A healthy respect for Sexual Health. Dee Archbold CNC Princess Alexandra Sexual Health

Transcription

1 2018 A healthy respect for Sexual Health Dee Archbold CNC Princess Alexandra Sexual Health

2 Princess Alexandra Sexual Health (PASH) Sexual health service for Metro South (estimated >1million residents and 23% of QLD population) Based at PA Hospital Outreach to Logan Hospital (Fridays) Our Team - 2 Consultants (Dr Palmer & Dr Siebert) - 1 sessional Registrar - CNC (Dee Archbold) - Contact tracing support officer (Alan Walker) Clinical Nurses - 1 part time Indigenous Clinical nurse & 1 indigenous male health worker

3 Princess Alexandra Sexual Health (PASH) Variety of clinic locations Outreach clinics Logan district (1 clinic session/wk 3hrs) 9 appointments maximum PA district (4 clinic sessions/wk) Youth outreach screening (alternative education programs Focus is on HIV care, HIV prevention, screening and treatment of STIs Service does not provide routine cervical screening, routine contraception, sexual dysfunction or relationship counselling, general women s or men s health Why has the focus changed Increase in population in Metro South No increase in funding for clinical staff in past 8 years Core business is focused on Public health measures Referral from GP s (35%) and ED departments Significant increase in STIs Increase in infectious syphilis 50% in past year Gonorrhoea rates increase 39% in 2018 Chlamydia rates in to year to date in PEP, PrEP and HIV management has increased

4 Princess Alexandra Sexual Health (PASH) Appointment based outpatient service Shared OPD space with other hospital services Management of HIV & complex STIs, npep and PrEP Screening high risk population groups (MSM, CALD, Youth, ATSI) Contact tracing Referrals: DEM, GPs, RAPID clinic, etc. Self referrals Ph: Mon-Fri 8am- 4pm Triaged through the Sexual Health information line by Clinical Nurses Priority for MSHHS residents Medicare eligibility for some services Full names on pathology

5 Youth Outreach Screening Program led by Indigenous Clinical Nurse (Bel Connolly) Metro South alternative education facilities Yourtown facilities (Capalaba, Woodridge, Kingston, Beenleigh) Kingston Y school Kingston Centre Ed Kingston Adult Learning Yeronga SHS Babi Wynnum Hemmant Flexi Urine chlamydia and gonorrhoea PCR Education session If positive result, referred to PASH or GP for treatment

6 New Youth Service commencing May 2019 Shared care for patients accessing LADDERS (Logan Adolescent Drug Dependencies Early Response Service) for years experiencing problematic alcohol and other drug use Once a week on a Tuesday morning Focus on screening and treatment of STIs, contraception and sexual safety

7 STIs and young people considerations Screening >14 years Psychosocial Assessment (HEADSS tool) Assess ability to consent, risk factors, possible neglect and abuse Gillick Competency and informed consent Mandatory reporting Range of other social issues (home life, schooling, contraception, mental health, alcohol & drugs)

8 STI challenges Increasing rates of bacterial STIs (MSM, Indigenous & heterosexual) Increasing rates of syphilis Increasing rates of gonorrhoea Increasing rates of Mycoplasma genitalium

9 Biomedical HIV interventions HIV testing models Rapid testing (community organisations) Home testing (purchased online) HIV TasP (treatment as prevention) U=U (Undetectable = Untransmittable) Post-exposure prophylaxis (PEP) Pre-exposure prophylaxis (PrEP)

10 Chlamydia The most common bacterial STI >23, 000 cases in QLD in 2017 > 91, 000 cases nationally in 2017 Most common in years of age (80% of notification are people under 29 yo) Particular high notification rates include females, those aged 15 19, ATSI population, and people residing in regional & remote locations

11 Chlamydia testing for young people General practitioner Sexual health service Clinic appointment Youth outreach program Aboriginal Medical Services LGBTQIA+ community testing sites (RAPID) Web testing

12 Chlamydia right test, right site and right drug Consider testing at other anogenital sites if MSM (throat & rectal) or heterosexual having AIC not just urine PCR testing (correct collection technique) First line treatment with Azithromycin has less clearance rates in throat and rectal sites TOC for throat and rectal sites (one month) TORI for genital sites (3 months)

