable for this as it involves moving care from the clinic and into the community to offer sexual health services.
Testing for STIs and BBVs is simple, non-invasive and accurate, and for many diseases there are effective prophylactic measures and single-dose treatments. When testing is combined with discussions about contraception and condoms, a systematic and comprehensive approach to STI and BBV management and prevention in primary care can be adopted.

 


Specific sexually transmitted infections


Chlamydia

Chlamydia trachomatis is the most commonly diagnosed STI.7 Notification rates in Australia in the general population have plateaued since 2011 after rising for the 15 years prior. However, in 2015 the chlamydia notification rate in major cities for Aboriginal and Torres Strait Islander peoples was twice as high as among non-Indigenous people, increasing to eight times higher in remote areas.1 Asymptomatic infection is common in both sexes; for example, an estimated 85% of chlamydia infection does not present symptomatically.8 Asymptomatic males are at higher risk of developing urethritis, epididymitis and a reactive arthritis (Reiter’s syndrome) as a result of chlamydia infection. In women, chlamydia can cause cervicitis with the risk of developing salpingitis and pelvic inflammatory disease, ectopic pregnancy, infertility and chronic pelvic pain. Chlamydia can be transmitted from mother to baby during birth causing conjunctivitis, pneumonia and otitis media. Chlamydia infection in adults is easily tested for with a first void urine sample or high vaginal swab (often performed by the patient herself), and, if uncomplicated, treated with a single dose of azithromycin.9 In the event of complications such as those outlined above or in the case of rectal infection, single dose therapy is not indicated and doxycycline 100 mg orally twice daily for seven days may be given.7

Gonorrhoea

Gonorrhoea is diagnosed ten times more commonly in Aboriginal and Torres Strait Islander peoples than in non-Indigenous people.1 The incidence increases with remoteness, and with those belonging to higher risk groups such as sex workers and men who have sex with men (Box 1).1 Gonorrhoea is a purulent infection of mucous membranes caused by Neisseria gonorrhoeae. It is largely asymptomatic in women but approximately 90% of men may suffer symptomatic urethritis, proctitis, epididymitis and, rarely, prostatitis. In women, it is a major cause of cervicitis and pelvic inflammatory disease, which can lead to chronic pelvic pain, infertility and ectopic pregnancy. In both sexes, locally acquired infection during oral sex can lead to pharyngitis while disseminated infection from both genital and oral sex can cause gonococcal septic arthritis. Infection during pregnancy can cause premature rupture of membranes, and infection at birth can result in neonatal gonococcal conjunctivitis. Like chlamydia, gonorrhoea is easily tested for with first void urine or, in the case of women, endocervical or high vaginal swabs, and in most jurisdictions (check local guidelines) first-line treatment is with both intramuscular ceftriaxone and oral azithromycin owing to increasing antibiotic resistance.10

Trichomoniasis

Trichomonas vaginalis is a protozoal infection notifiable only in the Northern Territory. In Australia, trichomoniasis is more common in older women and women from rural and remote areas, and especially in Aboriginal and Torres Strait Islander peoples, among whom 2012 rates were 3595.7 per 100,000 population versus 38.6 in non-Indigenous people.11 It is an uncommon cause of vaginal discharge or male urethritis in urban settings. Trichomoniasis remains detectable for years and becomes a chronic disease if it is left untreated in women.12 Trichomoniasis infection is considered problematic not only because it increases the risk of serious complications in pregnancy, such as premature rupture of the membranes and pre-term delivery, but also because of increased susceptibility to HIV.13,14 Despite its association with pregnancy complications, treatment of asymptomatic trichomoniasis infection has not been shown to reduce the rate of these complications. Managing trichomoniasis infection in pregnancy requires specialist advice (refer to Chapter 2: Antenatal care, for more information about screening).
In rural and remote Aboriginal and Torres Strait Islander populations (Modified Monash Category 3 [MMC3] and above), trichomoniasis is important to screen for because of the high incidence of infection, which owing to the chronic nature of persistent infection13 appears to increase with age in women, and because it increases the transmission of HIV.1 Screening is recommended in people aged <35 years in high-risk populations (Box 1) and is easily added to a first void urine sample collected when conducting polymerase chain reaction (PCR) testing for chlamydia and/or gonorrhoea.

Syphilis

Infectious syphilis notifications in Aboriginal and Torres Strait Islander people who are residing in remote areas have increased in the last five years. This is related to an outbreak that originated in Far North Queensland in 2015 and subsequently spread to most of northern Australia. Although there have been several congenital syphilis cases associated with this outbreak, notifications of congenital syphilis overall have remained stable over the last decade.3 Syphilis notifications are also higher in men who have sex with men.

