Vulnerable populations left behind in race for sexual health

EXPERTS have applauded a range of advances in sexual and reproductive health and rights in Australia – from an overall decline in HIV diagnoses to a reduction in human papilloma virus (HPV) infections – but have warned that some of the nation’s most vulnerable populations are being left behind.

In response to a call by the Guttmacher–Lancet Commission for countries to critically analyse gaps in sexual reproductive health and rights, Dr Deborah Bateson, Medical Director of Family Planning NSW, and co-authors, have evaluated Australia’s progress in tackling the human immunodeficiency virus (HIV), sexually transmitted infections (STIs), unintended pregnancy, and sexual violence.

Bateson and colleagues, in a Perspective published by the MJA, say addressing gaps in these key areas of sexual and reproductive health and rights will set Australia on track to achieve progress in health and gender equity by 2030 and fulfil its commitment to the United Nations Sustainable Development Goals.

The authors noted that there had been a reduction in new HIV infections in Australia, reflecting earlier diagnosis, effective antiretroviral treatment and a recent Pharmaceutical Benefits Scheme listing of pre-exposure prophylaxis (PrEP). However, it was a different story for Aboriginal and Torres Strait Islander populations, in which new HIV diagnoses were up 41% between 2013 and 2016 (compared with a 12% reduction in the non-Indigenous population).

There has also been a huge decline in HPV infections (down 96% in women, and 88% in men) with the 2007 introduction of the HPV vaccine. However, the cervical cancer rate among Aboriginal and Torres Strait Islander women was four times that of non-Indigenous women. The authors also noted an increasing number of gonorrhoea cases and a significant burden of STIs among Aboriginal and Torres Strait Islander people.

Uptake of long-acting reversible contraceptives is increasing in Australia, albeit more slowly than in other high income countries, but there remains a lack of equity in access to contraception and abortion services and a gap in national abortion data collection.

The authors noted growing community awareness of sexual violence but low levels of reporting and prosecution. They pointed to recent Australian estimates that one in six women and one in 16 men over the age of 15 years had been subjected to physical and/or sexual violence.

Commenting on the MJA article, Professor Meredith Temple-Smith, Co-Chair of the Australasian Sexual Health Alliance, said Australia had clearly made some fantastic advances, but some of the problems were long-standing and never seemed “to reach the top of the pile”.

“Clearly, Indigenous sexual and reproductive health is one of these. But there is not a quick-fix solution, it requires a broader sustained approach to improving the overall health of Indigenous people, which will also require deeper understanding of cultural attitudes,” Professor Temple-Smith told InSight+.

A further long-standing problem, she said, was access to sexual and reproductive health in rural Australia.

“In some rural areas, there are higher numbers of GPs who are internationally trained and this can compound particularly young people’s insecurity and discomfort about seeking sexual and reproductive health advice,” said Professor Temple-Smith, who is Director of Research Training in the University of Melbourne’s Department of General Practice.

She noted that the rising rates of STIs in the heterosexual population were also being seen in other high income countries.

“We need to do more behavioural research to find out what is underpinning this. It’s possibly a combination of less safe sex and the Tinder age, and ignorance of issues like potential antibiotic resistance.”

Associate Professor James Ward, Head of Infectious Diseases Research – Aboriginal Health at the South Australian Health and Medical Research Institute said there were multiple factors contributing to the recent increase in HIV diagnoses among Aboriginal and Torres Strait Islander people.

“First,” he said, “the benefits of new HIV biomedical strategies care not being fully realised, particularly Treatment As Prevention (TAS) and PrEP. In terms of TAS, we think ta smaller proportion of  Aboriginal people living with HIV are reaching undetectable viral load achieved by adherence to antiretroviral therapy.”

“With PrEP, we can assume that fewer Aboriginal and Torres Strait Islander people are taking up this preventive medicine for a range of factors.” These include a lack of access to health services and PrEP trials, and a lack of awareness of PrEP in Aboriginal and Torres Strait Islander communities, Associate Professor Ward said.

“Over the past few years, we have [also] seen more and more HIV outbreaks occurring in outer regional and remote areas and we haven’t really seen that in the 30 years that HIV has been in Australia,” he said.

Professor Basil Donovan, Head of the Sexual Health Program at the Kirby Institute, said the emerging trend in Aboriginal and Torres Strait Islander people was a culmination of social marginalisation, limited health services, and downsizing of health promotion programs over the past 7–8 years.

“Similar, and often worse, trends have been seen with indigenous people in North America,” Professor Donovan said. “Proportionately, more of the HIV transmission in Australian Indigenous people is attributable to heterosexual transmission and drug injecting.”

While he said there was some levelling of the trend in 2017 data, this was likely to due to the relatively small numbers of people affected.

“The numbers of cases in the Indigenous population are relatively small (dozens per year) so the numbers jump around more. That said, they are now consistently higher than in the non-Indigenous population,” Professor Donovan said.

Associate Professor Ward said the huge gap in the burden of STIs between Aboriginal and Torres Strait Islander populations and the non-Indigenous community needed urgent action.

“There is an ongoing and unacceptably high burden of Chlamydia trachomatis, gonorrhoea, infectious syphilis [and] trichomoniasis in our remote and very remote outer regional populations,” he said, noting that the rate of gonorrhoea was up to 18 times higher in Aboriginal and Torres Strait Islander communities than in non-Indigenous populations, and the chlamydia rate was five times higher.

“We have infectious syphilis raging across the country and an ongoing outbreak [which has caused congenital disease and seven deaths],” he said. “The fact that governments have allowed this outbreak to go on for 6–7 years without appropriate intervention is appalling.”

Associate Professor Ward said optimal health service delivery and improved health literacy with comprehensive sexual and reproductive health programs that are targeted specifically for Aboriginal and Torres Strait Islander men and women were all urgently needed.

One success story highlighted by Bateson and colleagues was the 2007 introduction of the HPV vaccine, which has seen a significant decline in genital warts.

Professor Donovan said Australia led the world in HPV vaccination, including adding schoolboys to the program in 2013.

“Over the coming decades, we will see a progressive decline in genital, anal and throat cancers – but those improvements will take many years to document. One of our priorities should be to get our Asia–Pacific neighbours vaccinated as well,” he said.

However, increasing rates of gonorrhoea were concerning, given the significant threat of multidrug-resistant infection.

Professor Donovan said gonorrhoea was the most infectious bacterial STI.

“Any solutions will need to be research-driven,” Professor Donovan told InSight+. “Led by a group at the Melbourne Sexual Health Centre, we are investigating if mouthwash has a protective effect against gonorrhoea for the throat. There is a potential vaccine (the meningitis B vaccine) but we are having difficulty getting a trial funded. We are also doing a trial of rapid resistance testing technology so that we can keep our last-line drug (ceftriaxone) on reserve as much as possible.”

And we also need to talk about sex, said the experts.

Professor Temple-Smith said we should be aiming to destigmatise the discussion of sexual and reproductive health over the next decade.

“Despite sex being widely depicted publicly, there are still many people who feel uncomfortable discussing sex, even with a new potential partner. The need to break down barriers when it comes to conversing about sex is one thing that has not changed.”