Sexual and Reproductive Health among Australian Aboriginal People in Remote Communities: Burden of Disease and Interventions.

Compared with non-Aboriginal people, Aboriginal Australians have disproportionate rates of curable sexually transmissible infections (STI), particularly those living in remote communities. Despite high rates of STI in these communities, there has been little research on interventions to reduce their occurrence and their impact on reproductive outcomes. The overall aim of this thesis is to provide new knowledge on the occurrence, outcome and control of chlamydia, gonorrhoea and trichomoniasis in remote Aboriginal communities. Four discrete projects were conducted: (i) a retrospective cohort study to determine the incidence and demographic correlates of new infections; (ii) a comparison of two STI screening approaches, clinic based and community based, to identify predictors of testing and positivity; (iii) a medical record audit to assess the diagnosis and management of pelvic inflammatory disease (PID); and (iv) a systematic review and meta-analysis of the evidence on the association between trichomoniasis and perinatal morbidity. These studies have provided new knowledge that will guide future sexual health service provision and policy in remote primary care. This thesis has provided the first age and sex-specific incidence estimates from anywhere in the world of all three STI. Extreme incidence of all three STI in young people was identified, emphasising the need for an increase in screening frequency. Research presented in the thesis showed that a community screen approach reached more young people, especially men, compared to opportunistic clinic screening, suggesting that a combined approach is needed to maximise screening coverage, detection of infections and repeat testing. The extreme STI incidence found coincides with the age that many Aboriginal women enter their reproductive years. Further, presentations with PID, known to be associated with infertility, were common in primary care settings, but largely undiagnosed and poorly managed. Finally, the meta-analysis found that trichomoniasis was associated with preterm birth and other outcomes showing that current guidelines are not evidence based and that further research is required to identify suitable screening and treatment algorithms for pregnant women. In conclusion, the reproductive health of many Aboriginal women continues to be at risk, but there are a number of key directions that can be followed to improve outcomes