Syphilis management is complicated and infection is usually asymptomatic, so screening is an important control measure.15
Newly acquired syphilis is diagnosed in the presence of symptoms or signs such as chancre, rash, or wartlike condylomata lata, or alternatively this diagnosis is made when previous serology has become positive within two years of the original negative test. Typically, all patients will experience a chancre; however, this is not always obvious to the patient and generally resolves spontaneously. Complications of newly acquired syphilis include pregnancy loss and congenital syphilis. Longer term sequelae are rare but include neurosyphilis and cardiac complications. A lesion is required for sexual transmission to partners to occur.
Following newly acquired syphilis, there is typically a latent phase whereby secondary syphilis may develop. Latent syphilis is defined as asymptomatic infection together with positive serology where there have either been no previous tests (ie it is of unknown duration), or more than two years since the last negative test. Latent syphilis is usually only transmitted vertically from mother to child, not to partners; however, should secondary syphilis develop with symptoms, the patient is once again infective to partners until symptoms resolve. Highly specific treponemal antibody syphilis tests usually remain positive for years and are a poor marker of disease activity.16 Therefore, in the event a patient has had a previous infection, expert interpretation is often indicated via the local public or sexual health unit.

Human papillomavirus

Human papillomavirus (HPV) genotypes 16 and 18 are the causative agents in 70–80% of all cervical cancers and are also implicated in vulval, vaginal, anal and penile cancers. HPV genotypes 6 and 11 are associated with 90% of genital warts and are rarely associated with cancer, and as such they are considered low risk.17,18 Infections tend to occur most commonly in those aged 15–25 years in Australia; however, prevalence rates are changing due to the introduction of vaccination programs (refer below). Vaccination is recommended and funded for all school-age Australians. Education around the harms of HPV infection should be part of a comprehensive approach and include use of condoms for prevention and discussion of smoking as a risk factor for genital cancer.12

Other STIs

Donovanosis is an ulcerative STI affecting predominantly Aboriginal and Torres Strait Islander communities. There have been no locally acquired notifications in Australia for four years and eradication of this condition in Australia is becoming more likely.19 This is largely due to case finding those with symptoms and use of effective azithromycin-based treatment regimens delivered within comprehensive primary healthcare settings.

Genital herpes is a common STI caused by herpes simplex virus types 1 and 2, and over half of cases are type 1. Men and women present similarly, typically with an initial episode of ano-genital ulceration and systemic features, followed by multiple relapses, recurrent, painful splitting of the skin and erythema with or without itch. The largest disease burden comes from the significant psychosexual affects owing to frequent relapses and increased HIV transmission. Diagnosis of genital herpes requires visual lesions to be present as swabs must be taken from a de-roofed ulcer or from the base of the ulcer. Following this, antiviral treatment with valaciclovir 500 mg orally twice daily for five days or longer (if severe) is indicated. Recurrences may be treated with the same dose of valaciclovir for three days because viral replication in recurrent infection tends to be shorter lived. Suppressive therapy for at least six months’ duration is indicated for frequent, severe recurrences and may also prevent spread to partners.7

Neonatal herpes is the most significant complication of genital herpes and carries a high morbidity and mortality. It is important to ask pregnant women about past genital herpes simplex virus infections, especially if immunocompromised,20 to determine if suppressive therapy may be required.

Blood-borne viruses

Human immunodeficiency virus

Human immunodeficiency virus (HIV) prevalence in Australia is lower than in most comparable high-income countries and this has been attributed to early adoption of needle and syringe programs (NSPs) and effective early education and community engagement, particularly for those in high-risk groups such as men who have sex with men. Co-infection with chlamydia, gonorrhoea and/or trichomoniasis is a significant risk factor for HIV, both in acquisition and transmission, highlighting the importance of regular STI screening to reduce the risk of HIV co-infection.12
HIV incidence in 2015 was more than two times higher for Aboriginal and Torres Strait Islander peoples than for other Australians. Notification rates were highest in Aboriginal and Torres Strait Islander people aged >35 years at 9.8 per 100,000 – nearly three times higher than in the Australian-born non-Indigenous population of the same age group. While HIV notification rates in Aboriginal and Torres Strait Islander males were stable previously, from 2011 to 2015 there was a two-fold increase (from 6.2 per 100,000 in 2011 to 12.4 per 100,000 in 2015). Over the same time, rates in other Australian-born males decreased by 12%. Increased notifications of newly diagnosed HIV in Aboriginal and Torres Strait Islander peoples when compared to non-Indigenous people have been attributed to intravenous drug use (16% versus 3% of HIV notifications respectively) and heterosexual transmission (21% versus 14% of HIV notifications respectively). In one-third of new HIV diagnoses among Aboriginal and Torres Strait Islander peoples in 2015, the infection was likely to have been present for more than four years prior to diagnosis based on immune function tests.1 Late diagnosis is likely to be have been a legacy of lesser access to health services and reduced awareness of risk in this population.

