Introduction by Croakey: Behind the Federal Budget’s allocation of $126.5 million over the next two years to support the national response to blood borne viruses and sexually transmitted infections (STIs) is a longstanding public health crisis, reports Dr Emily Humphries, a GP registrar and University of Sydney Master of Global Health student.
In investigating gaps and delays in Australia’s response to an infectious and congenital syphilis crisis, which began over a decade ago, Humphries speaks with the Kimberley Aboriginal Medical Service about their experiences, and also shares public health lessons from Thailand, a global leader in the elimination of mother-to-child transmission of syphilis.
The article was produced for her Global Health Capstone project.
Emily Humphries writes:
Australia is in the midst of an infectious and congenital syphilis crisis. In 2011, an outbreak of infectious syphilis was declared in northwest Queensland. This later spread to rural and remote areas of the Northern Territory and Western Australia in 2013 and 2014 and to South Australia in 2016.
In March 2023 the Australian Department of Health reported that: “The last 12 months marks the highest number of [syphilis] cases reported for a 12 month period since infectious syphilis became notifiable in 2004”.
Aboriginal and Torres Strait Islander peoples living in rural and remote areas continue to be disproportionately affected, while rates of infectious syphilis are rising among women of childbearing age in metropolitan and regional areas, resulting in 2020 recording the highest number of congenital syphilis cases diagnosed since 2001.
Australia is not alone – many high-income countries are seeing a rise in syphilis and congenital syphilis cases. Why is Australia going backwards and what are we doing about it?
Key points
- Syphilis is rising across Australia in regional and metropolitan areas. It has serious health implications, especially for pregnant women and babies
- ASHM has syphilis resources and training available for clinicians, including the Syphilis Decision-Making tool to assist assessment and treatment
- All asymptomatic STI testing should include both HIV and syphilis testing
- Clinicians should be on high alert for syphilis in pregnancy – consult your state or territory guidelines for antenatal testing protocol
- Anyone can get a sexually transmitted infection (STI) – it is important to get an STI check whenever there is a new partner, unprotected sex or every six to 12 months.
A short history
Syphilis is a sexually transmitted infection caused by the bacteria Treponema pallidum. It is difficult to detect clinically and diagnose as it is often asymptomatic and test results can be tricky to interpret if a clinician is not experienced with syphilis testing.
When it does display symptoms, they can be highly variable and mimic other conditions. The classically described symptom of early syphilis is a painless genital or anal ulcer (chancre), which may go unnoticed by the patient.
An untreated syphilis infection is especially important in women of childbearing age as it can be passed from mother to child while pregnant, causing stillbirth, prematurity and severe organ damage in affected babies.
In Australia, young people aged 25 to 29 years, male gender, Aboriginal and Torres Strait Islander peoples, men who have sex with other men and people living in rural and remote areas are most affected by syphilis, but we are seeing a rise in cases among women of childbearing age.
Syphilis has been around for hundreds of years. The HIV/AIDS crisis of the 1980s and 1990s saw a decline in cases due to disruption of sexual networks, change in sexual behaviour and widespread sexually transmitted infection testing.
A global genetic study of syphilis published in Nature in 2021 found that the genetic lineage of the dominant syphilis strains circulating today is different to those causing infection prior to the HIV/AIDS crisis, and that these dominant syphilis strains are now widespread across the world. This indicates that there is frequent, widespread global transmission of syphilis.
Reasons for this may include the return of higher risk sexual practices after the introduction of antiretroviral therapies and improvement in HIV survival rates, increasing globalisation and re-establishment of sexual networks as well as chronic underfunding of syphilis public health campaigns in many countries.
Behind many infectious and congenital syphilis cases there are often complex socio-economic determinants at play, such as unstable housing or employment, mental and physical illness, poverty and systemic racism. This is reflected in the fact that Indigenous peoples and marginalised populations worldwide who face systemic inequities are also disproportionately affected by infectious and congenital syphilis.
