Guidelines for preventive activities in general practice

Infectious diseases

Sexually transmissible infections including HIV

      1. Sexually transmissible infections including HIV

Infectious diseases | Sexually transmissible infections including HIV

Screening age bar – women for chlamydia and gonorrhoea

0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 ≥80

In Australia in 2021 there were 86,916 diagnoses of chlamydia, 26,577 of gonorrhoea and 5,570 of infectious syphilis.1 Young people aged 15–29 years are significantly impacted by sexually transmissible infections (STIs),2 with this age group accounting for 70% of all chlamydia notifications in 2021.1 Notification rates of gonorrhoea and syphilis continue to increase in young people, with nearly half of new gonorrhoea diagnoses and approximately one-third of new syphilis diagnoses occurring in people aged ≤29 years.1

STIs are frequently seen in general practice, especially chlamydia, which is typically asymptomatic.3,4 It is important to detect chlamydia early to prevent transmission to others and to minimise potential complications, such as infertility.5 It may also be appropriate to screen for other STIs. The individual’s age, sexual behaviour and community HIV or STI prevalence all influence the level of risk and should influence the choice of STI screening tests.

In asymptomatic, sexually active people up to 29 years of age, the overall absolute risk of infection is approximately 5% for chlamydia and 0.5% for gonorrhoea.6

Rates of gonorrhoea and syphilis are higher among men who have sex with men (MSM) and among Aboriginal and/or Torres Strait Islander peoples, particularly those in remote communities.1 The rates of gonorrhoea, syphilis and HIV have grown considerably in the past 5 years among heterosexual populations, with considerable concern in recent years about syphilis in pregnant women leading to increased cases of congenital syphilis.8

Screening

Recommendation Grade How often References
Screening for chlamydia and gonorrhoea is recommended in all sexually active women aged ≤24 years, but only in those who are at increased risk (see Box 1) among women aged ≥25 years. Conditionally recommended Opportunistically if indicated (evidence is unclear on testing interval) 9
Although current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhoea in heterosexual men, it should be considered in order to prevent transmission to their partner/s. Practice point N/A 9
Test all pregnant women for syphilis during routine antenatal screening in the first trimester of pregnancy, or if presenting for the first time in late pregnancy without previous antenatal care.
Recommend repeat testing early in the third trimester (28–32 weeks) and at the time of birth for women at high risk of infection or reinfection.
Actively follow up pregnant women who do not attend for testing.
Recommended (Strong) As per recommendation 10

Case finding

Recommendation Grade How often References
Perform an asymptomatic STI check for people who:
  • have been exposed to any STI or have a history of an STI within the past 12 months
  • are at increased risk of an STI (eg new sexual partner, living or travelling to areas of higher prevalence in Australia or in other countries)
  • request STI testing
  • are a partner of a special subpopulation (eg MSM, sex workers, pregnant women, Aboriginal and Torres Strait Islander people, trans and gender-diverse people) or a partner of anyone meeting any of the above.
STI testing is detailed in the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine’s (ASHM) STI management guidelines for use in primary care (see Further information for recommended STI tests).
Practice point Opportunistically 11
Asymptomatic Mycoplasma genitalium testing is not recommended (see Further information for more details). Practice point N/A 11

Preventive activities and advice

Recommendation Grade How often References
Advise people that safe sex is the use of condoms and water-based lubricant during anal or vaginal intercourse.
Safe sex can:
  • prevent HIV transmission
  • prevent pregnancy
  • help prevent most STIs.
Practice point Opportunistically 12

Identify the risk of an STI by taking a sexual history and clarifying sexual practices with the patient.11

Information and example questions on how to take a sexual history are available in the ASHM’s STI management guidelines for use in primary care.

