Do Australian sexual health clinics have the capacity to meet demand? A mixed methods survey of directors of sexual health clinics in Australia

Introduction

Sexually transmitted infections (STIs) have risen steadily over the past 20 years in Australia and overseas. In 2023, there were 110,032 diagnoses of chlamydia, and 5290 diagnoses of infectious syphilis in Australia.¹ Particularly concerning are the increasing cases of infectious syphilis among women with parallel rises in congenital syphilis, which are now at their highest level since records surveillance began in 2003.^1,2

Access to health care for sexual health (SH) services is primarily provided by general practitioners who are supported by a network of SH clinics that were originally funded for return service men after World War I.³ General practices in Australia are funded by the Federal Government through a fee for service insurance scheme know as Medicare.⁴ The patient may also have to pay a fee for each service in addition to the funding from Medicare. SH clinics are free for attendees and are funded by State Governments.⁴ The number of SH clinics and, therefore, their geographic access vary significantly between states, with New South Wales having the largest number, and Victoria having essentially a single, albeit large, clinic based in the capital city.⁴ SH clinics generally provide services preferentially to higher-risk individuals.⁴ More recently, Internet-based services have developed and provide laboratory test requests for STI testing through Medicare, but these are for screening for asymptomatic individuals.⁵

Access to health care is the most important factor that determines the incidence of STI within populations, and is a considerably more effective intervention for controlling STIs than interventions to change behaviour.⁵ Limited access to health care increases the reproductive rate and incidence of both HIV and STIs by prolonging the duration of the infectious periods.⁵ Given the rising rates of STIs in Australia, it is reasonable to ask the question whether the current SH services are ‘accessible’ to the public, particularly for individuals with symptomatic STIs who have recently acquired their infection and benefit most from immediate treatment.^5,6 Inadequate access to health care creates a vicious cycle, where poor access to services results in more STIs, which reduce access further, and then STIs rise in response to this reduced healthcare access. This situation in Australia is further complicated by the growing difficulty in accessing general practices and reduced rates of bulk billing, which is where patients do not pay to see general practitioners. In Australia, general practitioners provide primary care for all medical conditions that include individuals with STIs.^7,8 The inadequate number of general practitioners in Australia had led general practices in some areas to not accept any new patients who have not previously been seen in the clinic, leaving individuals with STI symptoms or asymptomatic individuals requiring screening with limited alternatives for care other than SH clinics.⁹

The aim of the study was to understand the current capacity of publicly funded SH clinics in Australia to meet patient demand and to explore challenges faced by the SH clinics.

Methods

Results

Characteristics of participating SH clinics

Twenty-seven of 35 clinics (77.1%) consented to participate in the study. Tables 1 and 2 describe the characteristics of these clinics and the services they provide. The clinics provided a median of 4500 (IQR 1762–7710) consultations per year, and served a median population of 521,077 (IQR 250,000–1,000,000). The median number of consultations provided per 100,000 head of population was 877 (IQR 193–2380), with a minimum of 34.

Table 1.Characteristics of the 27 sexual health clinics that participated in the survey.

Characteristic	n (%)
Sate or territory
New South Wales	11 (40.7)
Queensland	8 (29.6)
Western Australia	2 (7.4)
Victoria	2 (7.4)
South Australia	1 (3.7)
Australian Capital Territory	1 (3.7)
Tasmania	1 (3.7)
Northern Territory	1 (3.7)
Services provided
Telehealth services	27 (100.0)
HIV testing	27 (100.0)
HIV pre-exposure prophylaxis	27 (100.0)
HIV post-exposure prophylaxis	27 (100.0)
Antiretroviral therapy for patients with HIV	27 (100.0)
STI testing	27 (100.0)
STI treatment	27 (100.0)
Contact tracing (syphilis and HIV)	27 (100.0)
Outreach	22 (81.5)
Health promotion	17 (63.0)
Specific clinics that are only for sex workers	7 (25.9)
Specific clinics that are only for MSM	3 (11.1)
Other services A	20 (74.1)
Characteristic	Median (IQR)
Population of catchment area	521,077 (250,000–1,000,000)
No. of new diagnoses in 2023
HIV	7 (3–15)
Infectious syphilis	43 (25–104)
Gonorrhoea	133 (63–346)
Mycoplasma genitalium	40 (20–62)
Trichomonas	6 (3–20)
Chlamydia	261 (281–546)
Staffing levels (FTE)
Nurses	4.2 (3.2–8.1)
Doctors	3.2 (1.0–6.0)
Counsellors	0.0 (0.0–1.4)
Laboratory technicians	0.0 (0.0–0.0)
Pharmacists	0.0 (0.0–0.3)
Contact tracing support officers	0.0 (0.0–0.0)
Health promotion	0.0 (0.0–1.1)
Dietician	0.0 (0.0–0.0)
Social worker	0.0 (0.0–1.0)
Nurse practitioners	0.0 (0.0–1.0)

FTE, full time equivalent; IQR, interquartile range; STI, sexually transmitted infection; MSM, men who have sex with men.