13 Gonorrhoea Significant increase over last 7 years, > 5000 cases in QLD in 2017 > 28,000 cases nationally in 2017 (10,324 cases 2010) 53% of diagnoses in people aged years of age (75% residing in major cities) Highest risk for MSM, ATSI population and increase in heterosexual infections Between 2012 and 2016, there was a 63% increase in notification rates from 61.9 per in 2012 to per in 2016, with increases in both males (72%) and females (43%) in this period Almost a third (32%) of gonorrhoea notifications in Aboriginal and Torres Strait Islander people in 2016 were in people aged years, compared with 7% in the non-indigenous population

14 Gonorrhoea

15 Gonorrhoea challenges Increase in young people Increase in indigenous people (especially youth and remote) Increase in MSM (asymptomatic, increase in rectal infections) Increase in heterosexual men and women (locally acquired) Increase in young reproductive women (vertical transmission, asymptomatic, gynaecological complications) TIP of the Iceberg Increasing resistance patterns Limited access to treatment in the community

16 Gonorrhoea resistance WHO has listed highly drug-resistant Neisseria gonorrhoea as one of the twelve priority pathogens posing a threat to human health globally due to drug resistance 3 cases of extensively drug resistant gonorrhoea (XDR) Penicillin and ciprofloxacin resistant is widespread in Australia with increasing resistance to azithromycin High level resistance to both Azithromycin and Ceftriaxone is currently rare, but there has been two Australian cases of high resistance to both these drugs Issues Change to PCR testing (less culture sensitivities to identify changing resistance patterns for individual and surveillance) Increase in asymptomatic presentations (identified by screening and contact tracing) Decrease in condom usage in all groups Increased need for contact tracing and TOC follow up Change in sexual networks (websites, phone apps) Increased and fast pace partner change

17 Public health strategies Increase testing awareness (health providers & community) Dual PCR testing for both chlamydia & gonorrhoea All positive PCR samples and symptomatic presentations to include culture and sensitivities Surveillance of resistance patterns (public health units & state notifications) Improve access to ceftriaxone in community settings Intensive contact tracing and TOC Rapid testing in community (GeneXpert) Automated and rapid detection Urine, endocervical swabs, throat and rectal Sometimes individual pooled samples rather than site specific Results minutes (dependant on how many cycles) Inhibitory substances (blood, mucus, semen, anogenital medication or products) Sensitivity 86-91% and specificity %

18 Syphilis Significant increase over last 7 years, > 1000 cases in QLD in 2017 (338 Cases in 2011) 310% increase > 4,000 cases nationally in 2017 (887 cases nationally in 2006) 16% notification in ATSI, 87% of infectious syphilis were in men, 36% aged years and 70% residing in major cities Highest risk for MSM, ATSI population and increasing cases in heterosexuals (antenatal) High rates of missing data for indigenous status and likely to underestimate rates within the indigenous community

19 Syphilis in Indigenous communities There is an ongoing outbreak of infectious syphilis affecting young Aboriginal and Torres Strait Islander people, predominately aged between 15 and 29 years, living in northern Australia. The outbreak began in northern Queensland in January 2011, extended to the Northern Territory in July 2013, and then onto the Kimberley region of Western Australia in June In March 2017, South Australia declared an outbreak in the Western, Eyre and Far North regions from November The Australian Health Protection Principal Committee (AHPPC) Governance Group has developed a National strategic approach for an enhanced response to the disproportionately high rates of STI and BBV in Aboriginal and Torres Strait Islander people (Strategic Approach). This will address the disproportionately high rates of syphilis and other Blood-Borne Viruses (BBV) and Sexually Transmissible Infections (STI) in regional and remote Indigenous communities.

