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Review of Investment in Sexual Health and Blood Borne Virus Activity – Final Report

1.2 Background

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1.2.1 Sexually transmissible infections and blood-borne viruses among Aboriginal and Torres Strait Islander populations

Sexually transmissible infections and blood borne viruses can have a significant impact on individuals, families, and communities. Many of these conditions are asymptomatic for long periods of time and, although treatable, are often not diagnosed until the untreated disease has begun to cause further damage to the individual, or been transmitted to others through sexual contact or sharing of needles. While considerable progress has been made in reducing blood borne viruses and STIs in both

Indigenous and non-Indigenous Australians, Aboriginal and Torres Strait Islander Australians continue to experience higher rates of the major STIs and BBVs than non-Indigenous Australians – particularly hepatitis B and hepatitis C, chlamydia, syphilis, and gonorrhoea (Department of Health and Ageing 2010). Some of the factors which may impact upon Aboriginal and Torres Strait Islander Australians’health status include availability of health services and health service providers, socio-economic disadvantage, population mobility, and opportunity to access services which demonstrate a culturally appropriate understanding of Aboriginal and Torres Strait Islander conceptions of health and well-being (NCHECR 2009b, Newman et al 2007).

There are considerable gaps in the reporting of Aboriginal and Torres Strait Islander status for disease notifications. In 2008, for example, Aboriginal and Torres Strait Islander status was not reported in 52% (over 30,000) cases of chlamydia diagnosed in Australia, in 28% (2,178 cases) of diagnoses of gonorrhoea, or in 58% (6,561 cases) of hepatitis C diagnosed in Australia (NCHECR 2009b). On the other hand, 95% of syphilis notifications nationally reported Aboriginality (NCHECR 2009b). The figures cited below only include those jurisdictions where Aboriginality is recorded for over 50% of notifications. The data may therefore be an under-estimation of actual incidence within the Aboriginal and Torres Strait Islander populations.

Unlike other BBVs and STIs, the rate of HIV diagnosis within Aboriginal and Torres Strait Islander populations is slightly less than that of non-Indigenous Australians, at about 3.8/100,000 compared to 4.8 in the non-Indigenous population (NCHECR 2009b). While the primary mode of transmission for both the Indigenous and the non-Indigenous populations continues to be men who have sex with men, within Aboriginal and Torres Strait Islander populations nearly a quarter of people are infected through heterosexual contact, and a similar number are infected through injecting drugs (NCHECR 2009b). Transmission of HIV through injecting drug use is higher in the Aboriginal and Torres Strait Islander population than in the non-Indigenous population (NCHECR 2009b).top of page

There are an estimated 284,000 people living in Australia who have been exposed to the hepatitis C virus (NCHECR, 2009a). Of these, approximately 57% will have a chronic infection or early liver disease, 25% will have cleared the virus, and the remainder will have developing stages of liver disease. In 2008, 626 Aboriginal or Torres Strait Islander people were diagnosed with hepatitis C, representing 6% of diagnoses (NCHECR 2009b). While rates of diagnosis are decreasing in some regions, rates overall remain much higher than for the non-Indigenous population, particularly in the 15- 19 and 20-29 year old age group (NCHECR 2009b). The primary route of transmission for hepatitis C is through injecting drug use.

Chlamydia was the most frequently reported STI notified in Australia in 2008, and substantially higher rates of diagnosis are reported for Aboriginal and Torres Strait Islander Australians than for non-Indigenous Australians (NCHECR 2009b). However, higher increases over time were reported in the non-Indigenous population. The incidence of chlamydia in Australia is increasing and it is not clear whether this is due to increased rates of infection within the community or increased testing and reporting. The highest rates of chlamydia in the Aboriginal and Torres Strait Islander populationsappear in the 15-19 year age group (NCHECR 2009b).

