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Tier 1 - Health status and outcomes

1.12 HIV/AIDS, hepatitis and sexually transmissible infections

Key facts

In 2016–2018 there were:

Why is it important?

This measure reports on the sexually transmitted infections (STIs): chlamydia; gonorrhoea; non-congenital syphilis; and also the blood-borne viruses: hepatitis B and C; and human immunodeficiency virus (HIV). This measure no longer captures data on acquired immunodeficiency syndrome (AIDS) as it was removed from the National Notifiable Disease List in 2016.

If left untreated, STIs can have serious long-term health consequences, such as pelvic inflammatory disease, infertility, adverse pregnancy outcomes, miscarriage, and neonatal infections. Untreated syphilis can cause heart and brain damage (Bowden et al. 2002; Campbell et al. 2011; DoH 2014; Guy et al. 2012). Chlamydia, gonorrhoea, and syphilis are treatable but cases are often asymptomatic for long periods (Bowden et al. 2002). There is also evidence that these STIs can enhance transmission of HIV (Cohen 1998). Aboriginal and Torres Strait Islander people currently experience a relatively high number of notifications for bacterial STIs, relative to their representation in the total population. Although rates of HIV are not particularly high, Indigenous Australians are possibly more susceptible due to the high rates of STIs (Australasian Sexual Health Alliance 2017).

HIV is a blood-borne virus that targets the immune system and gradually weakens the body’s immune response. As the body becomes immunodeficient it is at increased susceptibility to a wide range of infections and some cancers. The advanced stage of HIV infection is AIDS, which can take years to develop and is characterised by development of severe illnesses and infections and certain cancers such as lymphoma and Kaposi’s sarcoma. However, with appropriate treatment, HIV is now a manageable chronic health condition with patients able to lead long and healthy lives (World Health Organization 2020).

Hepatitis B and C are blood-borne viruses that cause inflammation of the liver. It is estimated that of the 1% of the Australian population that is living with chronic hepatitis B, 9% are Indigenous Australians (MacLachlan et al. 2013). As these forms of hepatitis can become chronic, they can cause serious illness and can also progress to cirrhosis of the liver, cancer, and premature death (Australasian Sexual Health Alliance 2017). Hepatitis B is transmitted through exposure to infective blood such as through shared injecting needles and sexual contact, but this disease is vaccine preventable. Hepatitis C is most commonly transmitted through shared injecting needles and there is no vaccine available (World Health Organization 2019).

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 programs 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 health care can lead to increased testing and a corresponding increase in notification rates.

Burden of disease

Infectious diseases were responsible for 3.2% of the total disease burden for Indigenous Australians in 2011. HIV accounted for 4% of the disease burden within the infectious diseases group, and 77% of the disease burden due to HIV was experienced by males. Premature death accounted for 75% of the disease burden due to HIV. The total disease burden for Indigenous Australians attributable to unsafe sex was 3.9 times that of non-Indigenous Australians (AIHW 2016).

Findings

What does the data tell us?

Chlamydia

Over the period 2016–2018, there were 20,305 chlamydia notifications among Indigenous Australians in the five jurisdictions with Indigenous identification data of adequate quality (Queensland, Western Australia, South Australia, the Australian Capital Territory and the Northern Territory).

After adjusting for differences in the age structure between the two populations, the notification rate for Indigenous Australians was almost 3 times the rate for Other Australians (1,208 per 100,000 compared with 423 per 100,000) (Table D1.12.1, Figure 1.12.1). Note that in this measure ‘Other Australians’ includes non-Indigenous Australians and those whose Indigenous status was not stated.

Chlamydia notifications for Indigenous females were 1.8 times the rate for Indigenous males (1,552 compared with 879 per 100,000) in 2016–2018. Most chlamydia notifications for Indigenous Australians were among those aged 15–24 (5,078 per 100,000) and 25–34 (2,258 per 100,000) (Table D1.12.2).

Figure 1.12.1: Age-specific notification rates for chlamydia, by Indigenous status, Qld, WA, SA, ACT and the NT combined, 2016–2018

This bar chart shows that for Indigenous Australians, the rate of notification for chlamydia was almost 3 times as high as it for Other Australians, 1,208 compared with 423 per 1,000. By age group, the rate was highest in 15-24, at 5,079 per 100,000 for Indigenous and 1,731 for non-Indigenous, followed by the 25-34 age group, at 2,258 per 100,000 for Indigenous and 881 for non-Indigenous.