^A Reproductive health care, gender affirming care, management of HCV/HBV, management of gender diversity, sexual function, post cancer sexual rehabilitation, transgender service, endoscopy, teaching and training, medical termination of pregnancy, transgender reproductive health, Aboriginal sexual health, HIV and viral hepatitis services, youth sexual health services, and professional and community education.

Table 2.The number clients seen in 2023, STIs diagnosed and the proportion of clients seen with specific STIs by clinic.

No. of clients 2023	HIV n (%)	Syphilis n (%)	Gonorrhoea n (%)	Mycoplasma n (%)	Trichomoniasis n (%)	Chlamydia n (%)
61	0 (0.0)	1 (1.6)	0 (0.0)	0 (0.0)	5 (8.2)	7 (11.5)
500	5 (1.0)	12 (2.4)	40 (8.0)	12 (2.4)	12 (2.4)	120 (24.0)
800	2 (0.3)	20 (0.3)	40 (5.0)	10 (1.3)	40 (5.0)	50 (6.3)
1131	5 (0.4)	11 (1.0)	42 (3.7)	5 (0.4)	3 (0.3)	171 (15.1)
1300	N/A	N/A	N/A	N/A	N/A	N/A
1700	6 (0.4)	40 (2.4)	70 (4.1)	28 (1.6)	0 (0.0)	84 (4.9)
1783	N/A	N/A	N/A	N/A	N/A	N/A
2500	3 (0.1)	50 (2.0)	62 (2.5)	40 (1.6)	10 (0.4)	240 (9.6)
3000	0 (0.0)	25 (0. 8)	96 (3.2)	73 (2.4)	1 (0.0)	250 (8.3)
3000	7 (0.2)	60 (2.0)	200 (6.7)	25 (0.8)	6 (0.2)	271 (9.0)
3600	7 (0.2)	45 (1.3)	111 (3.1)	34 (0.9)	3 (0.1)	211 (5.9)
4200	23 (0.5)	160 (3.8)	391 (9.3)	47 (1.1)	20 (0.5)	532 (12.7)
4500	16 (0.4)	59 (1.3)	211 (4.7)	23 (0.5)	7 (0.2)	305 (6.8)
4500	8 (0.2)	25 (0.6)	180 (4.0)	20 (0.4)	5 (0.1)	220 (4.9)
4500	2 (0.0)	25 (0.5)	9 (0.2)	N/A	5 (0.1)	58 (1.1)
5000	10 (0.2)	50 (1.0)	80 (1.6)	50 (1.0)	150 (3.0)	300 (6.0)
6676	12 (0.2)	91 (1.4)	353 (5.3)	58 (0.9)	4 (0.1)	514 (7.7)
7000	10 (0.1)	109 (1.6)	366 (5.2)	51 (0.7)	4 (0.1)	651 (9.3)
7000	4 (0.1)	4 (0. 1)	88 (1.3)	15 (0.2)	28 (0.4)	216 (3.1)
7500	1 (0.0)	26 (0.3)	238 (3.2)	25 (0.3)	10 (0.1)	687 (9.2)
8340	5 (0.1)	30 (0.4)	64 (0.8)	40 (0.5)	75 (0.9)	250 (3.0)
12,000	25 (0.2)	500 (4.2)	500 (4.2)	250 (2.1)	0	550 (4.6)
12,092	18 (0.1)	108 (0.9)	324 (2.7)	62 (0.5)	2 (0.0)	695 (5.7)
12,344	11 (0.1)	35 (0.3)	155 (1.3)	89 (0.7)	15 (0.1)	298 (2.4)
35,000	21 (0.1)	384 (1.1)	1748 (5.0)	130 (0.4)	3 (0.0)	2187 (6.2)
37,000	45 (0.1)	450 (1.2)	2700 (7.3)	700 (1.9)	80 (0.2)	4000 (10.8)
N/A	N/A	N/A	N/A	N/A	N/A	N/A

Percentages for Mycoplasma genitalium were not included, because it is not routinely tested for and, therefore, the comparison will be invalid.