Antiviral therapy is recommended in all with HIV, and strict adherence to multidrug regimens is critical to both minimising the risks of resistance and suppression of viral levels. Effective viral suppression minimises ongoing damage to the immune system and decreases risk of transmission.9
HIV testing in early pregnancy is strongly recommended as antivirals administered during pregnancy and labour can prevent up to two-thirds of neonatal HIV infection,21 and shorter courses can prevent transmission in between a half and two-thirds of cases.22

Hepatitis C virus

The rate of hepatitis C virus (HCV) diagnosis in Aboriginal and Torres Strait Islander peoples in 2015 was nearly five times higher than in non-Indigenous people.1 The rate of newly acquired HCV infection (ie hepatitis C infection with evidence of acquisition in the 24 months prior to diagnosis) in Aboriginal and Torres Strait Islander peoples in 2015 was 13 times that of non-Indigenous people (26 versus two per 100,000 respectively), possibly reflecting higher rates of risky behaviours. In the last five years, there has been a 45% increase in the notification of newly diagnosed HCV infection in Aboriginal and Torres Strait Islander peoples, whereas the rate in non-Indigenous people decreased by 10% over the same period.1 In a 2015 survey, receptive syringe sharing (sharing a needle after an HCV-positive person has used it), a key risk factor for HCV transmission, was reported to be higher among Aboriginal and Torres Strait Islander peoples (24%) than among non-Indigenous people(14%).1
Medications made available recently under the Pharmaceutical Benefits Scheme (PBS) for hepatitis C treatment are highly effective, easy to take and have low rates of side effects. A sustained virological response (ie no detectable virus six months after completing treatment) can be expected in between 80% and 95% of cases with oral regimes of between eight weeks and six months’ duration, depending on the serotype of virus and the presence or absence of cirrhosis. Treatment in primary care should be considered for all people with HCV regardless of the presence of risky behaviours such as ongoing illicit substance use. In the case of complex infections (eg HBV co-infection, presence of cirrhosis), referral for specialist management is recommended.23

Hepatitis B virus

In 2015, the notification rate of newly diagnosed hepatitis B virus (HBV) infection for Aboriginal and Torres Strait Islander peoples was three times higher than for non-Indigenous people across all age groups. Over 2011–15, there was a 22% decline in the notification rate of newly diagnosed HBV infection in Aboriginal and Torres Strait Islander peoples (from 85 per 100,000 in 2011 to 66 per 100,000 in 2015), compared to a plateau in rates in the non-Indigenous population (22 per 100,000 in 2015). At the end of 2015, of all the Australians living with chronic HBV, 9% were Aboriginal and Torres Strait Islander people, with higher rates among those living in a remote area.12,24 In 2013, the prevalence of HBV in an Australian annual prison intake survey was 3.6% in Aboriginal and Torres Strait Islander people and 2.6% in non-Indigenous people.1
Universal vaccination programs commenced in 1990 in the Northern Territory and were implemented Australia-wide in 2000. The decrease in HBV prevalence, especially in those aged 15–29 years, may reflect a cohort who are immune upon the commencement of sexual activity.1
Hepatitis B serology interpretation can be confusing, but recent guidelines are helpful to primary clinicians.24 Chronic HBV infection causes cirrhosis in approximately 25% of adults over a 20-year period and is a risk factor for hepatocellular carcinoma. The lifetime risk of cirrhosis is 20–30% in those with perinatal and childhood HBV infections.25 While treatment of chronic HBV is not as effective as that now available for HCV, treatment reduces the progression to cirrhosis and induces some regression of cirrhosis in 70% of cases,26 thereby decreasing the risk of hepatocellular carcinoma by two-thirds.27 Trained and accredited general practitioners (GPs) can prescribe hepatitis B treatment or refer patients for specialist management.28
Additionally, HBV is more likely to be chronic if acquired early. Therefore, encouraging screening and vaccination pre-pregnancy and during pregnancy is very important in order to manage the risk of mother-tobaby transmission.


