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1.12 HIV/AIDS, hepatitis and sexually transmissible infections

Why is it important?

Aboriginal and Torres Strait Islander peoples currently experience a relatively high number of notifications for bacterial sexually transmissible infections (STIs) (12%–43% of new cases in 2011–13) and high notification rates for hepatitis B and C. Each of these infections can have potentially serious consequences if left untreated. Chronic hepatitis causes serious illness and can also progress to cirrhosis of the liver, cancer, and premature death (CDC 2008). It is estimated that of the 1% of the Australian population that is living with chronic hepatitis B, 9% are Aboriginal and Torres Strait Islander peoples (MacLachlan et al. 2013; Couzos et al. 1999). STIs can have serious long- term consequences, such as chronic abdominal pain or infertility in women after gonorrhoea and chlamydia, and heart and brain damage caused by syphilis (Bowden et al. 2002; Couzos et al. 1999). Several of these infections can cause miscarriage (Campbell et al. 2011). The impact of HIV is well documented.

Notification data includes cases that have been tested, diagnosed and notified to health authorities, representing only a proportion of the total incidence of disease. Changes in notification rates over time are influenced by a range of factors including access to health care, improved screening programmes for Indigenous Australians and improved accuracy of tests. For Indigenous Australians, the accuracy of Indigenous identification in the data is also an issue and varies by jurisdiction. Improved primary healthcare can lead to increased testing and a corresponding increase in notification rates.

Findings

During the three years 2011 to 2013 there were approximately 20,000 notifications among Aboriginal and Torres Strait Islander peoples for chlamydia (in Qld, WA, SA, Tas and the NT combined). After adjusting for differences in age structure, the notification rate was 3 times as high as for other Australians. Between 1996–98 and 2011–13, in WA, SA and the NT combined, the notification rate for chlamydia doubled for Indigenous Australians. While rates for other Australians also increased, they did so at a slower pace and so the gap widened.

For this same period, there were approximately 12,600 notifications for gonorrhoea among Aboriginal and Torres Strait Islander peoples (for all jurisdictions combined excluding NSW). After adjusting for differences in age structure, rates were 20 times higher than for other Australians. Between 1996–98 and 2011–13 in WA, SA and the NT combined, there was no significant change in rates for Indigenous Australians and no change in the gap. For other Australians there was a significant increase for males but no significant change for females.

There were also approximately 1,100 notifications for syphilis among Indigenous Australians over this period (all jurisdictions). After adjusting for differences in age structure, rates were 6 times as high as for other Australians. Between 1996–98 and 2011–13 in WA, SA and the NT combined, the notification rate for syphilis decreased for Indigenous males and females while increasing for other Australian males (no change detected for females). The highest rate for chlamydia and gonorrhoea was in the NT while the rate of syphilis was highest in Qld.

During the three years 2011 to 2013 there were 402 new notifications for hepatitis B and 847 for hepatitis C among Indigenous Australians. Rates were 3.3 times the other Australian rates for hepatitis C and 2.6 times for hepatitis B. Between 2006–07 and 2012–13 there was a significant decline in the hepatitis B notification rate for Indigenous Australians. For hepatitis C, notifications were highest in the 25–44 age groups for both populations. There have been no significant changes over time in hepatitis C notification rates for Indigenous Australians while over the same period there was a decline for other Australians and an increase in the gap (1996–98 to 2011–13 in WA, SA and the NT combined). The pattern of infection by age groups varies by disease. Those aged 15–24 years have the highest rates for chlamydia and gonorrhoea while the other diseases extend into the middle years.

There have been no significant changes detected in the incidence of HIV infection for Aboriginal and Torres Strait Islander peoples between 1998–2000 and 2010–12. Over this period, the notification rates for other Australians increased by one- third (34%) and have now overtaken the Indigenous rate. For the period 2010–12, the incidence of HIV was 4.2 per 100,000 for Indigenous Australians and 5.1 for other Australians. Sexual contact between men was the highest HIV risk for both populations; however, injecting drug use represented 9% of Indigenous risk exposure, compared with 2% for others. The AIDS notification rate for Indigenous Australians is now too small to publish.

Implications

STIs are a major health problem for Aboriginal and Torres Strait Islander peoples. These infections are treatable through antibiotics, but if left untreated can have significant health consequences. High rates of infection for Indigenous Australians and disparity with rates for non-Indigenous Australians highlight the need for targeted prevention and information (Graham et al. 2012; Fairley et al. 2012; O'Connor et al. 2014). Evidence suggests that comprehensive strategies including community education and health promotion are most effective in reducing STIs (Strobel et al. 2012). Hepatitis B notifications have declined for Indigenous Australians since 2006–07. As at December 2013, hepatitis B vaccination rates were at 94% for both Indigenous and non-Indigenous children aged two years.

