Sexually transmissible infections (STI) and HIV testing and diagnosis among Aboriginal and non-Aboriginal adolescents in contact with the Australian justice system: a cross-sectional study

Introduction

Young people, those in custodial settings, and Aboriginal and Torres Strait Islander peoples (First Nations people, respectfully hereafter Aboriginal peoples) are recognised as priority populations in Australian national sexually transmissible infections (STI)¹ and HIV² strategies, with prevention and increasing testing rates identified as priority areas for action.^1,2

These groups are often-intersecting as Aboriginal peoples are substantially over-represented in the Australian juvenile detention population. One half (50%) of the young people in detention on an average night in the 2021 June quarter were Aboriginal, yet only 6% of the Australian population aged 10–17 years are Aboriginal.³ This is due to a wide range of complex factors linked to colonisation, including social and economic disadvantage, targeted police practices, and increased likelihood of conviction.⁴

Detained young people have poorer health than their community counterparts and this includes sexual health. A global scoping review found that the detained youth population had a younger age of sexual debut, were less consistent in using contraception or condoms and had a higher prevalence of sharing injecting equipment compared to their community counterparts, resulting in an increased prevalence of STIs.⁵ However, despite these risk behaviours, HIV diagnosis among detained youth was low in high-income countries.⁵

In Australia, the number of HIV diagnoses has been declining in recent years and is lower for young people compared to those aged 30 years and over.⁶ However, young people in Australia, aged 15–19 years, have higher STI notification rates per 100 000 population compared to the overall community (in the year 2021, these were 926.2 vs 362.7 for chlamydia and 136 vs 109.4 for gonorrhoea).⁶ While infectious syphilis rates have remained lower for the 15–19-year-old group compared to the overall population, these rates have been increasing in the past 10 years (17 per 100 000 population in 2021 compared to 1.4 in 2012 with a peak of 18.7 in 2019).⁶

Community surveys of adolescents in Australia indicated that 4.1% of school students in Years 10, 11 and 12 (normally aged between 15 and 18 years) had ever been tested for HIV (with no robust data on how many had ever been tested for STIs) and among those sexually active, 2.3% had ever been diagnosed with an STI.⁷ Over half (51%) of young Aboriginal Australians aged between 16 and 19 years reported being tested for STIs and among these, 15% had ever been diagnosed with an STI.⁸

Although there is literature on STI testing among young people in the wider community,^7,9 including Aboriginal young peoples,^8,10,11 in Australia and internationally, few studies have examined the sexual health of justice-involved adolescents. Justice-involved populations are typically underrepresented in, or excluded from, mainstream community health surveys, particularly those based on household sampling methods. Additionally, previous studies on this population have mostly focused on sexual risk behaviours^12–14 and/or estimating STI and HIV rates,^15–20 and rarely examined factors associated with STI/HIV testing or diagnosis.

To address this gap, we analysed data from the first Australian survey on the sexual and reproductive health needs of justice-involved adolescents to examine factors associated with not getting STI/HIV tested and a prior STI diagnosis. In this study, the term justice-involved refers to those who had come into contact with the police or the courts and were living in the community at the time of the survey. By examining these factors this study can contribute to understanding need for Aboriginal and non-Aboriginal adolescents, and to connecting and tailoring STI prevention education and services to this priority population.

Materials and methods

Results

Discussion

This study aimed to describe the sexual behaviours of a sample of justice-involved adolescents in Australia (WA and Qld), and examine the factors associated with never having been tested for STI/HIV and ever having an STI diagnosis, as self-reported by the participants.

Just over one third (37.9%) of the participants who reported being sexually active had ever been tested for STIs or HIV. Australian guidelines for STI testing recommend that all sexually active young people should be offered STI testing at least annually.²⁷ Even fewer participants (31.2%) indicated they had been tested for STIs or HIV in the year prior to interview. While our study is looking at STI and HIV testing rates combined, this is higher than STI testing rates in the Australian general population in 2019 where 14.9% of 15–29-year-olds had at least one chlamydia/gonorrhoea test in the prior year,²⁸ but lower than testing rates in the Aboriginal community where 41.0% of sexually active 16–19-year-olds reported being tested for an STI in the year prior to interview.⁸ In our study, we found no significant differences in self-reported STI/HIV testing rates between Aboriginal and non-Aboriginal participants. Considering a large proportion of our sample reported not always using a condom (almost 60%), had their sexual debut before 14 years of age (41.3%), and had multiple sexual partners in the past 12 months (46.6%), increasing testing in this population is crucial for reducing STI transmission rates and preventing possible infertility issues caused by leaving these infections untreated.

