Integrating testing for sexually transmissible infections into annual health assessments for Aboriginal and Torres Strait Islander young people: a cross-sectional analysis

Sexually transmissible infections (STIs) predominantly affect adolescents and young adults aged 16–29 years,¹ and if untreated, they can result in complications including pelvic inflammatory disease, ectopic pregnancy, and infertility.^2,3 Untreated syphilis during pregnancy can have severe outcomes for the foetus.⁴ STIs are also associated with shame, stigma, reputation damage, relationship breakdowns, and negative health outcomes.⁵

Adolescents and young Aboriginal and/or Torres Strait Islander people are identified as a priority population in Australian STI and HIV strategies,^6–8 particularly those residing in remote and very remote regions, where prevalence of chlamydia and gonorrhoea is much higher and there is a sustained syphilis outbreak.⁹ Infectious syphilis has also more recently spread into metropolitan areas, demonstrating the need to increase syphilis testing among all young Aboriginal and/or Torres Strait Islander people.¹⁰

In Australia and other countries primary care services for adolescents and young adults play a significant role in STI prevention and management, as up to 90% of young people attend primary care at least once annually.¹¹ To facilitate inclusion of sexual health in primary care, clinical guidelines in Australia and other countries recommend regularly screening for STIs in routine primary care consultations,¹² recognising that adolescents and young adults may not proactively request STI tests and may not disclose risk behaviours to health care providers unless prompted.¹³ Qualitative research conducted in mainstream primary care with clinicians¹⁴ and young women¹⁵ strongly supports normalisation of age-based STI screening to reduce the stigma associated with clinician risk assessment. In Australia, Aboriginal and Torres Strait Islander people can access primary care via either mainstream general practice or Aboriginal Community Controlled Health Services (ACCHS), which are Indigenous-specific primary health care providers managed by and for Aboriginal and Torres Strait Islander communities.¹⁶ The provision of culturally safe sexual healthcare through Indigenous-specific primary health care services such as ACCHS has been recognised in Australia and other Western countries with a history of colonisation as a solution for health disparities that is underpinned by self-determination.¹⁷ Aboriginal and Torres Strait Islander young people are more likely to access STI testing at ACCHS than other primary health care settings.¹⁸

An opportunity to normalise age-based STI screening occurs by offering it as part of a broader health check. Routine health assessments for Aboriginal and Torres Strait Islander people in primary care settings are reimbursed and incentivised by Australia’s universal health insurance scheme, Medicare. This is the only routine health assessment with an associated Medicare rebate for delivery in Australian primary care to include young people within its target age range of 15–54 years. STI testing is a recommended inclusion within the health assessment, and guidelines specifically emphasise STI testing for those aged under 35 years, providing an opportunity to support access to STI testing for a priority population.¹⁹ Routine adolescent health assessments have been implemented in other countries^20–22 and recommended as appropriate for low- and middle-income countries²³ but, to our knowledge, without an equivalent rebate as in Australia. As such, there is only one previous study in ACCHS in Australia that explored the association between participating in an incentivised health assessment and receiving an STI test and found a strong association at the health service level,²⁴ but this study did not explore completeness of STI testing or correlated patient socio-demographics.

A national sentinel surveillance network involving 34 ACCHS was established in 2016, providing a unique opportunity to determine the integration of STI testing for adolescents and young adults within health assessments in the ACCHS setting. The establishment and operation of the network has been described elsewhere.²⁵ In this analysis, we aimed to assess what proportion of health assessments conducted in ACCHS with Aboriginal and Torres Strait Islander young people aged 16–29 integrated STI testing and identified factors associated with integration.

Methods

Data collection

Using the ATLAS data, we obtained de-identified line-listed data on all health assessments completed for all individuals aged 16–29 years. The process for identifying health assessments in the datasets is outlined in Fig. 1. Other information collected included Aboriginal and Torres Strait Islander status, age, sex, postcode, and date of test/consultation.

Fig. 1.

Process for identification of MBS 715 Adult Health Assessment in ATLAS data extracted from an ACCHS EMR.