In 2008 the population rate of diagnosis of gonorrhoea among males was 46.7 per 100,000 populationand 25 per 100,000 population among females (NCHECR 2009a). The rate among Aboriginal and Torres Strait Islander Australians, however, in those jurisdictions with adequate recording of Aboriginality, was 36 times higher than that of non-Indigenous Australians, at 806/100,000. It appears that the transmission within the Aboriginal and Torres Strait Islander population is primarily through heterosexual contact, while within the non-Indigenous population gonorrhoea is primarily transmitted through sexual contact between men (NCHECR 2009b).

Infectious syphilis rates among Aboriginal and Torres Strait Islander Australians are substantially higher than non-Indigenous Australians, ranging from 90 times higher for women 15-19 years to 4 times higher for men 20-29 years (NCHECR 2009b). As with gonorrhoea, the primary mode of transmission among Aboriginal and Torres Strait Islander Australians is through sexual contact between men and women, while in the non-Indigenous population syphilis is primarily transmitted through sexual contact between men (NCHECR 2009b).

Aboriginal and Torres Strait Islander Australians may access primary health care services through Aboriginal Community Controlled Health Services (ACCHS), state-funded Aboriginal medical services or community health services, or private general practices. Aboriginal and Torres Strait Islander Australians in rural and remote locations generally have fewer choices for accessing health services, and some may choose not to attend local services for sexual health matters due to a perceived loss of privacy or confidentiality. Perceptions of stigma and shame may influence people’s choice of services (Ward et al 2010, Newman et al 2007), although some research has suggested that young people feel less of a burden of shame attached to sexually transmissible infections (Mooney-Somers et al 2009).top of page

1.2.2 The second strategy

The stated goal of the National Aboriginal and Torres Strait Islander Blood-borne Viruses and Sexually Transmissible Infections Strategy 2005 – 2008 was to reduce the transmission of and morbidity caused by HIV/AIDS, STIs and BBVs in the Aboriginal and Torres Strait Islander community and to minimise the social and personal impacts of these infections (Department of Health and Ageing 2005:1). Five objectives were identified to support this goal:

• to improve access to testing, diagnosis, treatment and care of HIV/AIDS, STIs and BBV for
• Aboriginal and Torres Strait Islander people
• to respond to Australia’s role in the prevention of a HIV epidemic in the Torres Strait region
• to improve surveillance and research activities in order to guide the development and implementation of prevention, treatment and care initiatives in the Aboriginal and Torres Strait Islander community
• to improve awareness of HIV/AIDS, STIs and BBV in the Aboriginal and Torres Strait Islander community
• to develop and strengthen links with the related national mainstream strategies (Department of Health and Ageing 2005:1).

Four priority areas were chosen which guided the activities of the strategy: STIs, people living in the cross-border region (Torres Strait), access to needle and syringe programs (NSP) and increased health and community workforce capacity. In addition, ten priority groups for action were identified:

• young people
• people who inject drugs
• people living in the cross-border region
• people in custodial settings
• people living with HIV/AIDS
• people living with Hepatitis C
• people with STIs
• gay men, sistergirls, transgender and MSM
• people who have traditional language as their first language
• people affected by sexual violence and abuse.

A national implementation plan was developed to support the strategy; in addition, each state and territory developed their own strategies or action plans to guide investment and activity in the area of STIs and BBVs. The national implementation plan, and the implementation plans for the other national strategies for HIV/AIDS, STIs and hepatitis C, identified a number of responsibilities for the Department of Health and Ageing. Of these, only one refers specifically to OATSIH: “establish sexual health committees in those jurisdictions that do not have an existing committee in consultation with DoHA OATSIH S/T Offices and S/T Health Departments, consistent with the National Strategic Framework for Aboriginal and Torres Strait Islander Health”². Notwithstanding this, OATSIH has funded a range of activities across jurisdictions and organisations, which seek to respond to the priorities identified in the second strategy. These activities, and OATSIH’s engagement, are discussed in section 3 of this report.

The second strategy was reviewed, along with the other three national strategies (for HIV/AIDS, hepatitis C and STIs) in 2009. The review found that while progress had been made during the life of the strategy in responding to the burden of disease from BBVs and STIs amongst Aboriginal and Torres Strait Islander populations, greater attention was required as rates of STIs and BBVs remain unacceptably high (Urbis 2009).

