STRIVE: making a difference for sexual health in remote Aboriginal communities

HIV Australia | Vol. 11 No. 3 | October 2013

By John Kaldor, James Ward, Rebecca Guy and Alice Rumbold on behalf of the STRIVE team¹

There is an urgency in Australia’s response in addressing the high levels of curable sexually transmissible infections (STIs) that have been present in many Aboriginal and Torres Strait Islander communities for as long as records have been kept.

The STRIVE trial in central and northern Australia, although still more than a year from completion, has already made important contributions to understanding what’s required to bring down rates of these infections and their many adverse social and health consequences, particularly for young people.

Common STIs in remote communities

The most common curable STIs in Aboriginal remote communities are gonorrhoea, chlamydia and trichomonas; in some remote communities over a third of adolescents and young adults have at least one of these infections.

Although often asymptomatic, these STIs can nonetheless cause long-term harm if not treated – particularly among women, where they can damage the reproductive tract, leading to infertility or adverse pregnancy outcomes.

These infections are all easily diagnosed with accurate tests, and curable with single dose antibiotics – strategies which have been available since the 1990s, and have formed the basis for policy and guidelines ever since.

Apart from their direct impact, these infections are also known to increase the risk of HIV transmission – which has so far remained very rare in remote communities.

This is in contrast to many other parts of the world, where HIV infection has moved rapidly into settings with high rates of other STIs.

Despite the policy emphasis on testing and treatment for curable STIs, few communities have seen a decline in the rates of these STIs since these strategies became available.

There have been some notable exceptions, including the Anangu Pitjantjatjara Yankunytjatjara lands of northern South Australia, where sustained annual rounds of community-wide screening have led to falls in chlamydia and gonorrhoea prevalence; and the Tiwi Islands, where an intensive effort involving community and clinical leadership led to high levels of testing and treatment and, ultimately, falls in prevalence of these infections.

Missed opportunities

Primary health services in many remote communities are faced with particular challenges in ensuring that testing for curable STIs is routinely offered to young people and that positive diagnoses are followed up according to guidelines, which include contact tracing and a repeat test at three months.

An issue with guideline compliance has been the relatively low priority that is assigned to sexual health service delivery by some clinicians.

Explanations for the low level of priority include the other competing demands of remote primary care, lack of training, and sensitivity about discussing sexual health with clients, particularly those of the opposite gender.

The STRIVE trial was conceived as a response to these concerns. The idea was that young people in remote communities were coming to clinics, but that many opportunities were being missed to offer testing.

If a framework of quality improvement for sexual health service delivery could be widely adopted, the result could be a general increase in the uptake of testing and appropriate followup for positive diagnoses.

It was proposed that a cluster randomised trial design was needed to evaluate the strategy, first of all to ensure that necessary data could be collected; second to assess whether the strategies put in place to support quality improvement had an effect across a diverse range of services; and finally to provide a mechanism for detecting any changes in prevalence that might result from the quality improvement.

Trial development

In early 2008, a workshop was held in Alice Springs to discuss the trial proposal. Representatives from government and community organisations came together to talk about the challenges of sexual health service delivery, and about what kind of research projects might be both feasible and useful.

The meeting left many questions unanswered, but provided valuable insights into the requirements of services if they were to join a large-scale research project of this kind.

The submission for funding to support a large-scale trial in the Northern Territory went to the National Health and Medical Research Council, and an award of over $1.7m was made in late 2008.

There was immediate interest from health services in Western Australia and Queensland, so plans were modified to include the Kimberley region and Cape York.

A long series of consultations with government and community controlled health services began and extended over the next 18 months, and governance structures were established for the trial.

Ultimately, participation agreements were signed that committed clinical services to involvement in the trial in some 68 remote communities, grouped by geographic and linguistic proximity into 24 clusters.

The clusters were randomly assigned into three annual groupings; the first group of clusters to begin the quality improvement support process was initiated in early 2011.

The third and last group joined in during the course of 2013, by which time all communities were in the ‘active’ arm of the trial.

Trial operations

Once a clinic is assigned to the active arm of STRIVE, one of the regional coordinators for the project visits the clinic to conduct a ‘systems assessment’.

This process is undertaken with clinic staff and management, and involves developing a comprehensive description of the current status of sexual health service delivery at the clinic, under a number of key headings.

Based on this assessment, and the area(s) identified in which there is room for improvement, the coordinator and clinic personnel develop an action plan aimed at addressing these areas.