Participants’ ages were categorised in the following age groups: 16–19, 20–24, and 25–29 years. Area of residence was assigned by postcode using the Modified Monash Model,³¹ and we collapsed inner and outer regional areas into a singular regional category. Socio-Economic Indexes for Areas (SEIFA) and Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD)³² were also created using the postcodes and categorised using quintiles. The first quintile represented the most relatively disadvantaged areas, whereas the fifth quintile represented the most relatively advantaged areas. To avoid sparseness of the data, we further collapsed quintiles 1 and 2 into one group and quintiles 3 and 4 into another.

Chlamydia, gonorrhoea, syphilis, and/or HIV tests were included in this analysis. Chlamydia and gonorrhoea (CT/NG) were assessed as a single variable, as these STIs are routinely combined in a duplex test using nucleic acid amplification technology, and even if only one test is requested, the other is conducted automatically. Testing for Trichomonas vaginalis was excluded from our analysis, as guidelines only recommend testing for this infection in high prevalence areas. Syphilis and HIV were assessed as single and separate variables, as both are conducted using the same blood sample but need to be individually requested by the clinician and involve different tests. At the time of data collection, guidelines recommended a CT/NG test annually for all Aboriginal and Torres Strait Islander young people and a syphilis and/or HIV test for those at increased risk or following a positive CT/NG result.¹⁹

Results

During the study period, there were 13 892 individuals who had at least one episode of a health assessment annually recorded as a clinical encounter in EMR; this was lower in 2020 (n = 1597) compared to 2019 (n = 6443) and 2018 (n = 5852). These health assessments were conducted among 10 641 unique Aboriginal and Torres Strait Islander patients, of whom 41% were men and 59% women with a median age of 22 years (interquartile range: 19–26). Of the 10 641 patients, 13% resided in very remote areas, 14% in remote areas, 44% in outer/inner regional areas, and 29% in a major city. Just under half (43%) of the patients lived in postcodes with SEIFA scores of 1 or 2 (most disadvantaged), 18% resided in postcodes with SEIFA scores of 3 or 4, and 39% resided in postcodes with SEIFA scores of 5 or higher.

Discussion

Among a large national sample of 16–29-year-old Aboriginal and/or Torres Strait Islander people attending ACCHS between 2018 and 2020, we found 23.9% of health assessments integrated a test for any STI and 11.5% included tests for all four STIs. When chlamydia/gonorrhoea testing was integrated, 67% also included a syphilis test, which was highest in very remote areas (80.9%). Although fewer than a quarter of total health assessments included an STI test, this was in part attributable to low uptake in metropolitan areas, as a considerably higher proportion (37.6%) included an STI test in very remote regions where the highest STI notification rates have historically been recorded.⁹ Correlates of integration of any STI test included patients aged 20–24 and 25–29 years compared to 16–19 years and patients residing in very remote, remote, and regional areas.

The very high rate of integration of syphilis testing into CT/NG tests done as part of the health assessment is encouraging, as the infectious syphilis notification rate for Aboriginal and Torres Strait Islander people is highest in remote and very remote regions and has increased most rapidly among 20–29-year-olds.³³ Higher uptake of testing in very remote regions could reflect the impact of recent health promotion programs³⁴ and clinical initiatives³⁵ conducted in response to the ongoing syphilis outbreak in remote regions across northern Australia,^10,36 indicating that interventions to increase syphilis testing have been accurately targeted to those most at risk. However, lower levels of integration for syphilis in urban and regional areas and for HIV in urban areas is of concern, as syphilis notifications are increasing in these regions and HIV prevalence in Australia is greatest in metropolitan areas.³³

