Evaluation of sexual health services within Australia and New Zealand

Abstract

MJA 1997; 166: 348-352  

Introduction

A 1983 survey of public STD facilities throughout Australia found that almost all clinics were located in major cities, leaving large areas of rural Australia unserviced by public clinics.⁵ Other deficiencies identified included inadequate opening times, lack of facilities in some clinics for treating both men and women, insufficient staff, inadequate contact tracing, limited use of facilities for teaching purposes, and inadequate maintenance of their role as reference centres for other practitioners and agencies. This survey included all 20 public STD facilities Australia-wide, and concluded that these facilities were "inadequate to meet the needs of the population".⁵

Over the past decade there have been many changes to sexual health care, including more clinics and better training for staff. Consequently, we felt that it was timely to establish what STD services were available from public and private STD clinics and Family Planning Clinics (FPCs); whether STD clinical services were adequately staffed; to determine the range of diagnostic, treatment, and contact-tracing services; and whether clinics were providing the community with education, counselling and other specialist services. Finally, we compared services in Australia and New Zealand and noted geographic differences in the provision of services within Australia.  

Methods

A questionnaire and prepaid addressed envelope were posted to the director (senior doctor or nurse) of each clinic. The 65-item questionnaire sought information about the geographic location and physical structure of clinics, as well as staffing, diagnosis, treatment and contact tracing for the various STDs, specialist medical services, and community and educational programs run by the facility. Non-respondents were sent a second questionnaire two months after the first.  

Statistical analysis

Results

Geographic distribution
and type of facility

Staffing

The most common duties of nurses at STD facilities included history taking, clinical examination and testing for STDs. Only 26% of clinics allowed nurses to prescribe treatment; more nurses in rural and remote areas were allowed to prescribe treatment than those in urban areas (36% v. 16%), but this difference was not significant. Nurses took histories "sometimes" (options were "always", "sometimes" and "never") in over 80% of clinics in New South Wales, compared with 39% in Victoria (P = 0.02), and examined patients at 70% of NSW clinics, compared with 22% in Victoria (P = 0.02). There were no significant differences in nursing duties between New Zealand and NSW. However, comparing New Zealand with Victoria showed that New Zealand nurses were more likely to take histories (P = 0.003), examine patients (P = 0.005), and test patients for STDs (P = 0.002).  

Diagnosis and treatment

Gonorrhoea: Eighty-one clinics (99%) used culture, and 77 (94%) used Gram stain to diagnose gonorrhoea. The three most common treatments for gonorrhoea were amoxycillin plus probenecid, ciprofloxacin, and ceftriaxone, used in 63%, 24% and 12% of clinics, respectively (Box 3). New Zealand clinics were more likely than Australian clinics to use amoxycillin plus probenecid as first-line therapy for gonorrhoea (93% v. 49%; P = 0.01). Urban clinics in both Australia and New Zealand were more likely to use ciprofloxacin than rural and remote clinics (51% v. 21%; P = 0.02).

Syphilis: Forty-seven clinics (57%) used dark-ground microscopy for diagnosing primary syphilis. For screening, 61 (74%) used the rapid plasma reagin (RPR) test, 58 (71%) the Treponema pallidum haemagglutination antibody (TPHA) test, and 25 (31%) the Ven ereal Disease Research Laboratory (VDRL) test. Fifty Australian clinics (91%), compared with 11 New Zealand clinics (41%), used the RPR test for screening (P < 0.001). The fluorescent treponemal antibody test (FTA) was used by 61 (75%) clinics to confirm the diagnosis. Procaine and benzathine penicillins were the first-choice treatments in all facilities.

Chlamydia and non-gonococcal urethritis: Chlamydia was most commonly diagnosed by direct immuno fluorescence (DIF), which was used by 44 clinics (54%), followed by: enzyme immunoassay (EIA) from swabs, 39 clinics (48%); culture from swabs, 35 clinics (43%); and EIA from urine, 10 clinics (12%).

Australian clinics were more likely to use culture to diagnose chlamydial infection than New Zealand clinics (58% v. 11%; P < 0.001), while New Zealand clinics were more likely to use DIF than Australian clinics (74% v. 44%; P = 0.01). Urban centres were significantly more likely to use culture to diagnose Chlamydia than rural and remote centres (58% v. 17%; P < 0.001).