Whenever possible, the systems assessment visit also involves jurisdictional level personnel who are responsible for providing support to services in sexual health, or in related areas such as quality improvement.

The coordinator also provides the service with a report on its recent sexual health service activity in the areas of testing coverage in the target age groups, as well as other key indicators of clinical quality in sexual health.

This initial report provides a baseline against which progress against key outcomes can be assessed by clinics as they implement the sexual health actions plan.

Subsequently, the coordinators provide the services with regular reports against a number of sexual health service indicators, and regularly check in with services to see how they are progressing with their action plans and whether further technical assistance is required.

Outcomes and achievements to date

A key development that was essential to the implementation of quality improvement was the upgrading of information systems at the participating clinics.

Although virtually all clinics had computerised systems in place, there was not a standardised clinical template for recording sexual health-related encounters, and no easy way to obtain data on the services’ activity levels in this area.

To address this, templates and reporting procedures were developed, to be integrated into the software systems at participating clinics.

At the time of writing, some work remains to be completed on these developments, but the goal of having purpose built software to support clinicians in optimising sexual health clinical activities is now clearly in view.

Many clinicians at primary care services participating in STRIVE have adopted regular use of the templates, and many services are receiving, scrutinising and acting upon regular reports on service activity.

Another major contribution that STRIVE has made, long before final results are available, is that it provides the first comprehensive epidemiological analyses of the occurrence of gonorrhoea, chlamydia and trichomonas among Aboriginal people in remote communities.

With tests in over 3,000 people available for analysis in baseline data collection, STRIVE has been able to provide an insight into geographic variations, the level and predictors of co-infections with multiple STIs, and the incidence of all three infections. This is the first time that these data have been available.

Striking findings were the extremely high rates of infection, both incidence and prevalence, among young people (aged 16–24); the age and sex specific patterns of trichomonas (which had never been reported before), and the co-infection patterns.

We have also been able to determine levels of HIV testing, and assess the extent of adherence to guidelines that HIV testing should be offered to anyone with a positive STI result.

On the basis of our preliminary results, it does appear that such testing is taking place quite consistently in many communities.

Future challenges

In the final year of the trial, the task that now lies ahead for STRIVE is to see how effective quality improvement measures have been in increasing the rates of testing in young people, and ultimately in driving down community prevalence of these insidious STIs.

Preliminary analyses of findings from the services that were randomised to quality improvement in the first year show improvements in the self-assessment by clinics of their capacity to deliver sexual health services.

These changes, across several domains of service activity, need to be assessed against the control clinics, but give some indication that the quality improvement activities have had an impact.

The STRIVE investigators have recently joined forces with researchers involved in quality improvement in other areas of primary health care, and were successful in an application for a National Health and Medical Research Council (NHMRC) Partnership Grant, with the Northern Territory government and the Aboriginal Medical Services Alliance of the Northern Territory as the partners.

This new five-year funding, under the name STRIVEplus, will enable investigators to track the longterm outcome of quality improvement activities, as well as identify the health service factors that are associated with successful improvement.

The project will also determine the extent to which sexual health quality improvement encourages or impedes improvement in other areas of primary care.

By the end of next year, the STRIVE phase of the research will be completed but the task will continue, as long as is needed, to ensure that Aboriginal communities no longer face the debilitating, stigmatising and ultimately health-compromising burden of curable STIs.

Reference

1 The STRIVE team.

Investigators: John Kaldor, James Ward, Alice Rumbold, Rebecca Guy, Basil Donovan, Christopher Fairley, Lisa Maher, John Boffa, Donna Ah Chee, Steven Skov, Matthew Law, Handan Wand, David Glance, Robyn McDermott.

Operational Group: James Ward, John Kaldor, Alice Rumbold, Rebecca Guy, Linda Garton, Skye McGregor, Amalie Dyda, Debbie Taylor –Thompson, Bronwyn Silver, Belinda Hengel, Janet Knox (to May 2013).

Key stakeholder representatives on the STRIVE Executive (members current at September 1 2013): Amanda Sibosado, Donna Ah Chee, Jacki Mein, John Boffa, John Loudon, Katy Crawford, Liz Moore, Nathan Ryder, Stephanie Trust.

Acknowledgements

The National Health and Medical Research Council, management and staff at all participating health services, health departments in Northern Territory, Queensland and Western Australia, Aboriginal Medical Services Alliance Northern Territory, Apunipima Health Council (Queensland), Kimberley Aboriginal Medical Services Council, Westerns Diagnostic Pathology, Pathwest, Queensland State Laboratories.