Sexual health -- reaching out

Australia should aim for world best practice in STD control. This means striving to eliminate endemic disease. As our HIV control strategies are among the most successful in the world, we should have the same aim for STD control.⁵ A necessary part of achieving this is reviewing our sexual health clinics, as reported by Marks and colleagues in this issue of the Journal.

This group surveyed sexual health clinics in Australia and New Zealand in 1993, and compared their findings with those of a similar study by Bradford and Philpot a decade earlier.⁶ The number of services provided and staff had increased and the complexity of medical conditions had broadened. There was still, however, a marked urban predominance of sexual health clinics, possible underuse of non-medical staff and, most importantly, there were deficiencies in tracing contacts of patients with STDs. Encouragingly, Australia's diagnosis and treatment of STDs complies well with the published guidelines.

The key question, then, is how can we use this information to improve the quality of care provided by our sexual health facilities and ensure that this results in a further fall in the prevalence of STDs? The answer relies on understanding what determines the prevalence of an STD.

The prevalence of a given STD at endemic equilibrium in a community is dependent on three factors:

• The duration an individual is infectious;
• The probability of transmission during sexual intercourse; and
• The rate of sexual partner change.⁷

Sexual health clinics and sexual health physicians do encourage the use of condoms to reduce the probability of transmission, but their greatest potential influence is likely to be on reducing the infectious period. This means providing very early treatment after each infection, and to do this effectively sexual health services must be highly accessible to all members of the community (no matter how geographically or socially isolated) and contact tracing must be very effective.

We should use the inconsistencies identified by Marks et al. to improve our sexual health system. Specifically, we should establish the most efficient method for contact tracing and ensure that it is widely used by all who treat STDs. In determining this most effective strategy, what should be kept in mind are the important lessons learnt with HIV control strategies, which focus on harm reduction rather than on a punitive approach.

Clearly, improved access to health services will reduce the duration of infectiousness. The practical difficulties of providing screening and treatment to Australia's geographically dispersed population may be largely overcome with the development of self-administered methods for collecting samples for STD diagnosis (e.g., tampons and first-void urine specimens for analysis by polymerase chain reaction) and the availability of single-dose treatments. With these innovations, it is to be hoped that substantial reductions in the currently high prevalence of STDs in many Aboriginal communities will not be long in coming.

Even within large capital cities access to treatment may be difficult for some. The 25 000 homeless Australians under the age of 25 may be so caught up with day-to-day survival that they find it impossible to attend a sexual health clinic.⁸ Access could be improved by simple measures such as long opening hours, free treatment, anonymous services and a flexible appointment system. The finding of Marks et al. that outreach services were provided by 60% of clinics is encouraging, as is the development of innovative services like the "Youth Health Bus". This bus is provided by the Inner South Community Health Service in Melbourne, and travels around in the evenings to areas where homeless people congregate.

Funding for STD control is likely to be included in HIV/AIDS funding in the near future. As the treatment of HIV/AIDS is being incorporated into large teaching hospitals, some may consider that this is the most appropriate place for the treatment of STDs. However, this is likely to be counterproductive as it would make services less accessible, thus transgressing one rule of STD control.

There is no reason why Australia cannot aim for a near-zero prevalence of some endemic STDs. After all, Sweden has nearly eliminated gonorrhoea.⁹ Our clinics have improved greatly over the past 10 years, and Marks et al. have highlighted areas that could be further improved. The most important benefit of decreasing the prevalence of STDs within our community is that it would reduce the risk of a tragic HIV epidemic among heterosexuals like the one currently occurring in the US.

Christopher K Fairley
Senior Lecturer in Infectious Disease Epidemiology, Department of Epidemiology and Preventive Medicine, Monash Medical School, Melbourne, VIC.

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