Most clinics used doxycycline as first-line treatment for Chlamydia and non-gonococcal urethritis (92% and 91%, respectively).

Genital herpes: Herpes simplex virus (HSV) was diagnosed by viral culture (79 clinics [96%]), EIA (16 clinics [20%]), and serological testing (10 clinics [12%]). Acyclovir was used to treat primary HSV infections by 79 clinics (98%), for long term suppression by 70 clinics (86%), and for recurrences of HSV infection by 58 clinics (72%).

Human immunodeficiency virus (HIV): All the clinics surveyed routinely offered counselling and voluntary HIV testing to all persons considered to be at risk of HIV infection. Fifty-two clinics (64%) had facilities to manage HIV- positive patients. Forty-one clinics (51%) provided antiretroviral therapy and prophylaxis and treatment of opportunistic infections.

Genital warts: Cryotherapy was the first-line treatment for human papillomavirus infection in 55 clinics (69%), and podophyllin was the second most common treatment option, used in 17 clinics (21%). Australian clinics were more likely to use podophyllin than New Zealand clinics (16/53 [30%] v. 3/27 [11%]; P = 0.03).

Trichomoniasis and bacterial vaginosis: To diagnose trichomoniasis, wet-film microscopy was the most common technique, used in 67 clinics (83%), while culture was used by 39 clinics (48%).

Gram staining was the most common diagnostic technique for identifying bacterial vaginosis (74 clinics [93%]). Alternative diagnostic techniques used included culture to identify Gardnerella vaginalis and other anaerobes (56 clinics [70%]), vaginal pH testing (44 clinics [55%]), and the potassium hydroxide test (which identifies volatile amines) (41 clinics [51%]). Most clinics used metronidazole to treat trichomoniasis (53/80 [66%]) and bacterial vaginosis (50/79 [63%]).

Viral hepatitis: Forty-four clinics (55%) offered antibody testing for hepatitis A and 79 (98%) for hepatitis C. Australian clinics were significantly more likely to offer antibody testing for hepatitis A than New Zealand clinics (36/54 [67%] v. 8/26 [31%]; P = 0.003). When screening for hepatitis B infection, 65 clinics (81%) meas ured surface antigen (HBsAg), 57 (71%) measured core antibody (HBcAb), and 48 (60%) measured surface antibody (HBsAb).

Figure 1 shows clinic policies for hepatitis B vaccination. Vaccination was recommended for health care workers by 52/53 (98%) Australian clinics, compared with 19/27 clinics (70%) in New Zealand (P < 0.001); for heterosexuals with multiple partners, these figures were 44/53 (83%) and 15/27 (56%), respectively (P = 0.01); and for intravenous drug users (IVDUs), 52/53 (98%) and 21/27 (78%), respectively (P = 0.002).

Contact tracing

Twenty-one of the 71 clinics (30%) employed specially trained contact tracers. Doctors were involved in contact tracing in 22 clinics (28%), counsellors in 23 (32%), and nurses in 44 (62%). Patients were encouraged to inform their own contacts in 28 clinics (39%). All 21 clinics in NSW stated that they undertook contact tracing, compared with 9/13 (69%) clinics in Victoria (P = 0.01), and NSW clinics were significantly more likely to involve counsellors in contact tracing than Victorian clinics (62% v. 8%; P = 0.002).

There were a number of differences in contact-tracing policies between Australia and New Zealand. Australian facilities were more likely than New Zealand clinics to involve doctors (22/55 [40%] v. 1/27 [4%]; P = 0.001), less likely to trace contacts by telephone (21/55 [38%] v. 18/27 [67%]; P = 0.02), and less likely to trace contacts by having staff visit them (22/55 [40%] v. 23/27 [85%]; P < 0.001).

Box 4 summarises the contact-tracing practices for each STD. Most clinics always traced contacts of patients with gonorrhoea, syphilis, Chlamydia , HIV and trichomoniasis.

Only one of the five FPCs (20%) provided contact tracing, compared with 65 of 66 (98%) sexual health clinics (Fisher's exact test, P < 0.0005).