The rate of HIV infection is similar between Indigenous and non-Indigenous Australians. Nevertheless, Indigenous Australians remain disproportionately vulnerable to HIV infection due to factors such as high rates of STIs, poorer general health, high levels of injecting drug use and also unique challenges in accessing HIV treatment and care. Studies have found improvements in years of expected life for people with HIV with early access to antiretroviral treatments compared with the period when no treatment was available (Atkinson et al. 2009). The Fourth National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2014–17 is one of a set of five national strategies aimed at reducing the transmission of STIs and blood-borne viruses and the associated morbidity, mortality, personal and social impacts. Priority action areas include improving vaccination coverage for hepatitis B and HPV, increasing provider initiated testing, increasing treatment rates for people with blood-borne viruses, supporting Aboriginal Community Controlled Health Organisations, reducing racism, stigma and discrimination in community and health-care settings and improving prevalence and incidence data. Previous strategies have increased testing and may account for improvements in detection and increased rates. However, under-identification of Aboriginal and Torres Strait Islander peoples and the volatility in small numbers means that caution should be used in interpreting trends in these data. Building on the achievements of the National Partnership Agreement on Sexual and Indigenous Early Childhood Development, the Australian Government has committed $25.9 million in 2014–15 for a new Indigenous Teenage Reproductive Health and Young Parent Support measure to continue Indigenous notification systems and to continue teenage sexual and reproductive health and antenatal care services.

Figure 1.12-1 Age-standardised notification rate for 5 infectious diseases, Aboriginal and Torres Strait Islander peoples, WA, SA and the NT, 1996–1998 to 2011–2013
chart showing Notification rate for 5 infectious diseases

Figure 1.12-1 shows notification rates for chlamydia, gonorrhoea, syphilis, Hepatitis B and Hepatitis C among Aboriginal and Torres Strait Islander peoples (rate per 100,000). Data is presented for WA, SA and NT for the period 1996–1998 to 2011–2013 and for the period 2005-07 to 2011-13 for hepatitis B. Between 1996–98 and 2011–13, in WA, SA and the NT combined, the notification rate for chlamydia doubled for Indigenous Australians and the gap between Indigenous Australians and other Australians widened. In the same period for gonorrhoea, there was no significant change in rates for Indigenous Australians and no change in the gap. The notification rate for syphilis decreased for Indigenous males and females. There was a significant decline for hepatitis B and no change for hepatitis C.

Note: Notifications data for hepatitis B is of insufficient quality prior to 2005

Source: AIHW analysis of National Notifiable Diseases Surveillance System

Figure 1.12-2 Age-standardised notification rates for HIV, by Indigenous status, 1998–2000 to 2010–12
chart showing Age-standardised notification rates for HIV

Figure 1.12-2 shows age-standardised notification rates for HIV among Aboriginal and Torres Strait Islander peoples (rate per 100,000). Data is presented for the period 1998–2000 to 2010–12. There have been no significant changes detected in the incidence of HIV infection for Aboriginal and Torres Strait Islander peoples between 1998–2000 and 2010–12.

Source: AIHW analysis of National HIV Registry

Figure 1.12-3 Notification rate for chlamydia and gonorrhoea by Indigenous status and age, selected states, 2011–13
chart showing Notification rate for chlamydia and gonorrhoea

Figure 1.12-3 shows notification rates for chlamydia and gonorrhoea among Aboriginal and Torres Strait Islander peoples and other Australians (rate per 100,000). Data is presented for Qld, WA, SA and NT for chlamydia and for Victoria, Queensland, WA, SA, NT, Tasmania and the ACT for gonorrhoea. Data is presented for the following age groups: 0-14 years; 15-24 years; 25-34 years; 35-44 years; 45-54 years; 55-64 years; 65 years and over; and the total age-standardised rate. After adjusting for differences in age structure, the notification rate was 3 times as high as for other Australians for chlamydia, with rates highest in the younger age groups for both Indigenous and other Australians. After adjusting for differences in age structure, notification rates for gonorrhoea were 20 times as high for Indigenous Australians as for other Australians. The biggest differences between Indigenous and non-Indigenous rates of gonorrhoea were in the younger age groups.

Note: Totals are age-standardised. Data are reported for Qld, WA , SA, NT, and Tas for chlamydia and for Vic, Qld, WA, SA, NT, Tas and ACT for gonorrhoea.

Source: AIHW analysis of National Notifiable Diseases Surveillance System

Figure 1.12-4 Notification rates for hepatitis B and C by Indigenous status and age, selected states, 2011–2013
chart showing Notification rates for hepatitis B and C

Figure 1.12-4 shows notification rates for hepatitis B and hepatitis C among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians (rate per 100,000). Data is presented for WA, SA, the NT, ACT and Tasmania for hepatitis B and for WA, SA, NT and Tasmania for hepatitis C, for 2011–2013. Data is presented for the following age groups: 0-14 years; 15-24 years; 25-34 years; 35-44 years; 45-54 years; 55-64 years; 65 years and over; and the total age-standardised rate. Rates were 3 times the other Australian Indigenous rates for both hepatitis B and C. Among Indigenous Australians, hepatitis B notification rates were 4 to 17 times higher than for other Australians in the age groups 45–54 years and above. For hepatitis C, notifications were highest in the 25–44 age groups for both populations.

Note: Totals are age-standardised. Data are reported for WA, SA, NT, ACT and Tas for hepatitis B and for WA, SA, NT and Tas for hepatitis C.

Source: AIHW analysis of National Notifiable Diseases Surveillance System