“Let’s not talk about sex”: reconsidering the public health approach to sexually transmissible infections in remote Indigenous populations in Australia

To the Editor: The proposal by Bowden and Fethers1 to abandon “screen, treat and contact trace” methods of managing endemic sexually transmissible infections (STIs) in remote Indigenous communities and replace them with mass treatment programs in groups with defined threshold prevalence levels is flawed. Primacy must go to the question of why some STIs are so prevalent. Why deal only with the consequences rather than the causes of STIs? Without resolving these questions, the problems will persist.

Bowden and Fethers’ approach has serious shortcomings. A major one is sweeping aside the concepts of one-on-one advice, counselling, opportunities to cooperate with health staff, avoidance of hazardous behaviours, and maintenance of effective follow-up. These cornerstones of public health strategies to control STIs depend on the ability of health professionals to establish meaningful relationships with Indigenous people.

Transient populations move frequently between towns and remote communities. Therefore, the authors’ strategy neglects the serious risk to remote communities from inadequately controlled reservoirs of STIs that allow the diseases to be repeatedly reintroduced from rural or remote towns.

The authors say, ironically, “Let’s not talk about sex”, but an essential part of the public health response to STIs must be to talk about sex. It is our observation that many Indigenous people are more comfortable talking about this subject than other Australians.

Another risk in the authors’ approach is to overlook detection of HIV infection. Their proposal could also be interpreted by many Indigenous people as suggesting that they no longer need worry about STIs because the new blanket approach from their health carers will protect them from all such infections.

Our long experience working in remote northern Western Australia suggests to us that a mass treatment approach would not resolve the problem of STIs. Control of many of the main chronic diseases of Indigenous people living in remote areas can be significantly enhanced by increased Indigenous community involvement, decision making, and trusting collaboration with health professionals.2 Crucially, additional government commitment is urgently needed to provide enough locally stable and adequately trained staff, facilities, and related resources to control these persisting problems in remote Australia.