N/A, data not available.

In 2023, clinics diagnosed a median of 261 chlamydia cases, 133 gonorrhoea cases, 43 infectious syphilis cases, 40 Mycoplasma genitalium cases, six trichomona cases and seven HIV cases. The percentiles for the proportion of patients diagnosed with different STIs are shown in Fig. 1. We calculated the ratio of the 75th percentile to the 25th percentile for each infection to provide a measure of the spread of STI risk among patients attending the different clinics. These ratios were 4.1 for HIV, 5.4 for syphilis, 3.6 for gonorrhoea and 2.0 for chlamydia (Fig. 1). There was a strong and highly significant correlation between the positivity for HIV, syphilis, gonorrhoea and chlamydia between different clinics (Table 3, Fig. 2, P < 0.05).

Fig. 1.

Median and interquartile ranges for proportion of individuals at each clinic with chlamydia, gonorrhoea, HIV (by 10) and syphilis. Footnote: for clarity the proportions of individuals diagnosed with HIV has been multiplied by 10.

Table 3.Correlations between the proportion of consultations with pairs of STIs in each clinic.

	Chlamydia	Gonorrhoea	Syphilis
Gonorrhoea	0.62 (P < 0.001)
Syphilis	0.40 (P = 0.048)	0.62 (P < 0.001)
HIV	0.74 (P < 0.001)	0.66 (P < 0.001)	0.53 (P = 0.007)

R-value for Pearson’s correlation and P-value for the correlation.

Fig. 2.

Correlations between the proportion of consultations with each STI and the clinics.

Discussion

We found that SH clinics in Australia were unable to see all patients with symptoms on the same day on approximately 30% of the days during summer, and approximately 25% of the days during winter. When we adjusted this by the number of consultations that the clinic provided, then for at least half of the time, symptomatic patients were likely to encounter a clinic that may be unable to see them. Inadequate STI services put upward pressure on STI rates, which can create a vicious cycle that leads to further increases in STIs.¹¹ Our findings suggest that clinics currently lack the capacity to adequately meet demand, and with rising STI rates and increasing barriers to accessing primary care, this will only worsen. On a positive note, we identified potential efficiencies within the existing system. For example, clinics could direct resources away from simple screening of asymptomatic individuals and focus on symptomatic individuals who have a higher risk of HIV/STI, and whose treatment is likely to prevent more transmission given they have only recently acquired their infections. The public health consequences of inadequate access to SH care are already evident in some jurisdictions, with rapidly rising rates of syphilis among women and the resurgence of congenital syphilis, which has been virtually absent for decades.¹

What matters most for effective STI control and for a person’s individual health is what happens to those most likely to be diagnosed with the infections of greatest health consequences, such as HIV and syphilis. A primary syphilitic chancre will resolve spontaneously without treatment, and despite symptoms resolving, that individual will remain infectious to others and at risk of serious complications themselves. Our study shows that most SH services prioritise patients with symptoms suggestive of high-risk infections, such as syphilis, but little is known about individuals who do not successfully navigate to these services or do not wait to be seen during particularly busy times when wait times can be hours.

We are not aware of what level of service translates into effective STI control, although a system that could always see 100% of symptomatic patients would be expensive. The British Association for Sexual Health and HIV have recommended that all patients with symptoms of an STI should receive care within 48 h, although this recommendation was not based on empirical evidence of what is or is not effective for STI control.¹² Additionally, to be confident of accessibility, clinics would need to monitor attendance rates to ensure people offered future appointments do actually access care. Clearly though, the current situation in Australia where on 50% of days clinics cannot see all patients is inadequate. What makes this situation particularly concerning is that sexual practices that put individuals at risk of STIs are rising. For example, the proportion of MSM who always use a condom for anal sex with casual partners has fallen from 47% in 2014 to 16% in 2022.¹³ These behavioural changes and the rising STI rates highlight how critical it is that access to health care is optimised as soon as possible.

