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Rising Chlamydia and Gonorrhoea Incidence and Associated Risk Factors Among Female Sex Workers in Australia: A Retrospective Cohort Study

Callander, Denton, PhD*†; McManus, Hamish, PhD*; Guy, Rebecca, PhD*; Hellard, Margaret, PhD; O’Connor, Catherine, C., DrPH*§¶; Fairley, Christopher, K., PhD∥**; Chow, Eric, P.F., PhD∥**; McNulty, Anna, MM††; Lewis, David, A., DA, PhD‡‡§§; Carmody, Christopher, MB, BS¶¶; Schmidt, Heather-Marie, A., PhD∥∥; Kim, Jules***; Donovan, Basil, MD*††

Sexually Transmitted Diseases: March 2018 - Volume 45 - Issue 3 - p 199–206
doi: 10.1097/OLQ.0000000000000714
Original Study

Background Female sex workers in Australia have achieved some of the lowest documented prevalences of human immunodeficiency virus (HIV) and other sexually transmissible infections globally but rates overall are increasing in Australia and warrant closer investigation.

Methods We constructed a retrospective cohort using repeat testing data extracted from a network of 42 sexual health clinics. Poisson and Cox regression were used to determined trends in incidence and risk factors for HIV, chlamydia, gonorrhoea, and infectious syphilis among female sex workers.

Results From 2009 to 2015, 18,475 women reporting sex work attended a participating service. The overall incidence of urogenital chlamydia was 7.7/100 person years (PY), declining by 38% from 2009 to 2013 before increasing by 43% to 2015 (P < 0.001); anorectal chlamydia incidence was 0.6/100 PY, and pharyngeal was 1.9/100 PY, which increased significantly during the study period (P < 0.001, both). For gonorrhoea, the urogenital incidence was 1.4/100 PY, anorectal incidence was 0.3/100 PY, P < 0.001), and 3.6/100 PY for pharyngeal; urogenital incidence doubled during the study period, anorectal increased fivefold, and pharyngeal more than tripled (P < 0.001, all). Incidence of infectious syphilis was 0.4/100 PY, which remained stable from 2009 to 2015 (P = 0.09). There were seven incident infections of HIV among female sex workers (0.1/100 PY). Inconsistent condom use with private partners, higher number of private partner numbers, recent injecting drug use, younger age, and country of birth variously predicted sexually transmissible infections among female sex workers.

Conclusions Although infectious syphilis and HIV remain uncommon in female sex workers attending Australian sexual health clinics, the increasing incidence of gonorrhoea across anatomical sites and increasing chlamydia after a period of decline demands enhanced health promotion initiatives.

An epidemiological study of female sex workers attending Australian sexual health clinics, which found increasing rates of gonorrhoea at all anatomical sites, increasing pharyngeal and anorectal chlamydia and, after a period of decline, increasing urogenital chlamydia. This study found low rates of human immunodeficiency virus and infectious syphilis among female sex workers in Australia.

From the *The Kirby Institute, †Centre for Social Research in Health, UNSW Australia, Sydney, NSW; ‡Burnet Institute, Melbourne, VIC; §RPA Sexual Health Clinic, Community Health, Sydney Local Health District; ¶Central Clinical School, University of Sydney, Sydney, NSW; ∥Melbourne Sexual Health Centre, Alfred Health; **Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC; ††Sydney Sexual Health Centre, Sydney Hospital, Sydney; ‡‡Western Sydney Sexual Health Centre, Parramatta; §§Marie Bashir Institute for Infectious Diseases and Biosecurity & Sydney Medical School-Westmead, University of Sydney, Sydney; ¶¶Liverpool Sexual Health Centre, Liverpool; ∥∥New South Wales Ministry of Health; and ***Scarlet Alliance, Australian Sex Worker Association, Sydney, NSW, Australia

Source of Funding: The ACCESS Project received funding the departments of health in New South Wales, Victoria, the Northern Territory and the Australian Capital Territory. Funding for sex worker health surveillance was provided by the BBV & STI Research, Intervention and Strategic Evaluation Program at UNSW Australia.

Conflicts of Interest: None declared.

Acknowledgements: The authors acknowledge the contribution of the ACCESS Sexual Health Clinic Network Steering Committee members not co-authors of this article (Andrew Grulich, John Kaldor, David Wilson, Marlene Kong and Lucy Watchirs Smith). The authors also acknowledge the work of Bridget and Simon Dickson (CaraData), Afrizal (Melbourne Sexual Health Centre) and Heng Lu (Sydney Sexual Health Centre) in preparing and managing the extraction of clinical data. Finally, the authors acknowledge all clinics participating in ACCESS, including the site investigators who contributed data to this analysis: Eva Jackson, Darren Russell, Emanuel Vhalkis, Manoji Gunathilake, Alison Nikitas, Lewis Marshall, Maree O’Sullivan, Debbie Allen, Nathan Ryder, Katherine Brown, David Smith, Yoges Paramsothy, Cheryn Palmer, Stephen Davies, Arun Menon and Angela Parker.

Correspondence: Denton Callander, PhD, Wallace Wurth Building, UNSW Australia, Sydney NSW, 2052, Australia. E-mail:

Received for publication April 26, 2017, and accepted August 20, 2017.

© Copyright 2018 American Sexually Transmitted Diseases Association