Additional services provided by STD clinics

Sixty-eight (82%) of the responding clinics offered education programs to other health professionals, schools or youth groups, while 46 (55%) offered some form of higher education/university courses.

Discussion

Increased availability of services does not necessarily lead to improvement in the sexual health of the community. The best measure of improvement is a reduction in the incidence of sexually transmitted diseases. In Australia, disease patterns have been difficult to in terpret because the collection of epidemiological data for most STDs (with the exception of gonorrhoea) from the States and Territories is uneven.⁴ None the less, there is considerable evidence to suggest that there has been a dramatic reduction in reported cases of gonorrhoea, syphilis and chlamydial infections since 1981,^10-12 with the most marked improvements in the large metropolitan centres.

By contrast, the incidence of gonorrhoea, syphilis, Chlamydia and donovanosis remained extremely high in many rural Aboriginal communities, particularly in the Northern Territory, far north Queensland, and the Pilbara and Kimberley regions of Western Australia.^13-15 These areas all have a limited number and quality of sexual health facilities, and improvements in clinical services and intervention programs are urgently needed.

Our findings show considerable consistency in diagnosis and treatment of STDs throughout Australia and also between Australia and New Zealand, with most facilities following the diagnostic and treatment guidelines produced by the United States Centers for Disease Control (CDC)¹⁶ or those of the Venereology Society of Victoria.¹⁷

However, we did identify some differences between Australia and New Zealand in the treatment of first choice for gonorrhoea, the method of detecting chlamydial infection, and in the likelihood that hepatitis A tests would be requested. There were also differing policies on hepatitis B vaccination and on tracing contacts of patients with STDs.

Varying patterns of antibiotic resistance in strains of the organism that causes gonorrhoea (penicillinase-producing Neisseria gonorrhoeae ) were more common in Australia, particularly along the east coast,¹⁸ than in New Zealand, and resistance to quinolones occurs in strains infecting a sizeable minority of travellers from the Philippines and neighbouring countries;¹⁹ this may explain the difference in antibiotic treatment.

Other factors contributing to the differences in practice include local availability of diagnostic tests, variation in populations attending clinics (travellers,^20,21 sex-industry workers^22,23 and homosexual men^24-26 ) and local variations in clinical practice.

The differences in hepatitis A testing policy and hepatitis B vaccination policy are intriguing, and may include differing financial arrangements between the clinical services in the two countries, availability of testing and vaccination from other sources (in particular, the recommendation for universal HBV vaccination in New Zealand),²⁷ and differing populations^28,29 and perceptions of risk.³⁰ Differences in contact-tracing policies probably reflect availability of staff, local working practices, or variation in the understanding of contact tracing.

There are a few minor differences between urban clinics and those in rural and remote settings, with a greater proportion of urban clinics using ciprofloxacin to treat gonorrhoea, using culture to diagnose Chlamydia , and requesting hepatitis A testing. This also reflects differences in the population groups attending different clinics (urban centres attract a higher proportion of overseas travellers, sex workers and homosexual and bisexual men than rural and remote centres), antibiotic sensitivities and local availability of tests.

Overall, the availability of contact-tracing services was excellent. However, it is of some concern that 4% of clinics never and 9% only sometimes traced contacts for gonorrhoea, 8% never traced contacts for syphilis and 2% never traced contacts for Chlamydia . Although we surveyed only five FPCs, our finding that only one of these five provided contact tracing is of concern, particularly with Chlamydia , which is often diagnosed within these facilities.³¹ Barriers to contact-tracing services within FPCs should be explored and solutions considered. One possible solution would be to encourage closer links between sexual health and family planning services.

Our findings in this survey should be of assistance in future sexual health service planning. In addition, the remarkable consistency in the diagnosis, treatment and contact tracing of STDs in Australia and New Zealand should encourage the development of national guidelines.  