Note: Totals are age-standardised.

Source: Table D1.12.2. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Between 2001–2002 and 2017–2018, after adjusting for differences in the age structure between the two populations, the notification rate for chlamydia increased by 47% for Indigenous Australians, from 823 per 100,000 to 1,300 per 100,000, in the three jurisdictions with Indigenous identification data of adequate quality (Western Australia, South Australia and the Northern Territory). Over this period, the chlamydia notification rate for Other Australians increased by 224%, from 122 per 100,000 to 409 per 100,000 (Table D1.12.3, Figure 1.12.2).

The rise in the chlamydia rate over time was associated with the gradual introduction of more sensitive laboratory tests and an increased number of tests being performed (AIHW 2018).

Figure 1.12.2: Age-standardised notification rates for chlamydia, by Indigenous status, WA, SA and NT, 2001–2002 to 2017–2018

This line chart shows that for Indigenous Australians, the age-standardised notification rates for chlamydia increased from 823 per 100,000 in 2001–2002 to 1,425 in 2013–14, and then dropped to 1,300 in 2017–2018. For Other Australians, it increased from 122 per 100,000 to 409 per 100,000 over the period.

Source: Table D1.12.3. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Gonorrhoea

For the period 2016–2018, there were 12,021 notifications for gonorrhoea among Indigenous Australians in the seven jurisdictions with Indigenous identification data of adequate quality (Victoria, Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory).

After adjusting for differences in the age structure between the two populations, the rate for Indigenous Australians was almost 7 times the rate for Other Australians (644 per 100,000 and 93 per 100,000, respectively) (Table D1.12.1, Figure 1.12.3).

Figure 1.12.3: Age-specific notification rates for gonorrhoea, by Indigenous status, Vic, Qld, WA, SA, Tas, ACT and the NT combined, 2016–2018

This bar chart shows that for Indigenous Australians, the rate of notification for gonorrhoea was almost 7 times as high as it for Other Australians, 644 compared with 93 per 100,000. By age group, the rate was high for people aged from 15 to 44. For Indigenous, the highest was in the 15-24 age group, at 2,041 per 100,000, followed by the 25-34 age group, at 1,416 per 100,000, and then the 35-44 age group, at 669 per 100,000. For Other Australians the rate for these age groups were 194, 253 and 123 per 100,000 respectively.

Note: Totals are age-standardised.

Source: Table D1.12.2. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Between 2001–2002 and 2017–2018, there was no significant change in the gonorrhoea notification rate for Indigenous Australians (from 913 to 993 per 100,000) and no significant change in the gap between Indigenous and Other Australians (from 893 to 888 per 100,000) in the four jurisdictions with Indigenous identification data of adequate quality (Victoria, Western Australia, South Australia and the Northern Territory) (Table D1.12.5, Figure 1.12.4).

Figure 1.12.4: Age-standardised notification rates for gonorrhoea, by Indigenous status, Vic, WA, SA and NT, 2001–2002 to 2017–2018

This line chart shows that, for Indigenous Australians, the age-standardised notification rates for gonorrhoea increased from 913 per 100,000 in 2001–2002 to 1,178 in 2005–2006, then generally decreased to 993 in 2017–18. For Other Australians, the rate increased from 20 to 105 per 100,000 over the period.

Source: Table D1.12.5. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Non-congenital syphilis

From 2016–2018, there were 2,853 notifications of non-congenital syphilis for Indigenous Australians (in all jurisdictions combined). After adjusting for differences in the age structure between the two populations, notification rates for Indigenous Australians were 5.8 times the rate for Other Australians (133 per 100,000 compared with 23 per 100,000) (Table D1.12.1).

Between 2001–2002 and 2017–2018, after adjusting for differences in age structure between the two populations, notification rates for non-congenital syphilis for Indigenous Australians declined from 152 to 64 per 100,000 from 2001–2002 to 2011–2012, before increasing quickly as a result of a syphilis outbreak (up to 150 per 100,000 in 2017–2018). These data were for the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia and the Northern Territory combined). Over the period, notification rates for non-congenital syphilis for Other Australians increased significantly, from 5.6 to 26 per 100,000 (Table D1.12.4, Figure 1.12.5).  