Any STI diagnosis detected in screening should lead to a comprehensive STI check.11

Recommended STI tests

(As per the ASHM’s STI management guidelines for use in primary care)

Blood tests
Test Consideration
HIV (antigen/antibody test) Repeat if recent exposure (6-week window period if antigen/antibody test)
Syphilis serology If recent exposure, repeat at 12 weeks and treat presumptively
Hepatitis B
HBsAg (hepatitis B surface antigen)
Anti-HBs (hepatitis B surface antibody)
Anti-HBc (hepatitis B core antibody)
Establish hepatitis B virus status and immunise if not previously documented
In Australia, routine adolescent hepatitis B immunisation commenced in 1997 and universal infant hepatitis B immunisation commenced in May 2000. Therefore, people aged ≤34 years in 2020 and who grew up in Australia can generally be assumed to have been vaccinated and do not need testing.
Gonorrhoea and chlamydia testing
Site/specimen Test Consideration
Self-collected vaginal swab
Urethral first-pass urine (FPU)
For MSM, oropharyngeal and anorectal swabs
Nucleic acid amplification test (NAAT) A vaginal swab is more sensitive than FPU and is the specimen of choice.
If speculum examination is indicated, then an endocervical swab can be collected in place of a vaginal swab.
 

Sexual health consultation

Many patients and doctors feel uncomfortable discussing sexual histories even when indicated or the patient is requesting STI testing. Taking a sexual history is an important part of the assessment and management of STIs, and it should not be a barrier to offering STI testing.13

A non-judgemental attitude and environment will facilitate disclosures on sexual matters.14 It is important to ask open-ended questions and to avoid assumptions about sexual orientation by using the term ‘partner’. Gentle enquiry about recent sexual activity, gender, number of partners, contraception (including the use of condoms), travel history and immunisation status helps inform decision making. In addition, ask about the risks for blood-borne viruses (hepatitis B, hepatitis C and HIV), such as injecting drug use, tattooing and piercing. Investigations should be explained, and patients should be asked for consent before tests such as HIV or hepatitis C are ordered (see Hepatitis C section).

Some patients may present with a request for one specific test, such as ‘I want an HIV test’. It is important to contextualise that HIV is relatively rare compared with infections such as chlamydia. These presentations represent an excellent opportunity for STI screening as per the recommendations and education. For people who may be at risk of HIV, this is an excellent opportunity to offer prevention information, such as condom use or pre-exposure prophylaxis (PrEP).

Mycoplasma genitalium

Mycoplasma genitalium is a sexually transmitted bacterial STI. Mycoplasma genitalium can cause urethritis, pelvic inflammatory disease (PID), cervicitis and rectal infections. Mycoplasma genitalium testing is only recommended in people who are symptomatic despite negative screening for chlamydia or gonorrhoea. Further information is available in the ASHM’s STI management guidelines for use in primary care.

Mycoplasma genitalium should not be routinely tested in asymptomatic people; however, if a person still has STI like symptoms after a negative chlamydia/gonorrhoea test, it is advised a Mycoplasma genitalium polymerase chain reaction (PCR) test is performed.

Contact tracing

Contact tracing is essential in reducing the transmission of STIs and HIV. It is the responsibility of the diagnosing clinician to facilitate the process of notifying current and past partners. This may be through a direct approach from the patient, their treating health professional or by using available online partner notification services, such as:

For more information and to determine ‘how far back to trace’, refer to the contact tracing manual at the ASHM website or the NSW Government’s STI/HIV testing tool.

For HIV contact tracing, seek assistance from local sexual health services. Getting assistance from local sexual health services is recommended for HIV and syphilis because it leads to more contacts being tested and treated.15

Referral to sexual health services should be considered for problematic or repeated infections.16

In the case of a notifiable condition, the patient should be informed that case notification to public health authorities will occur. Notification should be made as set by the department of health in the relevant state or territory.

Box 1. Increased risk of chlamydia and gonorrhoea9

Women aged ≥25 years are at increased risk if they:

  • have a new sexual partner, more than one sexual partner, a sexual partner with concurrent partners or a sexual partner who has a sexually transmissible infection (STI)
  • practice inconsistent condom use when not in a mutually monogamous relationship or have a previous or coexisting STI
  • exchange sex for money or drugs and have a history of incarceration.

Aboriginal and Torres Strait Islander peoples are at higher risk of STIs and should also be screened for gonorrhoea, chlamydia, syphilis and HIV. For specific recommendations and advice for Aboriginal and Torres Strait Islander people, refer to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

Some subpopulations (eg MSM, sex workers, pregnant women, Aboriginal and Torres Strait Islander people, trans and gender-diverse people) have special requirements for testing due to increased risk of infection, adverse health outcomes, community prevalence or other factors.11 Further information is available in the ASHM’s STI management guidelines for use in primary care.

