Despite the social restrictions in place in Australia during the COVID-19 pandemic, the testing and treatment of sexually transmitted infections (STIs) remain essential to optimise the health of people living in Australia.   This report is designed to provide clinicians with an update on changes in sexual health clinic services around Australia and in New Zealand, and to raise awareness around the likely increased needs around STI testing and treatment during the COVID-19 pandemic. Of note, general practitioners will play a vital role in the ongoing care of people with STIs.

The ASHM COVID-19 Taskforce spoke to several sentinel sexual health clinics in Australian capital cities and in rural and regional areas this week and to sexual health colleagues in New Zealand to ask them about changes in their service delivery and patient attendance. 

Our findings were as follows:

•    All the clinics we spoke to remain open, albeit several have changed their opening hours and some are offering fewer clinics
•    Larger clinics are still offering asymptomatic screening for individuals at high risk of having STIs while smaller clinics are prioritising seeing patients with symptomatic STIs and are currently not seeing asymptomatic patients
•    Some clinics are no longer seeing walk-in patients to help meet physical distancing guidelines
•    Telehealth is being used as much as possible to limit face-to-face appointments. 
•    Face-to-face services and telehealth are both being used to provide clinical services to people living with HIV
•    Clinics are mailing out scripts for HIV antiretroviral drugs for community dispensing
•    Overall staff redeployment, personal protective equipment (PPE) shortages, and efforts to reduce potential transmission of COVID-19 appear to have been the primary drivers behind these service changes 
•    Clinics reported a 30% – 50% reduction in demand for their services and two clinics reported a decline in positive syphilis test results and in positive test results for urethral gonorrhoea
•    Some clinics using peer-based services have suspended HIV point-of-care testing to minimise close contact between patients and providers. In place of this, some have increased HIV pre-exposure prophylaxis (PrEP) and STI service provision. These services also report a reduction in service demand
•    Some services reported a decline in requests for HIV pre- and post-exposure prophylaxis (PEP)
 

The Centre for Excellence in Rural Sexual Health (CERSH) contacted a number of sexual health organisations working across rural and regional Victoria and has provided an overview of the changes that are being experienced during the pandemic for this report:

•    As in metropolitan areas, the demand for routine STI & BBV screening is reduced across the services
•    Services are experiencing a lack of access to PPE
•    Referral services are seeing increased numbers of international students, people on temporary visas, and working holiday visas who have experienced loss of income and are struggling to afford sexual and reproductive health services. Living in rural areas exacerbates these issues
•    Access to free or low-cost condoms for rural young people has been impacted. Many public toilets where condom vending machines are located are locked and many of the places where free condoms are available are also closed
•    The health promotion workforce has been impacted by the need for reorientation to other priorities related to COVID-19. For programs and services still operating there is low uptake of initiatives such as online education sessions for organisations on HIV PrEP and PEP

In Queensland, some remote communities have had their biosecurity plans updated to ensure sexual health practitioners are able to travel within remote communities as essential services . Broader concerns around the decline in attendance in sexual health services in remote areas, including Mount Isa have been highlighted recently (2). 
 

It is too early to determine what the key factors may be that have led to a decline in patient attendance at sexual health clinics. However the following factors may be contributing:

•    Social restrictions may have led to less sex with casual partners and therefore there are fewer STIs. Of note HIV/AIDS peak organisations, including Thorne Harbour Health and the AIDS Council of New South Wales, have led campaigns to dissuade people from have casual sex. The report from two clinics that fewer tests are positive for syphilis and urethral gonorrhoea would corroborate the idea that people are having less casual sex, however clinics are reporting ongoing STI transmission despite the current social restrictions
•    Individuals may be fearful of acquiring COVID-19 in health care settings and are not presenting to sexual health clinics irrespective of their STI symptom status
•    Individuals may not know how to, or be unwilling to use telehealth to discuss sexual health issues. This reticence may be enhanced in settings where people are unsure if translation services will be available during telehealth

We will have to wait until results from social research initiatives and STI surveillance data become available in different jurisdictions to better understand changes in sexual behaviour and STI rates during the COVID-19 pandemic.

For many health care workers, discussing sexual health and STIs using telehealth proves to be a challenge. According to preliminary results from an ASHM Taskforce survey, health care workers are concerned that Telehealth does not afford the same level of engagement as face-to-face consultations and reduces the likelihood of opportunistic conversations about sexual health. 

For patients, with the intense focus on COVID-19 and the attendant stigma associated with breaking social distancing laws, patients who have been having casual sex may be less likely to request STI testing. In addition, as noted above, individuals may be unwilling to use telehealth to discuss their sexual health.
 

We contacted a number of private pathology laboratories to see if they are continuing to process STI tests including throat swabs as per normal and all laboratories reported that they are. However, there have been reports of laboratories not processing certain tests due to a shortage of reagents. In addition, there have been patient reports that some laboratories are refusing to perform throat swabs for STI testing; the Taskforce is following up on this issue.

Given that some sexual health clinics are offering reduced services, it is even more crucial that general practitioners continue to consider, test and treat for STIs.  Investment in building the capacity of general practitioners and nurse practitioners and bringing in peer workers to provide and increase sexual health care will be needed during the COVID-19 pandemic. 

1. https://www.datsip.qld.gov.au/coronavirus/travel-restrictions-remote-communities#human-biosecurity-management-plans-2
2. https://www.abc.net.au/news/2020-04-28/sexual-health-priority-during-coronavirus/12188722