An outbreak of syphilis began in January 2011 in Queensland, followed by the Northern Territory in 2013, Western Australia in 2014, and most recently in South Australia in November 2017 (DoH 2020a).

Figure 1.12.5: Age-standardised notification rates for non-congenital syphilis, by Indigenous status, NSW, Vic, Qld WA and the NT, 2001–2002 to 2017–2018

This line chart shows that, for Indigenous Australians, the age-standardised notification rates for non-congenital syphilis decreased from 152 per 100,000 in 2001–2002 to 64 in 2011–12, and then increased to150 in 2017–2018. For Other Australians, the rate increased from 6 to 26 per 100,000 over the period.

Source: Table D1.12.4. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Hepatitis B

For the period 2016–2018, there were 385 new notifications of hepatitis B in the seven jurisdictions with Indigenous identification data of adequate quality (Victoria, Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory).

After adjusting for differences in age structure between the two populations, the notification rate for Indigenous Australians was 1.3 times the rate for Other Australians (31 per 100,000 compared with 23 per 100,000) (Table D1.21.1, Figure 1.21.6).

Figure 1.12.6: Age-specific notification rates per 100,000 for hepatitis B, by Indigenous status, Vic, Qld, WA, SA, Tas, ACT and NT, 2016–2018

This bar chart shows that the rate of notification for hepatitis B was 31 per 100,000 for Indigenous Australians and 23 for Other Australians. By age group, the rate was highest for Indigenous persons aged 65 and over at 54 per 100,000, and highest for Other Australians in the 25-34 age group at 47 per 100,000. With exception of the 25-34 age group, the Indigenous rate was higher than that for Other Australians for all other age groups.

Note: Totals are age-standardised.

Source: Table D1.12.2. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

As at December 2018, the vaccination coverage for hepatitis B for children aged 2 was 97% for Indigenous children and 96% for Other children. For those aged 1, the proportion was 93% for Indigenous children and 95% for Other children (Table D3.02.1).

Between 2007–2008 and 2017–2018, there was a significant decline (82%) in the hepatitis B notification rate for Indigenous Australians, from 113 per 100,000 to 28 per 100,000, in the three jurisdictions with Indigenous identification data of adequate quality (Western Australia, South Australia and the Northern Territory). The gap between Indigenous and Other Australians narrowed from 133 to 18 per 100,000 (Table D1.12.7, Figure 1.12.7).

Figure 1.12.7: Age-standardised notification rates for hepatitis B, by Indigenous status, WA, SA and NT, 2007–2008 to 2017–2018

This line chart shows that the age-standardised notification rates for hepatitis B decreased from 164 per 100,000 in 2007–2008 to 38 in 2017–18 for Indigenous Australians, and from 31 to 20 per 100,000 for Other Australians.

Source: Table D1.12.7. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

Hepatitis C

In 2016–2018, there were 2,370 new notifications for hepatitis C for Indigenous Australians in the six jurisdictions with Indigenous identification data of adequate quality (Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory). After adjusting for differences in age structure between the two populations, the hepatitis C notification rate for Indigenous Australians was 4.5 times the rate for Other Australians (175 per 100,000 compared with 39 per 100,000) (Table D1.12.1, Figure 1.12.8).

In 2016–2018, notifications for hepatitis C were highest for Indigenous Australians aged 25–44 and for Other Australians aged 35–54 (Table D1.12.2, Figure 1.12.8).

Figure 1.12.8: Age-specific notification rates per 100,000 for hepatitis C, by Indigenous status, Qld, WA, SA, Tas, ACT and the NT, 2016–2018

This bar chart shows that for Indigenous Australians, the rate of notification for hepatitis C was over 4 times as high as for Other Australians, 175 compared with 39 per 100,000. By age group, the rate was high for Indigenous Australians aged from 25 to 44, with the highest was in the 25-44 age group, at 374 per 100,000, followed by the 35-44 age group, at 339 per 100,000. For Other Australians Highest was in the 35-44 age group with a rate 74 per 100,000.