Pregnant women

All pregnant women should be screened, with consent, for hepatitis B, hepatitis C, HIV and syphilis.11 Consider screening pregnant women up to 29 years of age for chlamydia (and gonorrhoea, if the patient is at high risk). Untreated pregnant women infected with chlamydia have a 20–50% chance of infecting their infant at delivery.17 See the First antenatal visit chapter.

Repeat syphilis testing at 28–32 weeks of pregnancy and at delivery in all women at risk of STIs, and in all women presenting with signs or symptoms of any other STI.

Repeat syphilis tests in all women in communities experiencing syphilis outbreaks. The Departments of Health in each state and territory will issue alerts to clinicians in areas where a syphilis outbreak occurs.

Men who have sex with men

MSM should be routinely screened for STIs (refer to the STIGMA guidelines for further guidance).

Chlamydia pharyngitis can be associated with oral sex. Gonorrhoea can be transmitted via oral sex. Throat swabs should be considered for chlamydia/gonorrhoea PCR in all MSM, but are worth considering for all sexually active patients.11,18

  1. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2022. The Kirby Institute, 2022 [Accessed 11 September 2023].
  2. Department of Health and Aged Care. Fourth national sexually transmissible infections strategy 2018–2022. Australian Government, 2019 [Accessed 24 July 2023].
  3. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). HIV, viral hepatitis & STIs: A guide for primary care. Sydney: ASHM, 2014 [Accessed 13 May 2016].
  4. Kong FY, Guy RJ, Hocking JS, et al. Australian general practitioner chlamydia testing rates among young people. Med J Aust 2011;194(5):249–52. doi: 10.5694/j.1326-5377.2011.tb02957.x.
  5. Hocking J, Fairley C. Need for screening for genital chlamydia trachomatis infection in Australia. Aust N Z J Public Health 2003;27(1):80–81. doi: 10.1111/j.1467-842x.2003.tb00385.x.
  6. Hocking JS, Temple-Smith M, Guy R, et al. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial. Lancet 2018; 392 (10156):1413–22. doi: 10.1016/s0140-6736(18)31816-6.
  7. Cook RL, Hutchison SL, Ostergaard L. Systematic review: Noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005;142(11):914–25. doi: 10.7326/0003-4819-142-11-200506070-00010.
  8. Department of Health. Congenital syphilis. Victoria State Government, 2022 [Accessed 21 August 2023].
  9. U.S. Preventive Services Task Force (USPSTF). Chlamydia and gonorrhea: Screening. USPSTF, 2021 [Accessed 11 September 2023].
  10. Department of Health. Congenital syphilis in Victoria. Victoria State Government, 2022 [Accessed 11 September 2023].
  11. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). STI management guidelines for use in primary care. ASHM, 2022 [Accessed 11 September 2023].
  12. NSW Health. Safe sex. Sydney: NSW Health, 2013 [Accessed 25 January 2023].
  13. Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking J. Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice. BMC Infect Dis 2008;8:62. doi: 10.1186/1471-2334-8-62.
  14. Preswell N, Barton D. Taking a sexual history. Aust Fam Physician 2000;29(5):533–39.
  15. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev 2013;10:CD002843. doi: 10.1002/14651858.cd002843.pub2.
  16. Burnet Institute. Partner notification of sexually transmitted infections in New South Wales: An informed literature review. Centre for Population Health, 2010 [Accessed 28 January 2016].
  17. Honey E, Augood C, Templeton A, et al. Cost effectiveness of screening for Chlamydia trachomatis: A review of published studies. Sex Transm Infect 2002;78(6):406–12. doi: 10.1136/sti.78.6.406.
  18. Chow EPF, Fairley CK. The role of saliva in gonorrhoea and chlamydia transmission to extragenital sites among men who have sex with men: New insights into transmission. J Int AIDS Soc 2019;22(Suppl 6):e25354. doi: 10.1002/jia2.25354.
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