Acknowledgements

References

1. Adler MW. Sexually transmitted diseases. In: Holland WW, Detels R, Knox G, editors. Oxford textbook of public health. Vol. 21. 2nd Ed. Oxford: Oxford University Press, 1991: 345-357.
2. Bingham JS. Genitourinary medicine should remain a separate specialty. Genitourin Med 1996; 27: 312.
3. Adler MW, Belsey EM, O'Connor BH, et al. Facilities and diagnostic criteria in sexually transmitted disease clinics in England and Wales. Br J Vener Dis 1978; 54: 2-9.
4. Mulhall BP, Hart G, Harcourt C. Sexually transmitted diseases in Australia: a decade in change. Epidemiology and surveillance. Ann Acad Med Singapore 1995; 24: 569-578.
5. Bradford DL, Philpot CR. A survey of sexually transmitted disease centres in Australia. Br J Vener Dis 1983; 59: 330-334.
6. SPSS: Statistical package for the social sciences [computer program], version 7.0. Chicago, Ill: SPSS Inc, 1995.
7. Rural/remote areas classification. Canberra: Department of Human Services and Health, 1994.
8. New Zealand Official Yearbook 1993. 96th Ed. Wellington: New Zealand Department of Statistics, 1993.
9. Donovan B, Finlayson RJ, Mutimer K, et al. HIV infection in sexually transmissible disease practice in Sydney: the effects of legislation, public education and changing clinical spectrum. Int J STD AIDS 1990; 1: 21-27.
10. The Australian gonococcal surveillance programme. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991. Genitourin Med 1993; 69: 364-369.
11. Hart G. STD epidemiology in Australasia; Syphilis and gonorrhoea. Venereology 1992; 5: 115-120.
12. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993; 159: 90-96.
13. Annual report of the national notifiable diseases surveillance system, 1992 - part 2. Syphilis. Commun Dis Intell 1993; 17(22): 507-508.
14. Bowden FJ. Surveillance of sexually transmitted diseases in the Northern Territory of Australia. Venereology , 1995; 8(1): 21-25.
15. Main J, Patel A, Bowden FJ. Surveillance of donovanosis in the Northern Territory. Venereology 1995: 8: 16-19.
16. sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1993; 42(RR-14): 1-102.
17. Management guidelines for sexually transmissible diseases and genital infections. 4th ed. Melbourne: Venereology Society of Victoria, 1995.
18. Anonymous. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991 . The Australian Gonococcal Surveillance Programme. Genitourin Med 1993; 69(5): 364-369.
19. Tapsall JW, Schultz TR, Philip EA. Characteristics of Neisseria gonorrhoeae isolated in Australia showing decreased sensitivity to quinolone antibiotics. Pathology 1992; 24: 27-31.
20. Mulhall BP, Hu M, Thompson M, et al. Planned sexual behaviour of young Australian visitors to Thailand. Med J Aust 1993; 158: 530-535.
21. Mulhall BP. Sexually transmissible diseases and travel. Br Med Bull 1993; 49(2): 394-411.
22. O'Connor CC, Berry G, Rohrsheim R, Donovan B. Sexual health and use of condoms among local and international sex workers in Sydney. Genitourin Med 1996; 72: 47-51.
23. Philpot CR, Harcourt JM, Edwards JM. A survey of female prostitutes at risk of HIV infection and other sexually transmissible diseases. Genitourin Med 1991; 67: 384-388.
24. Rowbottom JH, Tapsall JW, Plummer DC, et al. An outbreak of a penicillin-sensitive strain of gonorrhoea in Sydney men. Genitourin Med 1994; 70: 196-199.
25. Forsyth JRL, Sherrard J, Traynor P. Resurgent gonorrhoea in homosexual men [letter]. Lancet 1990; 336: 878.
26. McNulty A. Anorectal gonorrhoea revisited. Venereol 1993; 6(4): 109-111.
27. Goldwater PN. History of hepatitis B vaccination in New Zealand: lessons for Australia? Aust J Pub Health 1993; 17: 221-225.
28. Stewart T, Crofts N. An outbreak of hepatitis A among homosexual men in Melbourne. Med J Aust 1993; 158: 519-521.
29. Stokes ML. Infectious diseases: hepatitis A survey results. NSW Public Health Bull 1992; 3: 7-12.
30. Anderson B, Bodsworth NJ, Rohrsheim R, Donovan B. Hepatitis B virus infection and vaccination status of high risk people in Sydney: 1982 and 1991. Med J Aust 1994; 161: 368-371.
31. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993, 159: 90-96.