Note: Totals are age-standardised.

Source: Table D1.12.2. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

In the period 2001–2002 to 2017–2018 there was a significant increase (50%) in the notification rates for hepatitis C for Indigenous Australians (from 127 per 100,000 to 175 per 100,000) in the three jurisdictions with Indigenous identification data of adequate quality (Western Australia, South Australia and the Northern Territory combined). There was a significant decline (53%) in the notification rate for hepatitis C for Other Australians over the period (from 63 per 100,000 to 31 per 100,000). These changes resulted in a significant widening in the gap between Indigenous and Other Australians (from 63 to 144 per 100,000) (Table D1.12.6, Figure 1.12.9).

Figure 1.12.9: Age-standardised notification rates for hepatitis C, by Indigenous status, WA, SA and NT, 2001–2002 to 2017–2018

This line chart shows that, for Indigenous Australians, the age-standardised notification rate for hepatitis C ranged from 120 to 130 per 100,000 from 2001–2002 to 2009–2010, before increasing to 175 per 100,000 in 2017–2018. For Other Australians, it decreased from 63 to 31 per 100,000 over the period.

Source: Table D1.12.6. AIHW analysis of National Notifiable Diseases Surveillance System (NNDSS) data.

HIV

In 2016–2018, there were 110 notifications of HIV for Indigenous Australians. After adjusting for differences in the age structure between the two populations, the HIV notification rate for Indigenous Australians was 1.3 times the rate for Other Australians (4.9 compared to 3.8 per 100,000).

Australians aged 25–34 had the highest HIV notification rates, with 11.6 per 100,000 for Indigenous Australians and 9.3 per 100,000 for Other Australians. The relative difference between populations was highest for those aged 15–24, with HIV notification rates for Indigenous Australians 1.7 times the rate for Other Australians (5.7 and 3.3 per 100,000, respectively) (Table D1.12.9).

Between 2001–2003 and 2016–2018, the HIV notification rate for Indigenous Australians increased significantly by 46%, from 4.0 to 4.9 per 100,000, and for Other Australians the rate decreased by 11%, from 4.3 to 3.8 per 100,000 (Table D1.12.11, Figure 1.12.6).

Figure 1.12.10: Age-standardised notification rates for HIV, by Indigenous status, Australia, 2001–2003 to 2016–2018

This line chart shows that the age-standardised notification rate for HIV was lower for Indigenous Australians than Other Australians from 2001-2003 to 2010-2012, but then higher from 2013-2015 to 2016-2018. The Indigenous rate ranged from 3.5 to 5.2 per 100,000.

Source: Table D1.12.11. AIHW analysis of National HIV Registry.

In 2016–18, Sexual contact between males was the highest HIV risk for both Indigenous and Other Australians (4.6 and 5.1 per 100,000), followed by heterosexual sexual contact (1.2 per 100,000 and 0.8 per 100,000). In the same period, injecting drug use accounted for 9.1% reported of the risk exposure for Indigenous Australians and 2.4% for Other Australians (Table D1.12.10).

Of newly diagnosed HIV infections in 2016–2018, 38% of cases in Indigenous Australians and 49% of Other Australian cases were classified as late or advanced diagnoses (Table D1.12.12). Of newly diagnosed HIV cases in Indigenous Australians, sexual contact between males accounted for 63% % of the risk exposure and heterosexual sex accounted for 23% (Table D1.12.13).

AIDS was removed from the National Notifiable Disease List in 2016.

What do research and evaluations tell us?

Young Indigenous Australians experience high rates of STIs, particularly in Remote and Very remote areas (DoH 2018a). Syphilis is exacerbated in Remote and Very remote areas by an ongoing outbreak. In 2017, after adjusting for differences in the age structure between the Indigenous and non-Indigenous populations, the infectious syphilis notification rate for Indigenous Australians in Remote and Very remote areas was 27 times as high as the non-Indigenous notification rate, compared with twice as high in Major cities, and 19 times as high in Inner and Outer regional areas (Kirby Institute 2018). The notification rates for gonorrhoea and chlamydia in Remote and Very remote areas are also much higher for Indigenous Australians than for non-Indigenous Australians, with rates 30 times and 5 times higher respectively. The chlamydia notification rate for Indigenous Australians living in Remote areas is 6.5 times higher than for those living in major cities (DoH 2018a). In addition, the notification rate for HIV among Regional and Remote Indigenous Australians has increased from 2008 to 2017, while decreasing for those in Major cities (Kirby Institute 2018). Caution should be taken in interpreting this data, as it represents a small number of notifications. Between 2013 and 2017, the notification rate of hepatitis C infection in the Indigenous population increased by 60% in Remote and Very remote areas (Kirby Institute 2018).