Inconsistent screening guidelines
Any case of congenital syphilis is a missed opportunity for prevention and the outcome can be devastating for mother and child. Data from the National Notifiable Disease Surveillance System (NNDSS) shows that between 2016 and 2023, 71 congenital syphilis cases were reported. Of those 71 cases, 77 percent (55/71) were diagnosed late in pregnancy, with 11 of those mothers diagnosed with less than 30 days remaining before delivery.
In Australia, antenatal syphilis screening guidelines are inconsistent across states and territories.
At time of writing, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommend routine syphilis testing at initial visit only. Victoria, the Northern Territory and South Australia recommend repeat testing in pregnancy if considered to be at high risk of an STI.
What is considered ‘high risk’ may vary slightly between jurisdictions. Western Australia, Queensland and New South Wales have implemented syphilis screening for all pregnant women, regardless of risk status, at several time-points including at first appointment and in the third trimester.
Lack of national consistency on antenatal screening creates confusion for healthcare practitioners and patients.
Implementing antenatal syphilis screening for all pregnant women at multiple time-points may help to normalise testing, reduce stigma, offers an opportunity for patient education and protects against any unidentified risk factors.
Jessica Michaels, Deputy CEO at ASHM, said that the “recommended additional screening time-points and criteria defining risk vary by jurisdiction and sometimes by region, making it challenging to provide clear advice for clinicians”.
Identifying who might be at increased risk of syphilis infection is problematic for a few reasons. Syphilis can be challenging to diagnose and clinicians who work in centres with historically low numbers of syphilis cases may have less experience in routinely assessing and identifying risk factors.
Many primary care clinicians have time constraints and may not always be able to take the time needed to build rapport and take a detailed assessment of what remains a highly sensitive and stigmatised issue.
Patients may not disclose risk factors to their doctor due to lack of awareness, lack of symptoms or fear of stigmatisation and previous adverse experiences with the health system.
Lack of cultural safety and training in many health services may also discourage patients from seeking care. The Australian Health Practitioner Regulation Agency defines cultural safety as the ‘… ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism. This is determined by Aboriginal and Torres Strait Islander individuals, families and communities’.
As well, the state of general practice in Australia is increasingly burdened by systemic issues such as GP workload and burnout, patient access issues and out-of-pocket costs and underfunding of general practice. These upstream factors all limit equitable healthcare access and effective delivery of primary care services, including STI prevention and management.
Congenital syphilis cases often reflect complex social issues and the need to support pregnant women and partners who have difficulty engaging with antenatal care.
A review of policy initiatives to reduce congenital syphilis risk in metropolitan Perth, Western Australia, emphasised the importance of educating a range of frontline services who may encounter infectious and congenital syphilis cases.
This includes not only healthcare staff, such as general practitioners, dentists, eye specialists, emergency department staff and mental health professionals, but also community organisations working with Aboriginal and Torres Strait Islander communities, people experiencing homelessness, drug and alcohol services, and culturally and linguistically diverse communities.
Michaels also reiterated the importance of engaging with a range of multidisciplinary frontline health services and community organisations.
“We need to think about how we can engage as many people as possible during pregnancy, including those with little or no engagement with antenatal care,” Michaels said.
“This highlights the need for a multidisciplinary response and necessity of clear education, guidelines, and resources for settings beyond sexual health and antenatal care.”
A Department of Health spokesperson responded that “While the department supports nationally consistent syphilis testing guidelines, there are a wide range of guidelines… some of these belonging to state and territory governments and professional colleges.”
The Department is currently working with states and territories to “… establish national consistency in guidelines relevant to syphilis”.
Responses by Aboriginal and Torres Strait Islander communities
Aboriginal and Torres Strait Islander communities have been affected for too long.
According to the Kirby Institute, the notification rate in 2021 for infectious syphilis in Aboriginal and Torres Strait Islander peoples was 5.5 times as high and the congenital syphilis rate was 14 times as high as non-Indigenous people in Australia.