Interventions


Immunisation

The 2006 national school-based program of HPV vaccine is offered to both sexes from age nine years. Early data indicate the program is already effective and has resulted in declining incidence of both warts (59% decrease) and high-grade cervical lesions on Pap smears (48% decrease) in Australia.25 A significant decline in genital warts has also been observed in young Aboriginal and Torres Strait Islander people.29 This has yet to be translated to reduced cervical cancers in Aboriginal and Torres Strait Islander women. This is possibly explained by the long time after HPV exposure (decades) that it can take to develop cervical abnormalities.30 However, this vaccination program is expected to significantly alter the trajectory of HPV infection and associated complications.9
Australia-wide universal HBV vaccination at birth commenced from 2000. Although HBV incidence rates are declining, the need for prevention and management of chronic HBV infection remains, particularly among older Aboriginal and Torres Strait Islander people.
The Australian immunisation handbook recommends hepatitis A vaccine for people who have chronic HBV or HCV infection, as concurrent infection with hepatitis A can greatly increase the risk of liver complications.25 The original 1999 Queensland hepatitis A vaccination program was expanded in 2005 to include all Aboriginal and Torres Strait Islander children aged <2 years in the Northern Territory, Queensland, South Australia and Western Australia.25

Screening

Annual screening and management programs in Aboriginal and Torres Strait Islander communities have been shown to decrease STI prevalence locally, particularly if screening has good coverage of young people.31 Western Australian guidelines recommend six-monthly screening in younger populations residing in remote areas. There is also emerging evidence that more frequent population-based screening for STIs may reduce STI incidence rates further.14,31
With the introduction of nucleic acid amplification tests (NAATs) or PCR tests in the 1990s, screening for chlamydia, gonorrhoea and trichomoniasis on a single urine or swab test has a high sensitivity and specificity, is much more acceptable to people, and can be reliably performed in places far from laboratories.7 As NAATs do not currently detect antibiotic resistance in N. gonorrhoeae, strategies are required to culture specimens for antibiotic sensitivity surveillance to inform which antibiotics should be used. STI screening activity should also include education about STIs and safe sex advice including the use of condoms for prevention.25

Point-of-care testing (POCT) is increasingly being taken up in northern Australia.32 POCT uses robust tests on a par with the NAATs and the time taken for a result can be reduced from weeks to 90 minutes, which can reduce the time to treatment and for contact tracing. It should be noted, however, that for syphilis and HIV, POCT testing is not as effective as NAAT and thus should not be used. Further, POCT is costly and is not subsidised under the Medicare Benefits Schedule (MBS).

Routine syphilis screening is recommended in the first trimester for all Aboriginal and Torres Strait Islander women who are pregnant. Individual antenatal patients who remain at high risk for STIs and those from, or who have sexual networks with, northern Australian Aboriginal and Torres Strait Islander communities should be considered for re-screening for STIs, including syphilis, in the third trimester (refer to Chapter 2: Antenatal care). Point-of-care antenatal syphilis tests have been trialled overseas and show promise for improving timeliness of treatment, but are not yet available routinely in Australia.33

Behavioural factors

Screening for STIs provides the opportunity to offer prevention and health promotion advice. Consistent condom use for vaginal and anal sex significantly reduces the risk of STI transmission and is the most effective method of preventing HIV transmission.34 When discussing safe sex practices, it is important to recommend the use of condoms with water-based lubricant, and to discuss the barriers to condom use and how they might be overcome. Patients should be advised to use condoms in new relationships until both partners have had an STI check. Additional issues to raise may include exploring personal safety, self-respect and respect for others in sexual relationships.9
The Australasian Society for HIV Medicine (ASHM; full title now Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine) publication HIV, viral hepatitis and STIs: A guide for primary care9 includes excellent history-taking and risk-assessment approaches. It is vital to provide plain language information on STI transmission and prevention, and to build rapport with Aboriginal and Torres Strait Islander people during sexual health consultations. The guide includes an appendix by state and territory of clinicians’ legal obligations. It is important to be familiar with the legislation in your state or territory regarding sexual activity in persons aged <18 years given mandatory reporting requirements in some jurisdictions.
The Australasian contact tracing guidelines has an excellent section on contract tracing considerations when working with Aboriginal and Torres Strait Islander peoples.35 Contact tracing and partner notification are synonymous terms, and there are two different ways in which this can be conducted. The first form of contact tracing is through patient referral, whereby the index case contacts their own sexual contacts. In this circumstance, the health provider gives guidance on the advice to be translated to partners. This may also include ‘patient-delivered partner therapy’ (such as azithromycin for chlamydia). The second form of contact tracing is through provider referral, whereby the patient provides the healthcare provider with the contact details for their sexual partners. This allows for confidential contact tracing and is the method of choice for serious infections such as HIV.

