In reply: Although the title of our article was intentionally provocative, our suggested rethink of current approaches to control of sexually transmissible infections (STIs) in remote communities emphasises the role of individual autonomy and consent, education, health promotion and community involvement. We do not dismiss one-on-one advice, counselling, follow-up, the need for meaningful relationships with Indigenous people, or the risk of an HIV epidemic.
However, we do suggest that there should be a separation of the strictly medical components of the strategy from the community development components. Furthermore, in the presence of endemic disease, we propose that presumptive treatment should be based on an assessment of risk made at a community level rather than at the individual level, and that removing the otherwise unavoidable delays between screening and treatment may be a more effective first step in reducing the burden of STIs in remote populations.
A “screen, recall, treat and contact trace” approach works to some degree in the mainstream population, in which the prevalence of STIs is much lower than in remote communities, but what is considered “best practice” in suburban Australia does not automatically translate into best practice in the bush. We acknowledge the logistic difficulties of offering any type of broadly based community program in remote areas and we specifically address the problem of treating hard-to-reach groups in communities. We recognise the risk of giving a false sense of security to the target audience, but current approaches provide people in remote areas little protection from STIs. The recent roll-out of the human papilloma virus vaccination in young women could be similarly criticised, but it is possible to implement a biomedical intervention and still continue with education and health promotion.
The question of antibiotic resistance is an important one. The aim of increasing the intensity of treatment over a defined time period is to reduce the total amount of antibiotics prescribed in the longer term. An increase in the level of resistance is the price that is paid for a reduction in the prevalence of disease in any population receiving antibiotics. Nevertheless, we indicated the need for monitoring of resistance patterns in any trials that are undertaken.
The eradication of the eye disease trachoma is dependent on the availability of clean water and better housing, but while this crucial infrastructure is being built we have to continue to treat the condition where it occurs and apply “traditional” public health approaches to population-level control. We think it is reasonable to consider doing the same for STIs.
- Francis J Bowden1
- Katherine Fethers2
- 1 Academic Unit of Internal Medicine, ANU Medical School, Australian National University, Canberra, ACT.
- 2 Melbourne Sexual Health Centre, Melbourne, VIC.