Louis Roller takes a look at the issue of sexually transmitted infections
Sexually transmitted diseases or infections (STDs or STIs) include: HIV, hepatitis B, chlamydia, gonorrhea and syphilis as well as genital herpes and genital warts.
HIV (Human immunodeficiency virus): The number of HIV notifications newly diagnosed in Australia has remained stable for the past four years, with 1,065 notifications in 2012, 1,030 in 2013, 1,082 in 2014 and 1,025 in 2015.
The main route of HIV transmission in Australia continues to be sexual contact between men, which accounted for 68% of notifications in 2015, a further 20% of cases were attributed to heterosexual sex, 5% to sexual contact between men and injecting drug use, and 3% to injecting drug use only.
In the five year reporting period (2011–2015), a greater proportion of HIV notifications in the Aboriginal and Torres Strait Islander population were attributed to heterosexual sex (21%) or injecting drug use (16%), compared with the Australian‑born non‑Indigenous population (14% and 3% respectively).
Hepatitis B: There were a total of 6,502 notifications of newly diagnosed hepatitis B infections in Australia in 2015.
From 2006 to 2015, the population rate of notification of hepatitis B infection has declined in Australia in younger age groups, reflecting the impact of the infant and adolescent vaccination programs, but remained high in the 25–29 and 30–39 year age groups.
Chlamydia: There were a total of 66,033 notifications of chlamydia, and the majority (77%) of these notifications were among 15–29 year olds.
The rate of chlamydia notification has increased steadily between 2006 and 2011 (from 237 to 371 per 100 000) but since 2011 has remained relatively stable overall, with the same pattern seen in males and females.
Gonorrhoea: There were 18,588 cases of gonorrhoea notified in 2015. Between 2006 and 2015, notification rates nearly doubled in both males (from 56.4 per 100 000 in 2006 to 117.3 per 100,000 in 2015) and females (from 26.8 per 100,000 in 2006 to 41.8 per 100,000 in 2015). Trends varied by jurisdiction. In 2015, gonorrhoea notification rates were highest among men aged 25–29 years (357 per 100 000) and 20–24 years (334 per 100,000).
The rate of notification of gonorrhoea in the Aboriginal and Torres Strait Islander population was 10 times that in the non‑Indigenous population in 2015 (625.6 per 100,000 compared to 62.4 per 100,000).
Syphilis: The number of notifications of infectious syphilis (infections of less than two years duration) in 2015 was 2,736.
The notification rate of infectious syphilis among men has increased from 6.5 per 100 000 in 2006 to 21.0 per 100,000 in 2015.
In 2015, of the gay and bisexual men attending sexual health clinics, 9.7% of HIV‑positive men had a new diagnosis of syphilis infection compared with 3.7% of HIV‑negative men, and in the past five years incidence increased by 42% in HIV‑negative men and 38% in HIV‑positive men.
In the past five years (2011–2015) syphilis incidence in female sex workers was very low and relatively stable (with 0.2–0.4% of women with a new diagnosis of infectious syphilis per year).
How STDs present
The three commonest presenting symptoms are urethral discharge, genital ulceration, and vaginal discharge with or without vulval irritation.
Patients may also present with other symptoms such as rash, dysuria, jaundice, arthralgia, and rectal discharge.
Additionally, several diseases may present initially with complications (abdominal or scrotal pain, urinary retention). Since they may affect any system in the body they should not be regarded solely as diseases of the genitals.
Finally, the diseases are not always acute; many chronic conditions of the genital tract require long-term management; for example, pelvic pain, recurrent herpes genitalis, and vaginal candidiasis.
The most important aspects of management are accurate diagnosis and effective treatment. Diagnosis needs time and skill in taking a detailed sexual history from both the patient and his or her sexual contacts and in carrying out a comprehensive physical examination.
Microbiological and serological facilities are essential initially and at follow up for all patients to differentiate between the various diseases, exclude more than one occurring at a time, and identify asymptomatic disease.
Referral to a clinic by pharmacists and GPs or is strongly advised. These clinics now have a much more relaxed image and offer the patient a chance to seek help and advice with complete confidence and confidentiality.
The role of the pharmacist is to listen and accept all the information without prejudice, refer to a GP or a Sexual Health Clinic (in all capital cities) and if a diagnoses of one or other of the above infections, dispense and counsel the patients about their medications including antiretroviral medications, now available through pharmacies
Key steps in preventing sexually transmitted diseases include:
- staying educated about the various STDs;
- using condoms (male or female) when engaging in any type of sex (anal and vaginal);
- limiting the number of sexual partners;
- knowing the sexual history of all new partners before engaging in sexual activity;
- avoiding sharing needles with others and using only clean, sterile needles; and
- not sharing any personal instruments with blood residue (eg razors).
Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.