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Syphilis in remote Indigenous communities: can we eradicate it this time or is the risk now greater?

A recent syphilis outbreak in Central Australia has prompted renewed calls for urgent investment in sexual health services for young Aboriginal and Torres Strait Islander people living in remote regions.

As this recent article at The Conversation outlines, 134 cases of the sexually transmitted disease have been reported in the Barkly and Katherine regions over the past year, up from 15 reported cases in the 2013-14 financial year.

The authors warn:

There’s a serious risk the outbreak will extend into other parts of remote Australia. But suggestions that the recent rise in syphilis cases has something to do with child sexual abuse in Aboriginal communities are an irresponsible distraction from the issue at hand.

What both the territory and federal governments need to do is acknowledge that investment in primary health-care delivery in remote Aboriginal communities is inadequate. That’s why outbreaks of sexually transmitted diseases are confined to these regions, while being a rarity in mainstream Australia.

In the post below, public health physician Patricia Fagan outlines the gaps in effective action in the past and says governments and communities need to be aware that the current approach to STIs in remote areas is “ineffective and wasteful, being characterised by poorly or inappropriately resourced, uncoordinated, piecemeal and often ill-conceived interventions.” She says:

They should also take note of existing data and the evidence documenting the broad based benefits to be gained from steadily working over time with communities as trusting partners mutually committed to addressing a sensitive issue.

See also related stories from Croakey’s coverage of the International Indigenous Pre-Conference on HIV & AIDS staged in Sydney in 2014.

***

Patricia Fagan writes:

Syphilis is an ancient, curable but serious sexually transmitted infection (STI) with devastating impacts on the unborn baby and dire cardiovascular and neurological consequences for up to one third of untreated adults.

Although by the mid-20th century it was rare in Australia, it continued to affect two populations – men who have sex with men and remote-living Indigenous people.  Even then, up until a few years ago, syphilis was on the wane in the latter group with only 123 cases notified in Aboriginal and Torres Strait Islander people nationally in 2009. Experts had begun flagging the possibility of eliminating syphilis from remote populations once and for all… but that was not to be.

Now, in 2015, syphilis is being notified more frequently than ever, in increasingly scattered locations in remoter parts of Queensland, the Northern Territory and Western Australia, especially among young people less than 20 years old.

It started in 2010-2011 as a localised outbreak along the Northern Territory/north west Queensland border.  Efforts to contain it have been relatively ineffective. The outbreak response in Queensland came far too late and, once initiated, it floundered due to inexperience and the lack of a consensus regarding an agreed response framework.

This gap was remedied in 2014 by the introduction of a set of nationally agreed guidelines for the public health management of syphilis in remote populations.  But the horse had bolted! These populations now face the prospect that syphilis may once more become endemic, thus adding to the reproductive health risk experienced by young people and their unborn children.

It could be argued that the reasons for the dramatic decline of syphilis in remote populations in earlier decades were misunderstood, and this has contributed to the current difficulties. Rather than being due to better health services and dedicated syphilis surveillance systems across the country, syphilis may have been responding only in small measure to these initiatives but more decisively to its own inherent variability and the organism’s sensitivity to azithromycin.

Azithromycin is an antibiotic introduced in the mid 1990s in Australia and widely used in the treatment of another common STI, and the eye infection, trachoma – in doses that were never considered therapeutic but may well have an impact on sensitive strains of incubating syphilis. Many of the recent cases are reported to have been caused by strains no longer sensitive to azithromycin.  A deeper understanding of the dynamics affecting the transmission of syphilis would have given health systems pause for thought and the opportunity to better prepare for an outbreak.

That said, the capacity of syphilis to readily regain its foothold in so many locations across remote Australia should not surprise us.  The unacceptable level of other STIs – chlamydia, gonorrhoea and others – in these populations is well documented, has persisted for decades and reflects underlying youth sexual health disadvantage.  Until this is addressed, the vulnerability of these groups to syphilis and to HIV/AIDS will continue.  In my view, good luck alone has to date prevented HIV/AIDS from becoming a significant issue in these settings.  If the future only holds more of the same, the question must be, when will this luck run out?

Remote Australian youth share the general disadvantage of their families and communities – lower incomes, overcrowded housing, poor education outcomes, few employment opportunities. But in addition, they face specific, additional disadvantages in relation to their sexual health. These are evidenced in lower levels of knowledge about STI and HIV – particularly in relation to HIV transmission (when compared with mainstream Australian youth), significant levels of risk behaviours (early sexual debut, multiple partners), poor functional access to condoms, little awareness of personal risk from STI or HIV, combined with extremely high rates of the common notifiable STIs and inadequate access to skilled sexual health services.  The resulting elevated levels of pelvic inflammatory disease and infertility are also well documented.

To date, approaches to STI control in remote Indigenous populations have relied heavily on a “test, treat and contact trace” strategy implemented by primary care services. In reality, making a significant and sustainable difference to the level of risk requires a more strategic and sustained approach.

Significant gaps include the need for community awareness and genuine engagement that allow the development of population-wide sexual health communications strategies, the embedding of curriculum-based, age-appropriate, teacher-led, continuous sex education in schools from years 5 to 10, and the implementation of strategies that ensure condom access for youth 24/7 from at least one private location in each community.

Also, innovative approaches to STI testing, contact tracing and treatment must be continuously developed and refined. It has been shown that a comprehensive program based on strong cross-sectoral and community partnerships that implements such strategies simultaneously across a region will be effective, but each strategy requires the commitment of specialist staff, sustained resources, and time – at least a decade.  And implementation must be accompanied by a rigorous approach to evaluation allowing continuing timely review of the program.

Many may believe such a large investment is not warranted.  There is the perception that this is but one “small problem among many”, affecting (it is assumed) a diminishing proportion of the Australian Indigenous population.  In addition, STIs (excepting syphilis and HIV) are not generally lethal and, furthermore, some will argue, STI levels will eventually reduce as socioeconomic disadvantage improves.  Unfortunately, improvement in socioeconomic status for Indigenous Australians is not shared uniformly across the country and conditions in the communities most at risk are such that disadvantage is likely to be concentrated there for a long time still to come.

Governments and communities themselves need to make their resource allocation decisions. In so doing, they should be aware that the current approach is ineffective and wasteful, being characterised by poorly or inappropriately resourced, uncoordinated, piecemeal and often ill-conceived interventions. They should also take note of existing data and the evidence documenting the broad based benefits to be gained from steadily working over time with communities as trusting partners mutually committed to addressing a sensitive issue.

The way forward rests not so much on “what to do” – this is clear.  Success will ultimately hinge on wisely deployed resources and commitment – the commitment of health systems, communities and families to safeguard their youth.

Patricia Fagan is Associate Professor (adjunct) at the James Cook University School of Public Health, Tropical Medicine and Rehabilitation Sciences, and a public health consultant who has developed the Interim Guidelines for the Public Health Management of Syphilis in remote populations in Australia; endorsed and released by Communicable Diseases Network of Australia in February 2014.

She is a public health physician who has spent more than 30 years working in Aboriginal and Torres Strait Islander health in New South Wales and Queensland.