The incidence of sexually transmitted infections (STIs) is increasing in many parts of the world including Australia,1 and the release of the first Australian National Sexually Transmissible Infections Strategy to deal with STIs is timely.2 Three very appropriate priority areas have been identified: Aboriginal and Torres Strait Islander sexual health, STIs in men who have sex with men, and control and prevention of infection with Chlamydia trachomatis among young people.

Given that an implementation plan is under development, it is timely to comment on the Strategy, pointing out its strengths and weaknesses, so as to ensure that an effective, comprehensive approach is implemented. Experience from the United Kingdom, where a national STI strategy was developed in 2001,3 suggests that this is the first stage of a long, difficult and contentious process to improve sexual health within the community. The control of STIs involves a range of activities. As well as research, surveillance, and adequate training and support of professional staff, it is essential that we not only increase access to health care (including screening, treatment and contact tracing), but that we also promote health and educate the young about sex.

While the Strategy satisfactorily covers surveillance, service provision and research, sex education and behavioural prevention are not adequately addressed, except with reference to gay and other homosexually active men. There are no specific priority actions focusing on sexually active young people, and a lack of clarity with regard to the targeting of screening programs for young people.

The Australian Study of Health and Relationships, a recent survey of the sexual relationships and practices of 19 307 people aged between 16 and 59 years, showed that the median age of first intercourse among Australians aged between 16 and 19 was 16 years, and that the reporting of multiple sex partners was significantly associated with younger age and with identifying as bisexual or homosexual.4,5 As the authors noted: “This early onset of sexual activity indicates that it is important to ensure that all young people have information about contraception and disease prevention before they begin their sexual careers and not simply in their final years of schooling.”5 Health promotion, including mandatory sex education, is essential for all young people, male as well as female, and those under as well as those over 16 years of age.

A study comparing sexual health outcomes in young people in the context of sex educational policies in the Netherlands, the United States, France and Australia found that in France and the Netherlands, where there is mandatory secondary school sex education, there are fewer STIs than in Australia and far fewer than in the US, where sex education is patchy.6 Increasing access to health care is not enough. There is also evidence that school-based education is likely to be more effective if it is sex positive, that is, if education does not focus solely on delaying or abstaining from sex.6 In the UK, where STI rates are at an all-time high, a survey of young people’s experience of sex education came to the conclusion that such education was “too little, too late and too biological.”7 We should learn from such experience.

The Strategy refers to raising awareness of STIs among sexually active young people and recommends that there be a national health promotion campaign. However, the approach is coy. Although safer sex is mentioned, the only mention of condoms occurs under the action plan for gay men, where the Strategy mentions “reinforcing safer sex and condom use.” The consistent use of condoms is a highly effective method of reducing the risk of acquiring STIs, in particular the bacterial infections (gonorrhoea, chlamydia and syphilis) and HIV.8 Condoms have been and continue to be a major factor in the reduction in the incidence of HIV in homosexually active men in Australia. Widespread condom use is also the single most important factor in the continued low incidence of all STIs in commercial sex workers in Australia.9 Young sexually active people need to be aware of the risk of STIs and use condoms to prevent their transmission. The continued promotion and widespread availability of condoms must be one of the key elements of any successful STI strategy.

The incidence of chlamydia infection in Australia is increasing and has more than doubled between 2000 and 2004 with over 35 000 notifications, with the largest increases noted in women aged 15–19 and 20–29 years.1,10 In the Minister for Health’s press release, which accompanied the launch of the Strategy, funding of $12.5 million over 4 years was announced for increased awareness, improved surveillance and a pilot testing program for chlamydia infection,11 and this is very welcome. However, while the Strategy highlights the need to develop “a chlamydia screening pilot targeting sexually active young adults”, the Minister’s press release had a different spin, suggesting that the pilot testing program for chlamydia will target women aged 18–30 years. However, younger women and men, particularly young men, who seldom seek health care, should also be the target for the pilot.12,13 In the US and Sweden, where national chlamydia screening policies based largely on opportunistic screening of women have been in place for several years, rates of chlamydia infection remain high.14

There are many long-term physical consequences of STIs, in particular, pelvic inflammatory diseases and consequent infertility, and cervical and other genital tract tumours. In addition, STIs are often associated with psychological morbidity. The release of the Strategy provides a unique opportunity to reduce the prevalence of STIs and their consequences. We must ensure that we make the most of this opportunity.