IN Australia, gonorrhoea has remained a relatively uncommon sexually transmissible infection (STI) in urban heterosexuals and routine annual screening for gonorrhoea has not been recommended in clinical guidelines because of the low gonorrhoea prevalence. This is in contrast to gay and bisexual men (GBM), and young Aboriginal and Torres Strait Islander people in remote areas, where the prevalence has remained high at between 5–10% for decades.
However, the annual surveillance report on STIs and bloodborne viruses launched by the Kirby Institute at the 2017 Australasian Sexual Health Conference, held in November in Canberra, showed some important changes in this longstanding picture. By far the most obvious was a 99% increase in gonorrhoea notifications in men and women living in major cities over the past 5 years, with the sharpest increase in the past 2 years. Data from several states and territories show that the increase has been most pronounced among those people with a heterosexual partner at the time of diagnosis. Interestingly, although gonorrhoea notification rates were highest in people aged 20–24 years, the increase occurred in a broad age range: 20–24, 25–29 and 30–34 year-olds.
There has also been an increase in gonorrhoea diagnoses among men who have sex with men, but it has been more steady and over a 10-year period. This steady rise has been attributed to more frequent testing (the more you test, the more you find) and improved clinical practice with collection of samples from more anatomical sites, that is, throat, urine and rectum, and also men shifting from condoms to other non-condom based options, such as serosorting (choosing a sexual partner who shares the same HIV status), undetectable viral load and, in the past few years, pre-exposure prophylaxis, which all reduce the risk of HIV transmission but not STIs.
Public health experts are concerned about the increase in gonorrhoea because it increases the risk of sexual transmission of HIV and can result in genital tract complications, including pelvic inflammatory disease (PID) in women and epididymitis in men, as well as disseminated infection, and eye disease, such as conjunctivitis and macular rashes. Untreated PID, especially repeat infections, can lead to serious sequelae, including ectopic pregnancy, infertility and chronic pain. While chlamydia-related PID is more prevalent, gonorrhoea infection confers a substantially higher risk than chlamydia of hospitalisation or emergency department presentation for PID.
The rise in gonorrhoea among heterosexual people reported at the conference attracted the media’s attention, with headlines of “Gonorrhoea is on the rise, but no one really knows why” and “Kissing kids may be to blame for gonorrhoea spike”. The reasons for increases in gonorrhoea among heterosexual people in urban areas were debated at a special symposium, with a summary of the most likely and unlikely reasons below:
- Antimicrobial resistance was ruled out. While increasing global antimicrobial resistance is a concern, almost all current gonorrhoea cases in Australia remain susceptible to ceftriaxone as part of the currently recommended treatment regimen.
- More testing was not the reason. Australia collects comprehensive testing information, and although the number of Medicare-rebated tests has increased in the past 5 years, in 2016 there was about two diagnoses for every 100 Medicare-rebated tests done, 64% higher than in 2012.
- The 2016 National Drug Strategy Household Survey suggests no major increase in alcohol and drug use between 2011 and 2016 in young adults.
- Sexual norms are changing. Has condom use decreased, are young people having more sexual partners, what about more oral or anal sex? Gonorrhoea can be transmitted through oral sex (where condoms are rarely used); oropharyngeal infection is almost always asymptomatic, and heterosexual people don’t often have throat swabs collected. The most recent national survey in adults – the Australian Study of Health and Relationships in 2012–13 – was conducted prior to the sharp increase, and the next one is planned in a few years, so we will have to wait and see.
- What about location-based dating apps? A recent Australian study showed young people who used Tinder in the past year reported more sexual partners than those who did not, this could simply mean that the site attracts a more sexually active group. Conversely the sites make finding partners more efficient so even if condom use didn’t change, a person’s risk of STIs would increase (more exposures). Studies to prove this definitively are very difficult to undertake, so perhaps in the meantime the most sensible approach is for the public health experts to work with the companies hosting the sites to promote condom use and STI testing among their consumers.
- Other possibilities are that young people are travelling more, and dating apps are helping them to find more sexual partners while abroad.
- The reason for the rise could be a combination of some of these factors, or other unexplored reasons.
In the symposium it was noted that research is underway to investigate the factors that may be driving the increase, but more regular national sexual behaviour surveys in adults are needed. Meanwhile, there needs to be greater awareness raised among sexually active heterosexual people in urban areas aged up to 40 years about gonorrhoea, and getting tested if they have a new sexual partner or a risk exposure. Clinicians should be offering testing, as well as recommending that partners be treated, and websites such as “let them know” can help patients to notify partners if they have been diagnosed with an STI.
It is important to note that although the rise in gonorrhoea in recent years has been greatest in heterosexual people in urban areas, it has increased from a low base, and health promotion, testing and treatment initiatives should continue to be sustained and enhanced in men who have sex with men, Aboriginal and Torres Strait Islander people, especially those in rural and remote locations, and other priority populations in Australia.
Deborah Bateson is Medical Director of Family Planning NSW and Clinical Associate Professor in the Discipline of Obstetrics, Gynaecology and Neonatology at the University of Sydney. Deborah was Co-chair of the Australasian Sexual Health Alliance (2016-2017).
She writes on behalf of Dr Christopher Bourne, Dr Eric Chow, Dr Praveena Gunaratnam, and Professor Rebecca Guy.
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