Reproductive and Sexual Health Handbook

The term sexually transmissible infection (STI) is used to describe infections that are solely or commonly spread through sexual contact. Most STIs are asymptomatic or minimally symptomatic in their infectious stages, which increases the likelihood of onward spread of the infection. Most STIs are simple infections and easily treated.

A comprehensive public health approach to the management and control of STIs includes health promotion and education, access to clinical care, screening and testing, contact tracing, treatment, surveillance, notification and vaccination. This chapter’s focus is designed to provide a practical approach to the diagnosis and management of STIs in Australian primary healthcare settings.

The Australian STI Management Guidelines for use in Primary Care provide further comprehensive clinical guidance.

The following STIs will be considered in this chapter:

Chlamydia Gonorrhoea Mycoplasma genitalium Trichomoniasis Genital herpes Genital warts Hepatitis A Hepatitis B Hepatitis C Syphilis Human Immunodeficiency Virus

It is important to remember that genital symptoms may have causes other than STIs, although these are not discussed in this chapter. Candida and bacterial vaginosis are discussed in Chapter 4: The Vagina and Vulva (see Bacterial Vaginosis), Pelvic Inflammatory Disease (PID) is discussed in Chapter 13: Pelvic Inflammatory Disease, urinary tract infections are covered in Chapter 6: The Bladder and the

Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It was the most common notifiable infection in Australia in 2017, with 100, 775 notified cases in Australia.⁽¹¹⁾

The prevalence of chlamydia in Australia is estimated to be 417 /100, 000; however, some subpopulations have higher prevalence rates. The latest figures regarding chlamydia infections in 2018 from the Kirby Annual Surveillance Report reveal:

The age-standardised rate of chlamydia infections for Aboriginal and Torres Strait Islander people was 1193.9/100, 000, compared with 427/100, 000 for non-Indigenous people. Chlamydia infection rates were 395/100, 000 for males and 442/100, 000 for females. Higher rates in women may be due, in part, to more testing occurring in women. The majority of notified cases were in the 15-29 year age group and rates are highest in the 20-24 year age group.⁽¹¹⁾

Chlamydia can cause lower genital tract pathology (urethritis, cervicitis) and upper genital tract pathology (pelvic inflammatory disease, epidydimo-orchitis) and can infect the pharyngeal, anorectal and conjunctival mucosa. The contribution of oral sex to chlamydia transmission is unclear; routine testing of the oropharynx is not currently recommended in heterosexual people but is now recommended for gay men and other MSM.

Full details of the clinical presentation (when

Gonorrhoea is a less common cause of lower genital tract pathology (urethritis, cervicitis) and upper genital tract pathology (PID, epididymo-orchitis) and can infect the pharyngeal mucosa and anorectal mucosa. In 2017, 28, 364 cases of gonorrhoea were notified in the Australian population, and 74% of infections were in men.⁽¹¹⁾

Between 2013-2017 gonorrhoea notification rates increased by 115% in major cities and by 39% in regional areas but have remained stable in remote areas.⁽¹¹⁾ Rates of gonorrhoea are higher in Aboriginal and Torres Strait Islander people, with 30% of notifications occurring in the 15-19 year age group as compared to 9% in the non-Indigenous population.⁽¹¹⁾ Gonorrhoea rates are highest in remote and very remote areas.

N. gonorrhoea is increasing in prevalence in urban MSM. ⁽¹⁷⁾ Further, the Gay Community Periodic Surveys demonstrate increasing rates of comprehensive STI testing in gay and bisexual men.⁽¹⁸⁾ Increased rates of diagnosis of gonorrhoea and infectious syphilis in this population over the last 5 years may be partly explained by:

increased frequency of testing improved testing technologies an increasing trend in condomless anal sex in the context of greater access to pre-exposure prophylaxis (PrEP) for HIV prevention

Increased

Mycoplasma genitalium (MG) is an emerging sexually transmissible pathogen which was first recognised in the 1980s and implicated in urethritis in men and several inflammatory reproductive tract syndromes in women, including cervicitis, PID and infertility. MG is also thought to have possible roles in spontaneous abortion, preterm birth and female infertility.

