Early presentation of symptomatic individuals is critical in controlling sexually transmissible infections

Why Indigenous Australians in remote communities have such high rates of some sexually transmissible infections (STIs), most notably gonorrhoea, is an important and puzzling question confronting Australia.¹ It had been assumed that the high rates of STIs were due to individuals sexual practices, but work 25 years suggested limited access to health care was the primary cause. Limited access to health care leads to a long duration of infection and a substantially higher reproductive rate.² It was this work that led to the then Health Minster, Michael Wooldridge, to provide dramatically increased access to STI testing.³

But here we are 25 years later, and the rates of STIs among Indigenous Australia have not appreciably changed.^4,5 Testing rates for STIs have risen considerably and indeed in some communities many young people are tested every year.^4,5 Despite frequent testing though, even over several years, rates of gonorrhoea in remote Indigenous communities have been reduced by only a few fold and remain hundreds of fold higher than those observed in capital cities.⁵ Why?

In this issue of Sexual Health, two papers describe the sexual risks and health seeking behaviour of younger Indigenous Australians.^6,7 The first study by Williams et al. is a cross-sectional study undertaken during a community event in Perth, where most individuals lived.⁷ The second study by Scott et al. was also a cross-sectional survey and involved 155 individuals living in Townsville.⁶ Although both studies included individuals who lived outside of these areas, they did not include individuals from remote areas of Australia where STI rates are very high. Nevertheless, they do provide some important insights.

The study by Williams et al. reported that among 16–30-year-olds, 35% of sexually active individuals had had more than one sexual partner in the last year.⁷ This is similar to that reported in national population-based estimates of Australian sexual practices, where 33% of women and 43% of men aged 16–19 years had had more than one partner in the last year.⁸ The individuals in the study by Scott et al. were younger (19–22 years of age) than those in the Williams et al. study and 41% reported more than one sexual partner in the last 12 months; this is again consistent with the Australian population-based data.⁸ However, in contrast, condom use for the last sexual act was higher (62%⁷ and 82%⁶) in these two studies compared with the Australian population data, where an average of 23% reported condom use at the last sexual encounter, although age-specific data was not reported.⁹ In a large survey of Indigenous Australians, The Goanna Survey, 2877 participants reported remarkably similar results to those found by Scott et al. and Williams et al., with 55% of reporting using a condom at last sexual encounter and 46–51% reporting more than one sexual partner in the last year. Importantly, there were not substantial differences in The Goanna Survey in these two outcomes by the remoteness of the residence.¹⁰ These findings suggest that risks taken by these younger Indigenous Australians are not higher than that for the general Australian population and this is consistent with limited access to health care and delayed treatment being the primary driver of STI rates.

Health-seeking behaviour was also explored in both papers. In the study by Williams et al., 31% of young people had had a STI or HIV testing in the last 12 months, and in the study by Scott et al., a very similar 33% had been tested in the last 12 months.^6,7 These are not substantially different from the Australian public, where between 19 and 39% of men or women under 29 years of age had been tested.¹¹ But not surprisingly, because of the higher rates of STIs in Indigenous communities, two- to three-fold as many Indigenous individuals had had a STI than in the overall Australian community.

Why then do STI rates, and particularly gonorrhoea, remain so much higher despite similar sexual risks and testing practices? The answer may be related to symptom recognition and ‘access’ to services once symptoms appear. Almost all gonorrhoea in men, and approximately half in women, is symptomatic.¹² Furthermore, at a large sexual health service in an Australian capital city, the median duration of symptoms before seeking health care for urethral gonorrhoea in men was only 24 h (EPF Chow, pers. comm.). In contrast, if left untreated, gonorrhoea will last 6 months or 183-fold longer (183 days divided by 1 day) than in those seeking health care within 1 day of symptoms appearing. It is not hard to see then how early presentation and treatment of gonorrhoea dramatically lowers its reproductive rate. But in many Indigenous communities, gonorrhoea is commonly identified in individuals who have not sought health care, and hence the reproductive rate for gonorrhoea remains high.^13,14 Screening, even of everyone, every year can only reduce the duration of infection from 180 days to 120 days; early presentation is therefore the key.

But how can we create an environment in which individuals access testing and treatment within days? Several things are needed; enough community support so individuals can prioritise presenting for treatment of a urethral discharge, improved health literacy, confidential free treatment and testing services and health promotion, to name a just a few.¹⁵

A current National Health and Medical Research Council study by Kaldor et al. and work by many others are currently exploring ways to encourage the early presentation of those with symptoms, including ways to make testing more confidential in small communities with drop-off collection centres at night and self-collected specimens.

Hopefully, substantially improving early presentation of symptomatic individuals will drive rates of gonorrhoea down to very low levels seen in most developed countries in heterosexuals and make closing the gap, one step closer.¹⁵