There are no process markers (e.g. percentage of symptomatic individuals seen in <2 h), but it may be possible to imply what countries may have ‘accessible’ STI care by comparing the rates of syphilis in women (and congenital syphilis) between countries of similar economic status. These rates vary markedly. At one end of the spectrum are the Scandinavian countries or the Netherlands (population 17 million) in 2023, where rates are low, whereas at the other end is the US in 2022, where 26% of syphilis cases were in women, and there were 3882 cases of congenital syphilis (rate 105.8 per 100,000). In the Netherlands, only 2% of infectious syphilis cases were in women, and there were no cases of congenital syphilis in 2023. In Australia in 2023, 20% of infectious syphilis was in women (rate 10 per 100,000), and there were 20 cases of congenital syphilis (rate 0.1 per 100,000). These figures suggest Australia’s STI control is poor, and at risk of major rises in congenital syphilis unless services are substantially improved.

Encouragingly, there was scope for improving the efficiency and effectiveness of some of the SH clinics. Our results show that there are nearly four times as many consultations allocated to asymptomatic screening compared with symptomatic cases. Although some of these may be associated with important HIV prevention strategies, such as pre-exposure prophylaxis, many may not be. Given that treatment of symptomatic individuals is likely to have a larger effect on the duration of infection and the overall reproductive rate of an STI than treatment of asymptomatic individuals, prioritising symptomatic cases could be a more efficient strategy for improving the efficiency of the services.⁵ In addition, the relatively long time (20 min) for screening highlights a substantial resource allocation that could potentially be redirected towards symptomatic individuals. There are web-based services available at low cost or no cost (to individuals) for testing of asymptomatic individuals for STIs, and it may be that those with Medicare or insurance should be directed to such services.¹⁴

The other area where services might improve their efficiency is to increase the risk profile of patients that they see. In our study, there was substantial variation between clinics (2–5-fold) in the proportion of consultations with STIs, which suggests that some clinics are not attracting sufficiently high-risk individuals. Relatively simple changes in clinic process, such as moving from an appointment system to a walk-in triage system, can substantially improve the risk profile of the patients seen.¹⁵ Making data available on the proportion of consultations positive for different STIs would allow clinics to benchmark themselves against other services.

The key question for governments who have oversight of these clinics is what should be done? We have clearly shown that these services are understaffed and under resourced to meet the current patient demand, although there are some efficiencies that could be implemented. Unfortunately, obtaining more funding for these services is, and is likely to remain, a low priority for governments around the world. This is because this area of medicine is the lowest prestige medical speciality and, like other areas where individuals are seen to be responsible for their own conditions, is politically unpopular.¹⁶ General practitioners and their clinic staff play a major role in Australia, but need to be resourced for this role, which has been effectively done for a small number of general practice clinics in Victoria.⁵ Recent policy changes to improve access to Medicare-funded sexual and reproductive telehealth are likely to improve access to care; however, policy barriers still prevent the cost-effective automated services used extensively in the UK. Medicare-funded urgent care services have the potential to improve timely access to primary care for people with symptoms, but efforts are needed to ensure these services have access to the knowledge and skills to perform this role in a manner that meets the needs of most at-risk populations. However the stigma associated with STIs means there will remain a proportion of individuals who will only attend STI clinics, so adequate resources are required for SH clinics if optimal STI control is desired by governments.

Our study has several limitations that need to be considered. First, our survey relied on the perspectives and opinions of the clinic directors rather than actual data. This reliance on self-reported data may have introduced some biases, such as respondents overstating their difficulties in providing services to justify requests for additional resources. Although we cannot confirm the presence of these biases, our findings are consistent with anecdotal reports that clinics are struggling to adequately manage their current patient load. Second, we only surveyed public SH clinics and not private general practice clinics, which also provide a substantial portion of STI services in Australia. Therefore, we cannot infer that general practice clinics face similar pressures. However, there are reports indicating growing difficulties in accessing general practice services in Australia, which may suggest comparable challenges.^9,17

If Australia wants to avoid the devastating effects of relentless rises in STIs and a vicious cycle of rising rates with limited services, then something needs to change to avoid the exponential rises in cases of congenital syphilis currently being seen in some US states (e.g. Mississippi). Access to clinical services is the single strongest STI control strategy, and our data show it is not able to meet demand. Without adequate resources, the escalating burden of STIs is likely to worsen, potentially leading to higher disease burden and health complications that will be eventually more expensive to manage in the long term.

The Australian STI research group

Julian P. G. Langton-Lockton, Manoji Gunathilake, Alison Ward, Arun Menon, Josephine Lusk, Jenny McCloskey, Kuong Taing, David Lewis, David Templeton, Chris Carmody and Cheryn Palmer.