Key priorities for the future to emerge from the review included:

• workforce development and capacity regarding STIs and BBVs, both within mainstream and Aboriginal and Torres Strait Islander health services.
• continued improvement in surveillance systems to monitor disease incidence and prevalence
• high STIs rates among young people
• prevention for BBVs through NSPs, education and health promotion activities, particularly among people who inject drugs, people in custodial settings, men who have sex with men and sistergirls
• continuing vigilance with regard to the potential for the spread of HIV from Papua New Guinea through the cross-border region of the Torres Strait (Urbis 2009:42-43).top of page

  1.2.3 The third strategy

  Following the review of the national strategies of 2005-2008, new strategies were produced through a consultative process. The third national Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010-2013 is one of the suite of five national strategies addressing sexually transmissible infections and blood borne viruses. The third strategy has maintained a number of priorities from the second strategy, while identifying several new ones. The objectives of the new strategy are to:
• reduce hepatitis B infections
• work towards eliminating infectious syphilis in Aboriginal and Torres Strait Islander peoples
• decrease the proportion of HIV and hepatitis C infections caused by injecting drug use
• increase the level of systematic testing and treatment of sexually active 15 to 30–year–olds, noting that testing will likely increase the notifications of bacterial STIs in the short term—before a reduction in the long term
• improve Aboriginal and Torres Strait Islander young people’s knowledge of STIs and BBVs
• increase the number of Aboriginal and Torres Strait Islander peoples receiving treatment for HIV, hepatitis C and hepatitis B
• implement a national accreditation scheme for Aboriginal and Torres Strait Islander sexual health workers, under COAG’s National Registration Program (Department of Health and Ageing 2010:13-15).

The priority populations for the strategy are identified as:

• people aged 15 to 30 years
• people who inject drugs
• people in adult and juvenile corrections settings
• gay men, other men who have sex with men, sistergirls and transgender people
• people living with HIV and viral hepatitis
• people living in the Torres Strait Island region.

The new strategies will be implemented in the context of significant health reform at the national level. While the structures of these reforms are still being determined, the reform process is likely to have an impact upon the ways in which funding decisions in Canberra are implemented within jurisdictions. It is not clear yet the extent to which new Commonwealth responsibilities for primary health care may impact upon the delivery of BBV and STI activities within primary health care, particularly through Aboriginal Medical Services. The most recent public documents on the reform make virtually no mention of Indigenous health or the community-controlled health sector (Australian Government 2010a, 2010b).

In addition, a key commitment of the Rudd and Gillard governments, the Closing the Gap Initiative, is in the process of being implemented across the country and this will have a significant impact upon policy and funding priorities over the next few years. The extensive policy structure of National Partnership Agreements, and the focus on Closing the Gap with regard to health and Indigenous reform, means that many initiatives will be implemented which, while not specifically addressing Aboriginal and Torres Strait Islander BBV and STI, may influence the ways in which services are delivered on the ground or the way in which health issues are prioritised. As an example, of the several national partnership agreements which support the National Healthcare Agreement and the National Indigenous Reform Agreement, sexual health is named as a priority area only in the National Partnership Agreement on Early Childhood Development underneath the National Indigenous Reform Agreement³. This National Partnership Agreement includes teenage sexual and reproductive health.

However, the potential impact of untreated STIs and BBVs on reproductive health, the potential for transmission through populations, and the generally higher prevalence within Aboriginal and Torres Strait Islander communities mean that STIs and BBVs remain a significant public health priority. Notwithstanding the urgent need to respond to chronic and acute diseases such as kidney disease, diabetes and heart disease in order to reduce morbidity and mortality for Aboriginal and Torres Strait Islander peoples, STIs and BBVs also require a sustained focus to reduce the burden of disease within Aboriginal and Torres Strait Islander populations, including strengthening the evidence base for successful interventions in Aboriginal and Torres Strait Islander BBVs and STIs (Morris et al, 2004).

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² See http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-impl-plan-atsi-l, p.9.
³ The National Partnership Agreements are publicly available at www.coag.gov.au

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