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sexually transmitted infections (STDs/STIs)

introduction

  • rates of STD's dramatically fell in Australia in the 1990's presumably as a result of the Grim Reaper HIV advertisements which created fear, along with the depressive effects of the economic recession and conservatism of the politically correct culture of the 1990's.
  • rates of STD's exploded following the 911 Al Quaeda terrorism attacks in 2001 which after an initial global grief and fear reaction seems to have created a culture of living for the day as you don't know what the future will be. This culture combined with the increasing economic prosperity of the asset rich Australians benefiting from the real estate and stock market boom which flowed onto their children who started clubbing with a more sexually promiscuous attitude fueled by ecstasy use and binge alcohol drinking.
  • This has been further increased by online dating services - men who found partners online were six times more likely to have five or more sexual partners than those who didn't, and women who dated online were seven times more likely. In our hyperconnected world, the chance you'll sleep with someone quite different from you — older, younger or something else entirely — is greater than at any point in our history.
  • Another risk factor for STIs is travel - and we are traveling overseas more than ever before, and travel tends to increase risky behaviours, new casual partners, reduced condom use and increase substance use
  • a study of single, heterosexual men in Australia found only 35 per cent used a condom at their last sexual encounter with a casual partner, and even for younger people who used condoms, nearly half had done so incorrectly, or experienced slippage or breakage.The rate of condom use is falling, one report showed that 68% of gay and bisexual men surveyed in 2013 always used condoms with casual partners, the proportion had fallen to 47% in 2016
  • Chlamydia infections in Victoria rose from 2000 per year in 1999 to more than 11,000 in 2007 - a 5-fold increase.
  • Notified Chlamydia infections in Australia rose from just under 17,000 in 2000, to a record high of over 61,000 in 20091), and then to another record high of 82,000 in 2012, including 5400 aged 12-15yrs, and it is estimated up to 500,000 Australians have Chlamydia without knowing it!2)
  • rates of HPV infection in Melbourne women aged < 28yrs attending a Melbourne Sexual Health centre fell by 25% in each quarter of 2008 following introduction of Gardasil vaccinations. This compared with rise of 2% per quarter prior to vaccination. By 2012, rates of genital warts in girls under 21yrs dropped from 12% in 2007 to under 1% thanks to vaccination. Rates in women aged 21-30yrs dropped from 12% in 2007 to 4% in 2012.
  • syphilis increased in Victoria from 50 cases in 2001 to 400 in 2007 - an 8-fold increase, and to 1,500 new cases Australia-wide in 2012.
  • Gonorrhoea was virtually confined to the male homosexual and indigenous peoples populations in the 1990's but now is becoming increasing prevalent amongst heterosexual young adults. 13,649 new cases were diagnosed in Australia in 2012, still mainly in gay men and Aboriginal and Torres Strait Islander (ATSI) populations.
    • antibiotic resistant gonococcal disease is a major emerging threat
    • 18,588 cases of gonorrhoea were detected in Australia in 2015, up from 8,388 cases in 2006
      • far more common among younger than older gay men
  • in 2012, 200,000 Australians had hepatitis B virus and 230,000 had hepatitis C virus.
  • in 2008, Australian websites were created to assist people with STD's anonymously inform their contacts - usually with a sense of dark humour in line with inspot.org - the US website which started in 2004.
  • in the 1990's syphilis was extremely rare in non-indigenous communities in Australia (most cases were cases in men who have sex with men) and a very low endemic rate amongst northern Australian indigenous communities. In 2011 an outbreak began in indigenous communities in northern Queensland, spreading to NT then northern WA, and in late 2016 in SA, dramatically increasing infections to 2400 cases, 15 congenital cases and 7 babies have died from 2011-2018, with the disease spreading from northern Australia across Australia and into non-indigenous communities. Victoria has reported its 1st case of congenital syphilis in 14 years and since 2015 has been reporting women with the disease in addition to men who have sex with men.

screening

screening by local doctors or sex clinics for chlamydia, hep B should be offered if

  • patient requests a screen
  • sexually active people under age 29yrs or backpackers (also screen for gonorrhoea if ATSI and extend age up to 35yrs age)
    • 60% of chlamydia cases notified in Australia are aged 15-24yrs, especially females (3x risk cf males) - most are asymptomatic but risk infertility particularly if remain untreated
  • men who have sex with men (also screen for HIV, syphilis)
  • sex workers (also screen for HIV, syphilis, and oral swabs for gonococcus)
  • people who inject drugs (also screen for HIV, syphilis and hepC)

screening should be 4 times a year if

  • HIV positive
  • unprotected anal sex
  • more than 10 partners in preceding 6 months
  • group sex
  • recreational drug use during sex

screening for HIV should be offered if

  • patient requests it
  • men who have sex with men
  • people who inject drugs
  • sexual contacts of people with HIV infection
  • diagnosis of STI, viral hepatitis or TB
  • multiple sex partners or recent change in partner
  • high-risk behaviours, esp. in high-prevalence countries
  • migrants from high-prevalence countries
  • clinical features or presentations of unexplained immune suppression
  • pregnant women at 1st antenatal visit

NB. high risk HIV negative patients may benefit from pre-exposure prophylaxis but currently not subsidised on PBS in Australia (2015)

diagnosis

  • “Urine PCR for N. gonorrhoeae in women has a much lower sensitivity than traditional cervical sampling. Urine PCR should not be used for routine gonorrhea screening if the patient is agreeable to a speculum exam. Urine PCR for C. trachomatis in women is equal in sensitivity to that of cervical samples and is an adequate screening tool for chlamydia.”
  • chlamydia and gonococcal screening can be done by patient as a blind vulvo-vaginal swab sent for nucleic acid amplication tests (NAAT), an alternative is 1st stream urine sample although not as sensitive, and depending upon sexual practices, rectal or pharyngeal swabs
  • M. genitalium is best tested by PCR screen on endocervical swab or 1st stream urine (not rectal or oropharyngeal)

treatment

chlamydia

  • single dose o azithromycin 1g is adequate for uncomplicated genital or pharyngeal infection 3)
  • doxycycline 100g o bd for 7 days is recommended for rectal infection
  • contact trace
  • test for re-infection at 3 months

gonococcal disease

  • before Rx request culture and sensitivity testing for men with purulent urethral discharge, and from all sites found to be positive on NAAT testing.
    • also screen for HIV as HIV is 3x more likely in men who have sex with men with rectal gonorrhoea
  • single dose im or iv ceftriaxone 500mg plus azithromycin 1g o
  • contact trace
  • test for cure by culture swab 1wk after Rx, or by NAAT 3 wks after Rx
  • test for re-infection at 3 months

M. genitalium

  • single dose o azithromycin 1g
  • test for cure by rpt PCR swab or 1st stream urine at 4wks
std.txt · Last modified: 2018/12/26 10:05 (external edit)