Chemoprophylaxis

Specific to HIV transmission, PrEP with daily oral medication can prevent HIV infection from occurring. The efficacy of PrEP has now been established by several randomised placebo-controlled trials conducted in men who have sex with men, heterosexual adults and intravenous drug users. Daily PrEP is considered safe and effective to reduce the risk of HIV infection in high-risk adults who are able to take the medicine correctly and consistently.36 It is available currently in most jurisdictions to high-risk populations (men who have sex with men, intravenous drug users, or partners of HIV positive people) on a trial basis. Contact your local sexual health service for more information.

Post-exposure prophylaxis (PEP) with daily medication after exposure to HIV can also reduce the risk of infection. The exposure could be via a biohazard exposure 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 of exposure, which involves the prescription of a course of medication.37

Environmental interventions

Access to free condoms is an important consideration given their value in preventing HIV and STI transmission.34 The condom tree program in the Kimberley is an example of making condoms more available after hours in a rural setting.38 GPs in urban practices can also consider putting condoms in clinic patient toilets to improve access.

Harm minimisation is the principle underlying Australia’s National Drug Strategy, and this policy has been implemented 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 in many settings in Australia, including prison.9 NSPs provide sterile injecting equipment and are an effective, safe and cost-effective component of harm reduction strategies. Using a mathematical model, it is estimated that over the period 2000–09, NSPs cost $243 per capita but achieved a net saving of $1.03 billion in preventing 32,056 new HIV infections, and 96,667 new HCV infections.39
The incidence of injecting drug use among Aboriginal and Torres Strait Islander peoples, and the associated prevalence of HCV positivity, has been steadily increasing over the last decade. The rate of HIV in this population is low, with less than 1% being HIV positive over the NSP survey collection period between 1995 and 2007. Clients in contact with NSPs or in primary care settings should opportunistically receive brief interventions focused on motivation to assist with cessation of drug use.37

It is critically important that underlying substance dependence issues are addressed in order to lower the risk of BBV infection and other harms. Much of the evidence on environmental interventions relates to opioid use. Opioid-dependent individuals have been found to have an annual mortality of 2–4%, equating to 13 times that of their peers.40 This increased mortality is primarily due to overdose, violence, suicide, and smokingrelated and alcohol-related causes. Intravenous 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.40
Opioid substitution therapy (OST) consists of daily administration of an opioid agonist such as methadone, or an opioid partial agonist such as buprenorphine. The aim of OST is to reduce the use of illicit opioids, injection of drugs and risk of BBV infection, criminal activity and the risk of overdose, and improve psychological and physical health. It is a minimum standard recommendation by the World Health Organization (WHO) that opioid agonist maintenance treatment (OAMT) is an option and that this treatment is accessible to disadvantaged populations.40 The WHO also recommends the availability of a variety 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. OAMT has also been shown to reduce seroconversion to HIV.40 This correlates with measured reductions in drug-related and sex-related risk.

GPs often have patients who present with requests that hint at opioid addiction, such as escalating doses for chronic pain, ‘lost’ prescriptions and injection-related morbidity. These are opportunities to discuss harm-reduction strategies, including OST. It is important to be familiar with local opioid pharmacotherapy prescribers and referral pathways for patients who express an interest in accessing OST and other harm reduction programs. Patients can also present in crisis when their level of motivation for change is high. Each jurisdiction in Australia has its own requirements for training of opioid prescribers.
Additionally, methamphetamine (ice) is an injectable drug, widely misused in Australia.41 Although use of the drug remains stable across Australia, it is used heavily in certain groups of drug misusers.41 There are, however, more recent reports of increased misuse of ice, with the National Drug and Alcohol Survey 2013 demonstrating that 7% of Australia’s population have used ice at some point, and 2.1% within the past 12 months, compared with 6.3% and 2.3% in 2007.42 The use of ice has been associated with multiple physical and psychological harms including toxicity, mortality, cardiovascular damage (including infective endocarditis),43 cerebrovascular pathology, dependence and, importantly but often overlooked, BBV transmission.44 Prevention of ice use can be achieved by increasing public education, and epidemiological and surveillance studies. People injecting ice should be offered NSPs in the same way as those with opioid dependence,45 as well as tailored rehabilitation programs, because dependence patterns, and weaning, are different from alcohol rehabilitation, which is generally shorter in duration.
 

Resources

Sexually transmitted infections and blood-borne viruses resources

STIs – State-specific resources

STIs – International resources

Drug use resources

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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