MG is present in the general population at rates of 1-3 per cent, which is lower than those of Chlamydia trachomatis and Neisseria gonorrhoeae.⁽²³⁾ Most infections are asymptomatic, but higher rates of symptomatic infections with NGU, cervicitis and PID are seen in young people and MSM. A quarter of infections can persist for up to 12 months, and studies have shown persistent carriage of MG in treatment-resistant infections in women for up to 2-3 years. Asymptomatic urethral carriage in men has been demonstrated for up to 5 months.

MG is thought to be responsible for 10-20 per cent of the non-chlamydial, non-gonococcal urethritis and pathogen negative PIDs, which are seen in practice. It is thought to be present in at least 45 per cent of cases of persistent /recurrent urethritis. ⁽⁵¹⁾ A PCR test is available, and testing can be done on FPU samples, endocervical swabs and

Trichomonas vaginalis is a protozoan causing cervicitis and vaginitis. It is usually sexually acquired by intravaginal inoculation with body fluids containing the organism (vaginal exudates, semen, urine). It is thought to be uncommon in the general urban population in Australia. The prevalence in some Aboriginal and Torres Strait Islander women may be up to 30 times higher than in non-Indigenous people.⁽³⁾ Studies of trichomoniasis prevalence have shown an association with remoteness to be the critical factor, rather than Indigenous status.

Full details of the clinical presentation of Trichomoniasis (when symptomatic) as well as testing and treatment recommendations can be found in Australian STI management guidelines, see section on trichomoniasis.

Genital herpes is the most common cause of genital ulceration seen in Australia. Genital disease can be caused by herpes simplex viruses (HSV) type 1 (HSV-1) and type 2 (HSV-2). The HSV-2 virus is traditionally associated with genital lesions and HSV-1 with oral lesions, but the proportion of genital lesions now caused by HSV-1 appears to be increasing and is said to cause 50 per cent of genital lesions in Australia.⁽²⁹⁾ Serology demonstrates that 12 per cent of Australian adults are infected with HSV-2 and 76 per cent with HSV-1; however most of these will be asymptomatic.⁽²⁹⁾ Once infected with HSV, the virus achieves latency in the nerve roots and is usually a lifelong infection.

Full details of the clinical presentation of Genital herpes (when symptomatic) as well as testing and treatment recommendations can be found in Australian STI management guidelines, see section on herpes.

Warts are caused by the human papillomavirus (HPV), which often causes no clinical disease (i.e. the majority of people with HPV infection will be asymptomatic). Genital warts were once one of the most common STIs seen in general practice. However, the prevalence of genital warts in the Australian population under age 26 has fallen dramatically since HPV vaccination began in April 2007. Sexual Health Clinic surveillance data show a 96% decline in genital warts in women under age 21 years from 2007 to 2016 and an 83% decline in women aged 21-30 years as a result of HPV vaccination.⁽³²⁾ Among heterosexual men under age 21 attending a sexual health clinic, there has been a 88% decline in the diagnosis of genital warts between 2007 and 2017. In 2017 vaccination coverage at age 15 was 80% in females and 76% in males.⁽³³⁾

HPV is a small double-stranded DNA virus of which there are more than 100 genotypes. Around 40 different genotypes cause genital lesions, and these can be divided into those that cause genital warts with a low risk of progression to cancer and those associated with a moderate to high risk of progression to genital cancer.

Hepatitis A is a viral infection which affects the liver. It is spread from person to person through the faecal-oral route. This can be from the ingestion of contaminated food or water ⁽³⁵⁾but can also occur from oro-anal contact as part of sexual activity. Sexually transmitted outbreaks have been seen in MSM. The incubation period is approximately 28 days (range 15-50 days).

Full details of the clinical presentation of Hepatitis A (when symptomatic), as well as testing and treatment recommendations, can be found in Australian STI management guidelines, see section on hepatitis A.