20 Syphilis Action Plan Testing and treatment PoCT and STI testing guidelines Rapid access to treatment Workforce development and community engagement Increasing primary health screening (ED, other health checks) Surveillance and reporting Improved data collection (including indigenous status) Education and awareness Workforce training and resources Culturally appropriate education/health promotion resources Sporting venues, use of positive role models (enablers/influences), indigenous radio, incentives, peer education models Targeting young women, long term ramifications and engagement in antenatal care Antenatal care Improve antenatal guidelines for testing and retesting Surveillance and investigation of congenital syphilis cases

21 Mycoplasma genitalium

22 Mycoplasma genitalium Smallest free-living micro-organisms In the urogenital tract M.genitalium Ureaplasma urealyticum U.parvum M.hominis Mg first isolated in 1980

23 Mycoplasma genitalium Associated with male non-chlamydial nongonococcal urethritis (NCNGU), with consequences of urethritis, balanoposthitis, prostatitis, proctitis and possible male infertility (70% symptomatic) Most common clinical manifestation is acute and chronic urethritis Ranges from 10% to 35% cause for NCNGU In women, association with urethritis, cervicitis, endometritis and pelvic inflammatory disease, abnormal vaginal bleeding (40-75% are asymptomatic) Associated with increased risk of tubal factor infertility No suggestion of pharyngitis

24 Limited health promotion programs

25 Prevalence Few studies to determine the prevalence of Mg Variation of prevalence in different populations is multi-factorial Different types of samples Self collected vs clinician collected Storage conditions Restrictions for enrolment (often symptomatic only) Overall prevalence is 1% in low risk to 8% in higher risk groups

26 Transmission & risk factors High concordance rates within couples (up to 43%) HIV positive MSM have higher rates of Mg Adherence of mycoplasma to HIV infected cells can increase HIV virus release, and may play a role in the replication and pathogenicity of HIV Direct genital to genital mucosal contact Minimal incubation period is two weeks

27 Specimen collection PCR testing (access to macrolide resistance testing in some settings) No consensus which specimens are preferable Sensitivities Vaginal/cervical swabs (85.7%) First catch urine (97.4%) Rectal swabs (24.3%)

28 Who to test All men who present with urethritis Urine sample of first catch and use yellow urine jar not PCR kits for CH/GC All contacts of positive Mg (men and women) Women with cervicitis Urine and Rectal swabs for MSM Pharyngeal swabs not recommended

29 Treatment Only few antimicrobial classes have activity against mycoplasmas including tetracyclines (doxycycline, macrolides (azithromycin) and fluoroquinolones (moxifloxacin), streptogramins (Pristinamycin) Doxycycline has poor efficacy (cure rates 30-40%) Azithromycin 1 g single dose (cure rates 85% in macrolide susceptible infections) Macrolide resistance of up to 50% and combined macrolide/fluoroquinolones resistance of 8.6% Moxifloxacin has a cure rate approaching 75% in infections with susceptible strains but resistance is up to 15% in macrolide resistance strains Pristinamycin if failure to both Azithromycin, Moxifloxacin Possible use of extended doxycycline for 14 days

30 Treatment International debate First line doxycycline 100mg twice a day for 7 days to reduce bacterial load prior to other treatment options Followed by azithromycin 1g first dose then 500mg daily for further 3 days Persistent infection (symptomatic or positive TOC) Moxifloxacin 400mg daily for 7 days Persistent infection post Moxifloxacin course (symptomatic or positive TOC) Pristinamycin 1g four times a day for 10 days

31 Management Abstain from UP sexual contact (approx. 5 weeks) until partners have completed treatment, symptoms resolved and test of cure negative Patients with anal infection should be informed about the risk of transmission and maybe more difficult to eradicate and therefore TOC is important Patient s with Mg should be screened for other STI s Mg during pregnancy may be associated with a increase of spontaneous abortion and preterm birth

32 Test of cure Repeat PCR (including all positive sites) TOC at 4 weeks (after completion of treatment) If tested sooner, possible false positive result rather than reinfection or persistence Due to limited treatment options, important to ensure TOC done at optimal interval Contact tracing Unknown time period Focus on direct partners of symptomatic or persistent infection

33 Media promotion

34 Sexual Health Check for young people campaign qld.gov.au/ h/staying-healthy/sexualhealth 13HEALTH ( ) What are some of the challenges arising from health promotion campaigns How do we meet the needs of young people requesting sexual health screening

35 Sexual health resources Animations about sexual health

36 Health promotion resources /resources/ (indigenous young people includes factsheets, posters, videos

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