A study was conducted based on a national cross sectional survey of young Indigenous Australians aged 16–29 years between 2011 and 2013. The study found that the majority of study participants had sex for the first time when they were 14 years or younger. There is a strong association between an earlier age at sexual debut and a history of STIs. Earlier onset of sexual activity is also associated with low levels of education, risky sexual behaviours and illicit drug use (Wand et al. 2018).

A review of qualitative research was conducted regarding young Indigenous Australians’ perspectives on sexuality and sexual health, protective factors, and social vulnerability (which arises from interconnected social, cultural, economic, legal and health system-related factors and contributes to negative sexual health outcomes). Findings from the review show that some young Indigenous Australians are practicing a range of harm reduction measures to protect sexual health. Many young women are able to use peer networks for support and to share information. However, many had incomplete knowledge about the transmission and prevention of STIs and were more focused on preventing pregnancy. The dominance and controlling behaviour of young men and the influence of alcohol were negative factors raised in some studies as influencing sexual practice. There was also a clash between Western and Indigenous understandings of the body, which can cause confusion when accessing health services. There was evidence of positive family influences and supportive behaviours, but often a lack of inter-generational communication about sexual health issues. The positive role of Aboriginal Community Controlled Health Services and other support services in promoting good sexual health was identified but also a distrust among young Indigenous Australians of services which lacked cultural appropriateness (Bell et al. 2017).

A 2012 review found that there was limited evidence to support the effectiveness of sexual health education programs for Indigenous Australians, and that few evaluations had been completed (Strobel & Ward 2012). However the evidence available suggests that comprehensive strategies including community education and health promotion are most effective in reducing STIs (Strobel & Ward 2012). Peer education has also been noted as a potential strategy for prevention (MacPhail & McKay 2016).

A systematic review of the impact of STI programs delivered by primary health-care (PHC) centres in remote Indigenous communities found twelve evaluations of four programs delivered in South Australia, the Northern Territory and Western Australia (Guy et al. 2012). There was some evidence of success in three of the four programs, indicating that clinical best practice and well-coordinated sexual health programs can reduce chlamydia and gonorrhoea prevalence in remote Indigenous communities. Interpretation of the findings was limited by a lack of systematic reporting of program indicators, and other potential confounding factors. The authors identified characteristics of a comprehensive approach to STI control which although resource intensive, will reduce STI prevalence, and encompassed regular screening, timely treatment, partner notification, staff training, health education and promotion, disease surveillance, and monitoring and evaluation. Many other factors are likely to play a role in the success of a STI program including the retention of staff, recruitment of health-care workers with the appropriate gender, the variability in the types of health promotion programs undertaken in remote settings, young people’s access to health services, and historical and contemporary issues that impact on health service delivery between communities and health service providers.

Nattabi and others (2017) examined the extent of variation in delivery of recommended STI screening investigations and counselling within Aboriginal PHC centres. The study found that there are significant variations in STI testing and counselling among Aboriginal PHC centres. A number of Aboriginal PHC centres were achieving high rates of STI testing and counselling, while a significant number were not. The study also found a significant association between adult health checks and Pap smears with higher levels of STI testing and counselling, suggesting that adult health checks and Pap smears act as catalysts for STI testing (Nattabi et al. 2017).

A randomised crossover trial was conducted from 2013 to 2016 to assess the efficacy of a point‑of‑care molecular test for chlamydia and gonorrhoea (Guy et al. 2018). Molecular point-of-care tests can provide rapid results which make it easier to quickly treat positive cases – some of whom would not otherwise receive treatment. The findings showed that time to treatment could be substantially reduced by the use of molecular point-of-care tests, but retesting rates were too low to draw conclusions about the impact on reinfection rates.