 

Approximately 233, 947 (1 per cent) of Australians had chronic hepatitis B in 2017.⁽¹¹⁾ Of these, 21% were born in northeast Asia, 17% in southeast Asia and 11% were Aboriginal and Torres Strait Islander peoples.(11) Most of those acquiring hepatitis B virus (HBV) overseas were infected at birth or in early childhood. There are also higher rates of hepatitis B in men who have sex with men, inmates of correctional facilities, and injecting drug users.

Since 2000, there has been a universal neonatal vaccination program for hepatitis B in Australia, with a school catch-up program. Therefore most young people (born after 1991) should have been vaccinated against hepatitis B.⁽⁵³⁾  Rates of new hepatitis B infections have declined by 13% in Australia in the last 5 years. In 2017 there were 6,102 newly diagnosed infections, the notification rate of which has also declined.⁽¹¹⁾ 

In 2020 it was estimated that 27% of people with hepatitis B in Australia remain undiagnosed ⁽⁵⁶⁾ , so there is an important role for serological testing as part of STI screening. Testing for confirmation of vaccination status is also important because many young adults will have missed the booster

According to recent estimates more than 226,000 Australians were chronically infected with Hepatitis C virus (HCV)^(11,38) and are at long-term risk of developing liver cirrhosis, liver failure and hepatocellular cancer.

Hepatitis C is transmitted through blood-to-blood contact. Chronic complications of HCV are one of the most common causes for liver transplantation in Australia. Many people with chronic hepatitis C infection are asymptomatic; thus, it is important to offer screening to potentially at-risk patients when doing serological testing as part of an STI screen. HCV is rarely sexually transmitted outside of the setting of unprotected anal sex in HIV positive MSM. ⁽⁷⁾

There is a national campaign to test at-risk persons for HCV as active infections can now be cured in the vast majority of people with short courses of direct-acting antiviral agents (DAAs) which are available on the PBS.

For full details of the clinical presentation of Hepatitis C (when symptomatic), as well as testing and treatment recommendations (the scope of which is beyond this text) see:

Australian Hepatitis C guidelines ⁽³⁹⁾ Australian STI management guidelines section on hepatitis C.

Syphilis (caused by Treponema pallidum subspecies pallidum) is more common among the following groups:

Gay men and MSM: The rate of diagnosis of syphilis has increased during the past 10 years. A high proportion of MSM with syphilis are HIV positive or taking pre-exposure prophylaxis (PrEP) against HIV. Aboriginal and Torres Strait Islander: Indigenous Australians have about a 6.6-fold higher rate of syphilis diagnosis than non-Indigenous people.⁽⁴⁰⁾ However, rates vary widely in different communities, with more isolated communities reporting the highest rates of infection.

In Aboriginal and Torres Strait Islander communities in 2017 54% of infections occurred among men as compared to 94% of infections occurring among men in the non-Indigenous community.⁽¹¹⁾ One in five (21%) of infectious syphilis notifications were in people aged 15-19 years as compared to 2% in the non-indigenous population. High rates of infection are related to an epidemic of syphilis that has spread in northern Australia, starting in north Queensland in 2011, to the Northern Territory in 2013, north Western Australia in 2014 and then into South Australia in 2016. Over the last ten years (2008-2017) more than half (26 cases, 59%) of the 44 cases of congenital syphilis were among Aboriginal and

Human Immunodeficiency Virus (HIV) is the causative agent of Acquired Immune Deficiency Syndrome (AIDS). The virus is transmitted by vaginal and anal sex, infected blood or blood products, donated organs, use of contaminated needles and vertically from mother to child primarily at birth and via breast milk.

Transmission of HIV in Australia has been and continues to be mainly through sex between men. In the last 5 years, there has been a decline in the rates of new diagnoses of HIV infections, mainly due to decreasing notifications in MSM. While transmission of HIV continues to occur primarily amongst MSM, certain sub-populations have not seen as marked or sustained a fall in acquisition rates (including heterosexuals, Asian-born MSM and indigenous Australians), and the public health response to notifications in these groups requires further attention.^{(11), (44)}

Reductions in vertical transmission rates have been noted as well. In a recent reporting period (2013-2017), among the 191 babies born in Australia to women with HIV (PLWHIV), 1% of newborns were diagnosed with HIV, compared with 27% between 1993 -1997.⁽⁴²⁾ Most of this reduction is because of universal antenatal HIV testing and early use of antiretroviral drugs during pregnancy

