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STIs in Victoria who? why prevention Rebecca Guy Centre for Epidemiology and Population Health Research, The Macfarlane Burnet Institute for Medical Research and Public Health Why are STIs important? • Common • Morbidity • Asymptomatic • Often missed • Associated with systemic disease • Facilitation of HIV transmission Chlamydia • One of the most common STIs • Largely asymptomatic – about 85% (compared to gonorrhoeae - 30-60% females1,2,) • Genital infections – Urethra, Endocervix, Epididymis • Conjunctivitis 1. YT van Duynhoven (1999). "The epidemiology of Neisseria gonorrheae in Europe". Microbes and Infection 1 (6): 455–464. 2. Holmes (1999). Sexually Transmitted Diseases. Third Edition. Chlamydia Duration of infection ~50% clear in 12 months Chlamydia A significant public health problem • If left untreated it has serious complications, particularly for women: – ~8% of untreated chlamydia infections progress to PID1 – Up to two thirds of tubal factor infertility may be due to past chlamydia infection2 – Up to one third of ectopic pregnancy may be due to past chlamydia infection2 1. Am J Obstet Gynecol (1991) 164:1771-1781 2. New Eng J Med (2003) 349:2424-2430 Chlamydia notifications by gender Victoria, 2000 to 2006 50% aged Number of Notifications 15 to 24 yrs 12000 Females 10000 Males 60% heterosexual 32% male to male sex 8000 6000 4000 2000 0 2000 2001 2002 2003 Year 2004 2005 2006 2/3rds aged 15 to 24 yrs Majority heterosexual Chlamydia Who is affected? • Most infections among heterosexuals • High rates among MSM • High rates among Indigenous Australians 1. Sexual Health (2005) 2:185-192 Chlamydia interpreting trends • Because of its asymptomatic nature, notification data underestimate chlamydia prevalence • Testing increasing each year Chlamydia Correlation between notifications and testing 1999-2005 Notifications per 100,000 230 210 190 170 150 130 110 90 70 50 500 750 1000 1250 Tests per 100,000 1500 1750 Chlamydia Prevalence in Australia • ~4% of sexually active 18 to 24 year old women (1) • Victorian community survey • ~4% of heterosexually active 16 to 29 year old men (2) • ~5% in gay men • ~ 10%-15% in Indigenous Australian populations • Two sentinel surveillances systems • Victoria – implemented April 2006 • National –Early 2008 1. 2. Hocking et al. ISSTDR, November 2005 ANZJPH (2007) 31(3):243-6 Chlamydia - youth Risk Factors • Younger age • Increased number of partners • Recent partner change Chlamydia - youth STI knowledge, sexual behaviours • Secondary school kids, year 10,12 (2002) – Poor levels of knowledge – Increase in the levels of sexual activity – 35% reported sexual intercourse – Concerning rates of – Inconsistent condom use – around 50% – Australian Study of Health & Relationships (ASHR) – Inconsistent condom use – 35.8% of males aged 16-19 years with casual partners – 56.1% of females aged 16-19 years with casual partners Chlamydia Control issues • Without screening many infections will remain undetected • Short of a vaccine – screening is the key to control • Chlamydia is a good candidate for screening – Its complications are important health problems – It is easily diagnosed – simple urine test for men and women – It is detectable early – It is easily and effectively treated – single dose treatments (1g azithromycin) – Early treatment reduces the risk of complications Chlamydia Screening is cost-effective • Review of published costeffectiveness studies found that screening was cost-effective at prevalence rates of 3.1% and over1 1. STI (2002) 78:406-412 Department of Health and Ageing announced $12.5 million for increased chlamydia awareness, improved surveillance and a pilot testing program. Chlamydia Australian program • Screening likely to be based in primary health care – ~90% of young women and 70% of young men attend a GP each year – Only 6% of 16-24 yr old women get tested • Questions to be addressed – What resources/skills do GPs need to increase chlamydia screening – Who should be screened? • ?Age group – likely to be <25 years • Should men be screened? – How often should people be screened? – What coverage should we aim for? STI awareness Campaign • • • • Victorian government 14 June 2007 Aimed at 18 to 25 year olds Radio, posters “You never know who you’ll meet” • Raise awareness of STIs & increase safe sex behaviours, regular STI check ups • ` Syphilis • Pathogen: Treponema pallidum • A genital ulcerative disease • Highly infectious • Highly susceptible to antibiotics Syphilis Primary Presents as a solitary painless chancre Syphilis Secondary Wide variety of symptoms: • fever • lymphadenopathy • rash Why is syphilis a problem? • If untreated - years after it may cause cardiovascular disease or central nervous system involvement • Neurosyphilis can develop • Increase chance of HIV transmission • If acquired during the four years preceding pregnancy, may lead to infection of the fetus in over 70% of cases • Untreated early syphilis in pregnant women results in perinatal death in up to 40% of cases • ANC screening – most countries Infectious syphilis notifications by sexual orientation, Victoria, 2000 to 2006 Number of notifications 250 Females 200 Males - Non MSM Males - MSM 150 Majority 30 to 49 yrs 100 50 0 2000 2001 2002 2003 Year 2004 2005 2006 Infectious syphilis all males, select states Number of diagnoses 300 250 200 150 100 50 0 1999 2000 2001 2002 2003 2004 2005 2006 Year NSW VIC Source: National Notifiable Diseases Surveillance System Syphilis – gay men Risk factors • • • • • • More sexual partners1 More frequent unprotected anal intercourse More frequent unprotected oral sex2 Recreational drug use1,2 Use of sex on premises venues1,2 Meeting sexual partners through the Internet3 • HIV positive (around 50%, Sydney1, Melb) 1 Holt M, Jin F, Grulich A et al. Syphilis, STIs men who have sex with men in Sydney, Understanding and managing risk. National Centre in HIV Social Research, 2003 2 J Epidemiol Community Health (2002) 56(3):235-236 3 JAMA (2000) 284(4):447-449 Control strategies- more frequent testing syphilis rates among HIV positive men at one clinic in Melb None 1 test 2 tests 3 tests 4 tests 100% 80% 60% 40% 20% 0% 2000 2001 2002 2003 2004 HIV diagnosis rates, select states Diagnosis rate per 100 000 8 7 6 5 4 3 2 1 0 1996 1997 1998 NSW 1999 2000 2001 2002 Year QLD 2003 2004 2005 VIC 2006 Gonorrhoea diagnoses, 30 – 39 year males, select states Diagnosis rate per 100 000 60 50 40 30 20 10 0 1996 1997 NSW 1998 1999 2000 2001 Year QLD 2002 2003 2004 VIC 2005 Sexual behaviour 40 Percentage 35 30 25 20 15 1998 1999 2000 NSW 2001 2002 Year QLD 2003 2004 2005 2006 VIC Source: NSW, VIC and QLD Periodic surveys, 1998-2006, men aged 30-49 Note: the sample includes only men who had sex with casual partners Awareness Campaigns Summary • Chlamydia – youth • All STIs - gay men • Both groups - changes in sexual behaviour • Chlamydia - increased testing • Chlamydia - prevalence still high • Campaigns underway Acknowledgements • Danielle Horyniak – Centre for Epidemiology and Population Health Research, Burnet Institute • Dr Jane Hocking – NHMRC Postdoctoral Research Fellow School of Population Health Relationship between STIs and HIV • Increased likelihood of acquiring HIV – break the mucosal barrier (ulcers) – increase cells/receptors that become infected • Increased secretion of HIV – Increase in HIV in semen in gonococcal urethritis ¹ Laga, et al. 1993 AIDS