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Basil Donovan, Director, Sydney Sexual Health Centre, Sydney Hospital, Clinical Associate Professor, Department of Public Health and Community Medicine, The University of Sydney

Biologically and politically the gonococcus could hardly be more different from the human immunodeficiency virus (HIV). Yet both organisms speak the same language. Each is rare among heterosexual, non-injecting, non-prostitute, non-indigenous Australians who have not had sex overseas ('us').¹ Instead, they are concentrated among 'them': the faceless, the stigmatised, the under-served, 'the other'.²

Because it killed so obviously, HIV demanded our attention. Considerable resources have been committed to surveillance, clinical and social services, research, and health promotion programs which include removing institutional barriers to HIV control. The HIV-affected communities have been central players and skilled advocates. Australia nets an excellent return on its AIDS-dollar.³

By contrast, the curable gonococcus was left to its own devices along with the other sexually transmissible infections (STIs). Remarkable declines in the incidence of gonorrhoea and some other STIs in our cities during the 1980s¹ were viewed as unintentional but positive spin-offs of HIV control programs. Unfortunately, many community advocates still choose to ignore the overwhelming evidence that most other STIs directly promote the sexual transmission of HIV.⁴ With some justification, the other STIs are seen as trivial distractions from the Main Game, HIV control. 'HIV control in a broader sexual health context'³ has sometimes been positioned as a threat to singularity of purpose and a potential diffusion of precious resources. The opportunity to complement behavioural HIV control strategies with biological interventions (control of other STIs) has been resisted. STI control has only been conceded as relevant for indigenous Australians.

Left out in the political cold, the gonococcus has thrived. Elegantly documented in this issue by the Australian Gonococcal Surveillance Program (AGSP),⁵ the gonococcus is relentlessly returning to the hyperendemic levels that contributed to the peak incidences of HIV infections among our gay communities in the early 1980s. In Sydney the number of gonococcal isolates examined by the AGSP to the end of July 1998 exceeded the total number for 1996 (Prof J Tapsall, unpublished). At the Sydney Sexual Health Centre 67% of all cases of gonorrhoea since 1995 have been among gay men, a third of whom were HIV positive (unpublished data). The largely unspoken hope that advances in anti-retroviral therapy could yield a less infectious HIV-infected population overall (even if this cannot be assumed for individuals) could be at least partially offset by the gonococcus increasing that population's infectiousness or their partners' susceptibility to HIV infection.

So what is the gonococcus telling us to do? We could start with some national leadership and policy structures commensurate with the morbidity, mortality (direct and indirect) and controllability of the other STIs. Though they are inter-related it is naïve to assume that good HIV control is synonymous with good STI control. Each STI is different.¹
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To use the gonococcus as an example, education programs - for health professionals, policy makers, key communities and community leaders - which include the role of the gonococcus in enhancing the transmission of HIV may be timely. The much greater infectiousness of the gonococcus and its wide clinical spectrum need to be better understood.

New combined gonorrhoea/chlamydia polymerase chain reaction (PCR) screening tests are already being used among indigenous populations. PCR testing has the advantages of being able to use urine or other self-collected specimens, overcoming many of the cultural and logistic barriers to case-finding. PCR testing is likely to become standard in most clinical settings but, in its current form, it does not yield antibiotic sensitivity information. Modifications to the Medical Benefit Schedule (MBS) will need to be negotiated to ensure that this vital clinical information remains available from large representative samples.

The MBS also has structural barriers to screening for the gonococcus among gay men with HIV. A standard HIV monitoring visit to a GP (full blood count, biochemistry, T-cell subsets, viral load test) already exceeds the '3-test rule', under which the GP's pathologist(s) is only rebated for the three most expensive tests. Concurrent multi-site tests for gonorrhoea and chlamydia may be more than the pathologist can afford to absorb financially and is likely to be discouraged. Tests deemed to be of public health importance, such as the Pap smear, are already exempted from the 3-test rule. STIs could also be deemed to be of public health importance, at least in selected populations, if screening is to be encouraged.

The exclusion of sex workers from MBS rebates for STI testing is not only questionable from public health and economic perspectives, it is also legally dubious: all recent studies among sex workers have found their private risk greatly exceeds their professional risk of STIs.

As highlighted in the current report⁵ Australia no longer has access to a reliable oral treatment for gonorrhoea. Cefixime is such a drug. It is recommended and used by the U.S. Centers for Disease Control and Prevention. Unfortunately the small market and licensing fees in Australia make it uneconomic for the drug's manufacturers to bring cefixime to this country. This too needs to be negotiated.

Finally, because a substantial proportion of people with gonorrhoea develop symptoms within weeks of becoming infected, it has proven to be the model disease for studying how STIs move through populations. Insights into the epidemiology of gonorrhoea informed the study of HIV epidemiology and are likely to continue to do so as our ability to discriminate between gonococcal strains improves. Rarely manifesting as point-source outbreaks, the epidemiology of gonorrhoea and HIV is predominantly based on multiple small clusters of infections which reflect broader social trends and system failures. The AGSP has begun the task of translating the message. Are we prepared to listen?

References

1. Donovan B, Hart G, Minichiello V. Australia. In: Brown T, et al. (eds). Sexually Transmitted Diseases in Asia and the Pacific. Armidale, Venereology Publishing 1998:27-60.

2. Brandt AM. No Magic Bullet. New York, Oxford University Press, 1987.

3. Feacham RGA. Valuing the Past. Investing in the Future: Evaluation of the National HIV/AIDS Strategy, 1993-94 to 1995-96. Canberra, Australian Government Publishing Service, 1995.

4. Cohen MS. Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis. Lancet 1998;351 (Suppl. III):5-7.

5. Australian Gonococcal Surveillance Programme. Annual report of the Australian Gonococcal Surveillance Programme, 1997. Commun Dis Intell 1998;22:212.


This article was published in Communicable Diseases Intelligence Volume 22, No 10, 1 October 1998.