Family Planning NSW fact sheets:

HIV Genital herpes  Gonorrhoea  Genital warts Hepatitis B Hepatitis C Syphilis Trichomonas Vaginalis (VT) Chlamydia

Melbourne Sexual Health Centre fact sheets:

Mycoplasma genitalium Gonorrhoea Syphilis Hepatitis A Hepatitis B Hepatitis C HIV testing and results PrEP Pre-Exposure Prophylaxis

New Zealand Herpes Foundation 

Australasian Sexual Health Alliance Australian STI Management Guidelines for use in primary care 

NSW STI Programs Unit – Excellent resources and information for healthcare practitioners

Australasian Society for HIV Medicine (ASHM), or phone: (02) 8204 0700

NSW Health – to view policies on your legal responsibilities

Sexual Health Plus – for a full list of NSW Sexual Health Services, or call the NSW Sexual Health Information Line on 1800 451 624

Multicultural HIV and Hepatitis Service (MHAHS) for HIV – information in a number of languages

(02) 9515 1234 Freecall: 1800 108 098 (NSW country) Email: info@mhahs.org.au

The Albion Centre

NSW HIV/AIDS Information Line (02) 9332 9700 | 1800 451 600 (outside Sydney)

ACON (AIDS Council of NSW)

(02) 9206 2000 | 1800 063 060 (outside Sydney) Email: acon@acon.org.au

NSW Health Multicultural Health Communication for STIs, or phone: (02) 8753 5047 – information in a number of languages

Temple-Smith M (ed.) Sexual health: a multidisciplinary approach. Melbourne: IP Communications, 2014.

Department of Health. Eighth National HIV Strategy 2018-2022. [Internet]. Australian Government; 2018. Available from: https://www.health.gov.au/sites/default/files/documents/2022/06/eighth-national-hiv-strategy-2018-2022.pdf Department of Health. Third National Hepatitis B Strategy 2018-2022. [Internet]. Australian Government; 2018. Available from: https://www.health.gov.au/sites/default/files/documents/2022/06/third-national-hepatitis-b-strategy-2018-2022.pdf Department of Health. Fourth National Sexually Transmissible Infections Strategy 2018-2022. [Internet]. Australian Government; 2018. Available from: https://www.health.gov.au/sites/default/files/documents/2022/06/fourth-national-sexually-transmissible-infections-strategy-2018-2022.pdf. Department of Health. Fifth National Hepatitis C Strategy 2018-2022. Australian Government; 2018. Available from: https://www.health.gov.au/sites/default/files/documents/2022/06/fifth-national-hepatitis-c-strategy-2018-2022.pdf. Department of Health. Fifth National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2018-2022. Australian Government; 2018. Available from: https://www.health.gov.au/sites/default/files/documents/2022/06/fifth-national-aboriginal-and-torres-strait-islander-bloodborne-viruses-and-sexually-transmissible-infections-strategy-2018-2022.pdf. STI/HIV Testing Tool: Easy as 1-2-3 [internet]. New South Wales Sexually Transmissible Infections Programs Unit (NSW STIPU): NSW Government; 2017. Available from: https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online-version-2.pdf. Australian STI Management Guidelines for use in Primary Care [internet]. Australasian Sexual Health Alliance; 2019. [Updated 2019]. Available from: http://sti.guidelines.org.au/. Australian Sexually Transmissible Infection & HIV Testing Guidelines 2019: For asymptomatic men who have sex with men. Sexually Transmissible Infections in Gay Men Action Group (STIGMA): New South Wales Sexually Transmissible InfectionsPrograms Unit (NSW STIPU); 2019. Available from: https://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Guidelines2019_Final-1.pdf Royal Australian College of General Practitioners (RACGP). RACGP position on the use of chaperones in general practice. [Internet]. Available from: https://www.racgp.org.au/download/Documents/Policies/Clinical/racgpposition-chaperones.pdf. Australasian Contract Tracing Guidelines [internet]. Australasian Society for HIV, Viral