Male participants were approximately two and a half times more likely to have never been tested for STI/HIV compared to female participants. These odds increased to three and a half times for Aboriginal male participants. This finding is consistent with previous research showing that males, regardless of age or justice-involved status, were less likely than females to get tested^29–31 possibly due to having less contact with health services in general. Additionally, previous research suggests young men are more worried about the STI testing procedures than young women.³² For testing rates to increase, sexual health services need to better engage with justice-involved males before or as soon as they come into contact with the justice system. As proposed by previous studies, wider involvement from family, school and community might also play an important role in engaging adolescents with sexual health services.³³ Additionally, community-based sexual health education programs that consider culture and gender might help increase testing and reduce STI rates among Aboriginal adolescents.³⁴ Sexual health education should not only focus on the medical aspects, but also try to tackle perceptions of stigma, with regards to STI testing and diagnosis. Stigma has been identified as an important factor for both Aboriginal³⁵ and non-Aboriginal populations.³²

Being single was significantly associated with never having had an STI/HIV test for the non-Aboriginal sample. Previous community-based research looking at STI testing in students at a regional NSW university reported similar findings – those in de facto relationships had the highest STI testing rates.³⁶ In certain relationships, young women have less power to negotiate safe sex practices and therefore may use STI testing as an alternative.³⁷ Similarly, US-based research on heterosexual young adults indicated that mistrust and miscommunication were prevalent for those in exclusive sexual partnerships, and STI testing was commonly used as a risk reduction strategy after exposure to risky sexual behaviours.³⁸

Those who have never been to juvenile detention were more likely to have never had an STI/HIV test. This is probably due to the fact that on admission to Australian youth detention centres, young people undergo a health screening and are offered testing for HIV and some STIs.³⁹ However, due to the cross-sectional nature of this study, we cannot determine whether testing occurred prior, during or after a detention episode.

Attending school was associated with never having had an STI/HIV test for the non-Aboriginal sample, but not for the Aboriginal sample. This finding is difficult to interpret; however, past studies indicated that stigma plays a large role in stopping individuals from getting tested.³² In addition, structural barriers such as location and clinic opening times⁴⁰ might also affect testing accessibility for young people who attend school.

A factor associated with never having had an STI/HIV test in the Aboriginal sample was less than three sexual partners in the past 12 months. This is consistent with previous community-based studies from Australia,⁹ Canada⁴¹ and the US.⁴² It is hypothesised that those with less than three sexual partners do not feel at risk and thus believe STI/HIV testing would not be necessary. Similarly, those who never engaged in transactional sex are more likely to have never had an STI/HIV test.

Regarding STI/HIV knowledge, in the non-Aboriginal sample, those who have never sought information about sexual health and those who obtained a lower STI/HIV knowledge score were more likely to have never had an STI/HIV test. While the STI/HIV knowledge score factor did not reach statistical significance in the Aboriginal sample, the P-value was close to achieving statistical significance (P = 0.068). STI knowledge was identified as a factor associated with STI testing in past community-based Aboriginal¹⁰ and non-Aboriginal⁴³ research. Overall, these findings suggest that better STI knowledge is needed among justice-involved adolescents and that with better sexual health education, perhaps even those who do not consider themselves at risk of an STI would be more inclined to seek testing. Additionally, given the young age of sexual debut, this population should be engaged in education earlier than adolescents who are not involved with the justice system. In terms of sexual health education, STI prevention and testing, criminal justice and health agencies should work together to better support and provide appropriate health education and services to these young people. For Aboriginal adolescents, considering the disproportionate number who are justice-involved, sexual health delivery should be culturally appropriate and collaborations should include Aboriginal Community-Controlled health services who have expertise in providing culturally safe and accessible care for, and with Aboriginal communities.^44,45 An example of a culturally appropriate campaign in the community is the Mary G 2014 campaign for Aboriginal young people in WA.⁴⁶ Successful collaborations across sectors would result in less STI community transmission and improved sexual health for justice-involved adolescents.

Nearly one in five (17.8%) participants reported ever having had a positive STI diagnosis, compared to 2.3% of secondary school students⁷ and 15.0% of 16–19-year-old Aboriginal Australians.⁸ In this respect, our sample appears to be more similar to young Aboriginal Australians rather than Australian secondary school students, potentially due to the fact that Aboriginal adolescents are over-represented in the justice system. Participants reporting engagement in transactional sex for drugs or money, who identified as non-heterosexual and had sought sexual health information online were more likely to report a past STI diagnosis. Although some of the number of events was low for this analysis, some findings are consistent with previous US research on at-risk homeless youth which indicated that transactional sex was associated with STI diagnosis.⁴⁷ With regards to sexual orientation, our findings are consistent with Australian data which indicated that gay men and other men who have sex with men were more at-risk for an STI than heterosexual individuals.¹

Conclusion

This study examined the sexual behaviours, STI/HIV testing, and STI/HIV diagnosis reported by a sample of justice-involved adolescents. The findings support the need for sexual health services to work collaboratively across government sectors and with the Aboriginal community-controlled sector to provide appropriate education, testing and support. Engaging with young males, particularly young Aboriginal males, is important as STI/HIV testing rates were significantly lower than for young females in this study. Differences in STI diagnoses based on sexual orientation indicate that STI prevention and testing approaches should additionally be tailored to consider the different sexual orientations of adolescents. Collaboration between community-based organisations, the justice system and health agencies is required to increase education and testing in this population, and for reducing STI community transmission rates.

Supplementary material

Supplementary material is available online.

Data availability

The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to Tony Butler (tbutler@unsw.edu.au).

Disclaimer

Any material published or made publicly available by the researchers cannot be considered as either endorsed or an expression of the policies or view by the Western Australian Department of Justice and Western Australian Department of Health. Any errors of omission or commission are the responsibility of the researchers.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

The project was funded by the Australian National Health and Medical Research Council Project Grant No.1043693.