Although the first outbreak was declared in Queensland in 2011 and spread to the NT and WA in 2013 and 2014, it wasn’t until 2017 that the Federal Government implemented a national response.
The Australian Government Department of Health, in partnership with the National Aboriginal Community Controlled Health Organisation (NACCHO) and Flinders University, rolled out the Enhanced Syphilis Response program to tackle the outbreak.
The program, which continues to be supported by the Department of Health and Aged Care, works with 40 Aboriginal Community Controlled Health Services (ACCHSs) in outbreak areas to provide funding grants, workforce supplementation and training, Point-of-Care testing capabilities and national coordination and support.
A Department of Health spokesperson stated that the Enhanced Syphilis Response program “… provides testing, treatment and strategies to reduce the incidence of syphilis [in targeted communities]. This activity is driven by a trusted and embedded sexual health workforce funded through the program, which is key to success”.
Dr Lorraine Anderson, Medical Director of the Kimberley Aboriginal Medical Services (KAMS), spoke about their experience with the Enhanced Syphilis Response program.
The syphilis outbreak in the Kimberley region was declared in 2014 and mainly affects young Aboriginal and Torres Strait Islander peoples aged between 15 – 34 years.
KAMS had already implemented an outbreak response locally prior to the introduction of the Enhanced Syphilis Response program, partnering with member services to provide clinical education and sexual health promotion programs tailored to the Kimberley region, as well as increasing opportunistic and targeted screening for syphilis and blood borne viruses.
What’s working?
Anderson praised the roll-out of the Enhanced Syphilis Response program in the Kimberley, noting a rise in syphilis testing, the provision of useful clinical guidelines and resources to healthcare practitioners, as well as providing a pathway for the formation and strengthening of local, regional and national partnerships necessary to address the syphilis outbreak.
Clinical training had led to a perceptible improvement in workforce confidence and independence in assessing, testing and treating syphilis and other STIs.
The uptake of Point-of-Care testing (PoCT) for syphilis in clinic and outreach settings for use by doctors, nurses and Aboriginal Health Workers was a welcome addition, with over 100 staff across the Kimberley trained to use PoCT.
Anderson acknowledged the limitations of PoCT, including not being able to use it for syphilis re-infections. This highlights the ongoing need for parallel serology testing, which is often delayed in rural and remote areas.
A global shortage of benzathine benzylpenicillin (Bicillin L-A), a long-acting penicillin injection used to treat syphilis, has affected many countries. The Therapeutic Goods Administration has prioritised supply for “… rural and remote settings and some Aboriginal Medical Services or Aboriginal Community Controlled Health Organisations”.
Anderson stated that KAMS remains unaffected by the shortage so far and the Therapeutic Goods Administration has approved the use of an alternative benzathine benzylpenicillin in the meantime.
The program allowed for KAMS to tailor program delivery to the local context, especially health promotion.
On the Enhanced Syphilis Response program, Anderson said: “I have a list of things that this funding has actually been really helpful for… health promotion messages aimed at young Aboriginal people, culturally appropriate settings for educational sessions… Male and female project officers who deliver sexual health education are really important.”
“Social media tiles that we have put out there we think have worked well… We have Kimberley-born Aboriginal social media influencers that have been incredibly effective, which is exciting.”
Content produced in collaboration with the social media influencers, who were recruited through staff and local networks, were promoted through the ‘Her Rules Her Game’ social media campaign, available on Facebook, Instagram and Youtube.
Holistic approaches
Anderson highlighted the need for stable and accessible primary healthcare in remote areas and the importance of considering a patient’s health holistically, including social and cultural determinants and wellbeing.
“It’s about getting to the root of the issue by talking to people and listening, considering people’s emotional, spiritual and social needs … [healthcare practitioners] need to remember it’s not all about the syphilis but if you’re going to get to the syphilis, you need to talk to them about everything else that is going on as well,” she said.