We found no statistical association with receiving an STI test as part of a health assessment and gender, indicating that using the health assessment may have achieved gender parity, which is in contrast with past studies that have consistently shown that young Aboriginal and Torres Strait Islander men have lower uptake of STI testing in this setting.^{9,18,24,37–40} Another surprising finding was when the multivariate analysis found that receiving any STI test as part of a health assessment was most strongly correlated with residing in SEIFA – IRSAD 3–4 areas, not 1–2 areas (representing the areas of lowest socio-economic disadvantage) as anticipated. This may reflect unmeasured factors, such as greater health seeking practices or enhanced STI programs in the clinics in the SEIFA – IRSAD 3–4 areas, or the SEIFA of the community may be different to the SEIFA of those attending the health services due to the impacts of industry in these post codes.^41,42 We also identified that both the total number of health assessments and the proportion of health assessments that included an STI test decreased in 2020 compared to both 2018 and 2019, which may reflect the impact of coronavirus disease 2019 (COVID-19) on ACCHS service delivery.

Although uptake of STI testing among Aboriginal and/or Torres Strait Islander young people is substantially higher in settings where STI testing is a central focus, such as publicly funded sexual health clinics, previous research has found much lower testing uptake in both ACCHS and mainstream general practice settings,⁴⁰ reflecting that the majority of consultations in the primary care setting are sought for purposes other than an STI test. Previous research that examined STI testing in general ACCHS consultations outside of the health assessment have found annual testing rates under 15%.^39,43 Limited data is available on the uptake of STI testing among Aboriginal and/or Torres Strait Islander young people attending mainstream general practices, but one study has found an annual STI testing rate of 8.9% among a national sample of 16–29-year-olds (inclusive of Indigenous and non-Indigenous young people).⁴⁴ In line with our findings, this study found higher testing rates in non-metropolitan regions compared to urban areas. Within the context of the primary care setting, the MBS 715 health assessment presents an opportunity for an annual STI screen to be offered to all sexually active Aboriginal and/or Torres Strait Islander young people in line with clinical guidelines, and we recommend investment into further research to identify strategies to both increase the proportion of health assessments that integrate a comprehensive STI test and increase the proportion of Aboriginal and/or Torres Strait Islander young people who receive a health assessment annually.

However, although a comprehensive STI is a recommended inclusion of a health assessment for young people, clinician discretion to exclude an STI test from a young person’s health assessment may sometimes be warranted. This may include when the young person is not sexually active, or has recently received an STI test outside the health assessment, or when a clinician of a specific gender is preferred for sexual and reproductive health consultations for cultural reasons.⁴⁵ Previous research has also identified that many Aboriginal and/or Torres Strait Islander young people may choose to access sexual healthcare at non-Indigenous-specific health services, separate to their general healthcare, due to concerns about confidentiality in small communities.^46–48 We are unable to estimate the proportion of our sample who have accessed a different service for their sexual healthcare vs their routine annual health assessment, but this should be considered when assessing the completeness of STI testing within the health assessment.

The strength of our analyses lies in the use of data collected from patient medical records, rather than from self-reporting. The Medicare rebate attached to the MBS 715 health assessment provides a unique opportunity to measure uptake, as it must be recorded in the patient management system of a primary care practice as a specific consultation type. There are also some limitations to consider when interpreting these findings. First, as routinely collected data were used, we cannot be certain if some MBS items or STI tests were not recorded in clinic systems; however, findings are broadly consistent with other studies that have reported an uptake of STI testing in young people.⁴⁰ Further, we applied SEIFA – IRSAD at a postcode level, which may mask an individual’s socio-economic status. Finally, our findings include data collected from a national surveillance network of ACCHS across four jurisdictions with broad geographical coverage of metropolitan, regional, remote, and very remote regions nationally, although with slight under-representation from regional communities compared to actual geographic distribution of ACCHS.²⁵

In conclusion, this study has assessed the integration of testing for STIs into routine annual health assessments in Aboriginal and Torres Strait Islander young people aged 16–29 years attending ACCHS across Australia. The MBS 715 health assessment provides a unique opportunity for routine STI screening of this population in both young men and women and has the potential to lead to timely treatment, in turn reducing the morbidities associated with STIs and HIV. Further research is recommended to identify effective strategies to increase STI testing within the health assessment and culturally appropriate strategies to ensure all Indigenous young people receive comprehensive HIV/STI screening.