Implications

STIs are a major health problem for Indigenous Australians. Bacterial STIs are treatable through antibiotics, but if left untreated can have significant health consequences (Australasian Sexual Health Alliance 2017). A range of access issues have been identified for health care (see measure 3.14 Access to services compared with need) and shame has been found to be an additional factor for STIs (MacPhail & McKay 2016). Risky sexual behaviours, along with illicit drug use and alcohol use are important risk factors for STIs (Wand et al. 2016). There is also increased risk for some Indigenous Australians with research showing strong associations between early age of sexual debut (under 15 years) and subsequent high-risk sexual behaviours and STIs. Social determinants have also been linked to patterns of risky sexual behaviour (MacPhail & McKay 2016).

High rates of infection for Indigenous Australians and disparity with rates for non-Indigenous Australians highlight the need for targeted prevention, along with opportunistic testing (Fairley & Hocking 2012; Graham et al. 2015; O'Connor et al. 2014).

The response to the ongoing syphilis outbreak, which is predominantly affecting Indigenous Australians aged 15–29 years, is focussing on: opportunistic testing and community screening; immediate treatment of cases and sexual contacts; antenatal screening; public health alerts, campaigns and education; and active follow-up of cases (DoH 2020b).

The increase in hepatitis C notification rates continue to be of concern with a much higher rate among Indigenous Australians and the gap with non-Indigenous Australians widening. The Fifth National Hepatitis C Strategy 2018–2022, seeks to revitalise efforts in education and awareness, and in encouraging early treatment, testing and continued care (DoH 2018b).

Improvement in the notification rate for hepatitis B is encouraging, with high vaccination rates among Indigenous children. However, ongoing effort is required particularly among middle and older age groups with chronic hepatitis B, who need regular testing and treatment to prevent the development of liver cancer.

Indigenous Australians remain disproportionately vulnerable to HIV 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 (Bryant et al. 2016; Templeton et al. 2015).

The Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses (BBV) and Sexually Transmissible Infections Strategy 2018–22 was published in 2018. This is one of a set of five national strategies that together outline a framework for a high-quality and coordinated national response to BBV and STI in Australia (DoH 2018a). Young Indigenous Australians have been identified as a priority group in the Strategy, which recognises that young people are disproportionately affected by BBVs and STIs and need special consideration in the national response.

An achievement of previous strategies was to increase testing. This may have contributed to the increases seen in notifications for some STIs and BBVs. However, under-identification of Indigenous Australians and the volatility in small numbers means that caution should be used in interpreting short-term trends in these data.

The policy context is at Policies and strategies.

References

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  • Australasian Sexual Health Alliance 2017. Australian STI Management Guidelines for use in Primary Care. ASHA.
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  • O'Connor CC, Ali H, Guy RJ, Templeton DJ, Fairley CK, Chen MY et al. 2014. High chlamydia positivity rates in Indigenous people attending Australian sexual health services. The Medical Journal of Australia 200:595-8.
  • Strobel NA & Ward J 2012. Education programs for Indigenous Australians about sexually transmitted infections and bloodborne viruses.  (ed., Australian Institute of Health and Welfare & Australian Institute of Family Studies). Canberra: Closing the Gap Clearinghouse.
  • Templeton DJ, Wright ST, McManus H, Lawrence C, Russell DB, Law MG et al. 2015. Antiretroviral treatment use, co-morbidities and clinical outcomes among Aboriginal participants in the Australian HIV Observational Database (AHOD). BMC Infectious Diseases 15:326.
  • Wand H, Bryant J, Worth H, Pitts M, Kaldor JM, Delaney-Thiele D et al. 2018. Low education levels are associated with early age of sexual debut, drug use and risky sexual behaviours among young Indigenous Australians. Sexual health 15:68-75.
  • Wand H, Ward J, Bryant J, Delaney-Thiele D, Worth H, Pitts M et al. 2016. Individual and population level impacts of illicit drug use, sexual risk behaviours on sexually transmitted infections among young Aboriginal and Torres Strait Islander people: results from the GOANNA survey. BMC Public Health 16:600.
  • World Health Organization 2019. Q&A Detail: What is hepatitis?
  • World Health Organization 2020. HIV/AIDS.

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