“Individualised care between male and female people is really important in our sector … they don’t want to see a male health worker if they’re a female patient and talking about STIs.”
KAMS began routinely testing for syphilis at five time-points throughout pregnancy regardless of risk status and demographics, which Anderson noted had made discussing and testing for syphilis and other STIs “more approachable” for the community.
Anderson states that KAMS will strive to provide the same program and care it has developed for the community, regardless of federal funding.
The 2024 Federal Budget has committed $126.5 million over the next two years to support the national response to blood borne viruses and STIs, including $28.6 million.
A Department of Health spokesperson stated that this funding would continue to support the Enhanced Syphilis Response and Blood Borne Virus and Sexually Transmitted Infection programs to deliver testing, support workforce staffing, training, health promotion and community engagement in Aboriginal and Torres Strait Islander communities in collaboration with ACCHS.
The budget did not include funding for the interim Australian Centre for Disease Control, which began operations on 1 January and is involved in coordinating the syphilis response and the upcoming Fifth National STI strategy from 2024 – 2030, as well as national surveillance of syphilis.
The Enhanced Syphilis Response has resulted in a stabilisation of the syphilis outbreak in target areas, but there is still a long way to go to achieve pre-outbreak levels.
Writing for the Conversation in 2015, Professor James Ward, Director of the UQ Poche Centre for Indigenous Health, called for urgent investment into the integration of sexual health and primary healthcare services, with a need for quality health education and outreach programs.
The Enhanced Syphilis Response has implemented such measures in targeted areas, but expansion of the Enhanced Syphilis Response model and sustained government investment in culturally safe and accessible primary and sexual healthcare is crucial to prevent future outbreaks of syphilis and other STIs.
The 2024 Federal Budget marks a major investment in the STI and blood borne virus response, but it comes more than 10 years since the declaration of the syphilis outbreak in northern Australia.
“[Syphilis] has been affecting Aboriginal people in the north for so long… It’s just bloody heartbreaking” Dr Anderson says.
Global perspectives
Worldwide, less than 20 countries have achieved elimination of mother-to-child transmission of syphilis, as validated by the World Health Organization.
This includes achieving indicators such as 95 percent of pregnant women attending at least four antenatal appointments, having access to testing and treatment of syphilis.
Thailand achieved elimination of mother-to-child transmission of syphilis in 2016. Dr Rangsima Lolekha, current Chief of the Treatment and Care Section at the Division of Global HIV and TB Thailand and Laos, United States Centers for Disease Control and Prevention Thailand office, was actively involved in the process of elimination of mother-to-child transmission of syphilis and HIV validation in Thailand.
Lolekha attributes Thailand’s success to sustained government investment in quality and accessible maternal health programs, including routinely testing for HIV and syphilis at the first antenatal appointment and in the third trimester, community outreach programs, health promotion campaigns, and stigma and discrimination reduction program at health facilities to combat stigma, as well as working with sexual health non-government and advocacy organisations. Thailand has universal health coverage for all Thai citizens, including antenatal care.
Lolekha highlighted the importance of several key measures in the post-validation era, including sustaining public health prioritisation of congenital syphilis and sexually transmitted diseases prevention, need for clearly defined roles and responsibilities for government and non-government organisations, improved surveillance systems for congenital syphilis and syphilis in pregnancy (covering 70 – 80% of nationwide deliveries) and partner treatment.
Also important is addressing any ongoing mother-to-child transmission in marginalised groups, including adolescents and women who face difficulty engaging with antenatal care.
Testing for syphilis in partners of pregnant women who are treated for syphilis remains a challenge. Thailand is currently undergoing revalidation of its status for elimination of mother-to-child transmission of syphilis.
• With thanks to Mr Jasper Garay (Darkinjung/Ngarigo), Lecturer – Aboriginal and Torres Strait Islander Health and Wellbeing, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, for cultural safety review of this article.
Previously at Croakey
2015: Syphilis in remote Indigenous communities: can we eradicate it this time or is the risk now greater?
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