Prevalence and Correlates of a Diagnosis of Sexually Transmitted Infection Among Young Aboriginal and Torres Strait Islander People

Abstract

Background:
Young Aboriginal and Torres Strait Islander (Aboriginal) people are recognized as a priority population for the control of sexually transmissible infections (STIs) in Australia. This article reports the prevalence of self-reported STI diagnoses and their correlates among Aboriginal people aged 16 to 29 years.

Methods:
Results were analyzed from a survey conducted between 2011 and 2013 at regular community events. Univariate and multivariate logistic regression models were used to identify the correlates of a history of STI diagnosis among participants who reported being sexually active and ever having been tested for STIs. All analyses were stratified by sex.

Results:
Of the 2877 participants in this study, 2320, comprising 60% females, self-reported ever having had vaginal or anal sex, and a further subset of 1589 (68%) reported ever being tested for any of the following STIs: chlamydia, gonorrhea, syphilis, or trichomonas. Within this latter group, the proportion who reported that they had had a positive STI diagnosis was 25%. In multivariate analysis, women who reported sexual debut before the age of 16 years (prevalence ratio [PR], 1.53; 95% confidence interval, 1.16-2.81; P < 0.05), ever having had oral sex (PR, 2.66; 1.47-4.82; P < 0.001), inconsistent condom use in the past 12 months (PR, 1.71; 1.13-2.58; P < 0.012), having had sex with someone they had just met (adjusted odds ratio, 1.74; 1.21-2.50; P < 0.003), and using ecstasy (PR, 1.81; 1.16-2.81; P < 0.009) were significantly associated with a self-reported history of an STI diagnosis. For men, being older (25-29 years; PR, 2.10; 1.10-3.96; P < 0.023), being gay or bisexual (PR, 2.22; 1.16-4.27; P < 0.016), not using a condom during last sex, (PR, 1.74; 1.10-2.76; P < 0.019), past ecstasy use (PR, 1.88; 1.11-3.20; P < 0.019), and injecting drug use (PR, 2.81; 1.35-5.88); P < 0.006) were independent predictors of ever reporting being diagnosed as having an STI.

Discussion:
In the first community-based survey of this population, a self-reported history of ever being diagnosed as having prevalent STIs was common in sexually active young Aboriginal people who reported STI testing in the past. This population requires targeted education and health service interventions to address the high burden of STIs.

Full text

Prevalence and Correlates of a Diagnosis of Sexually
Transmitted Infection Among Young Aboriginal
and Torres Strait Islander People: A National Survey
James Ward, BA,* Handan Wand, PhD,†Joanne Bryant, PhD,‡Dea Delaney-Thiele, MPH,§
Heather Worth, PhD,¶ Marian Pitts, PhD,|| Kat Byron, Cert IV,** Elizabeth Moore, MBBS,††
Basil Donovan, MD,‡‡ and John M Kaldor, PhD†
Background: Young Aboriginal and Torres Strait Islander (Aboriginal)
people are recognized as a priority population for the control of sexually
transmissible infections (STIs) in Australia. This article reports the
prevalence of self-reported STI diagnoses and their correlates among Ab-
original people aged 16 to 29 years.
Methods: Results were analyzed from a survey conducted between 2011
and 2013 at regular community events. Univariate and multivariate logistic
regression models were used to identify the correlates of a history of STI
diagnosis among participants who reported being sexually active and ever
having been tested for STIs. All analyses were stratified by sex.
Results: Of the 2877 participants in this study, 2320, comprising 60% fe-
males, self-reported ever having had vaginal or anal sex, and a further sub-
set of 1589 (68%) reported ever being tested for any of the following STIs:
chlamydia, gonorrhea, syphilis, or trichomonas. Within this latter group,
the proportion who reported that they had had a positive STI diagnosis
was 25%. In multivariate analysis, women who reported sexual debut be-
fore the age of 16 years (prevalence ratio [PR], 1.53; 95% confidence inter-
val, 1.16–2.81; P< 0.05), ever having had oral sex (PR, 2.66; 1.47–4.82;
P< 0.001), inconsistent condom use in the past 12 months (PR, 1.71;
1.13–2.58; P< 0.012), having had sex with someone they had just met
(adjusted odds ratio, 1.74; 1.21–2.50; P< 0.003), and using ecstasy (PR,
1.81; 1.16–2.81; P< 0.009) were significantly associated with a self-
reported history of an STI diagnosis. For men, being older (25–29 years;
PR, 2.10; 1.10–3.96; P< 0.023), being gay or bisexual (PR, 2.22;
1.16–4.27; P< 0.016), not using a condom during last sex, (PR, 1.74;
1.10–2.76; P< 0.019), past ecstasy use (PR, 1.88; 1.11–3.20; P<0.019),
and injecting drug use (PR, 2.81; 1.35–5.88); P< 0.006) were independent
predictors of ever reporting being diagnosed as having an STI.
Discussion: In the first community-based survey of this population, a
self-reported history of ever being diagnosed as having prevalent STIs
was common in sexually active young Aboriginal people who reported
STI testing in the past. This population requires targeted education and
health service interventions to address the high burden of STIs.
BACKGROUND
Young Aboriginal and Torres Strait Islander (hereafter Ab-
original) young people are recognized as a priority population
for the control of sexually transmissible infections (STI) in na-
tional and jurisdictional strategies in Australia.
1,2
This priority
has been based on the epidemiological observation of higher rates
of STIs among this population. At a national level, data from no-
tifiable diseases reporting
3,4
have shown rates of diagnosis of chla-
mydia, gonorrhea, and syphilis in Aboriginal Australians at 3, 36,
and 5 times the rates reported for nonindigenous Australians,
5
re-
spectively. Prevalence data collected from 68 remote Aboriginal
communities also highlight the burden of disease, with prevalence
of chlamydia, gonorrhea, or trichomonas among 16- to 29-year-
olds at 41% for women and 29% for men.
6
As such, local and ju-
risdictional STI testing guidelines are in place for young Aborigi-
nal people that recommend more regular testing for STIs in
endemic areas or where epidemiological data suggest a higher
prevalence of STIs.
6,7
A major limitation of STI notification data, for the purposes
of understanding disease occurrence, is their dependence on
From the *South Australian Health and Medical Research Institute, Adelaide,
South Australia, Australia; †Kirby Institute and ‡Centre for Social Re-
search in Health, University of New South Wales, Kensington, New
South Wales, Australia; §Aboriginal Medical Service Western Sydney,
Mount Druitt, New South Wales, Australia; ¶School of Public Health
and Community Medicine, University of New South Wales, Kensington,
New South Wales, Australia; ||Australian Research Centre in Sex, Health
and Society, Melbourne, Victoria, Australia; **Victorian Aboriginal
Community Controlled Health Organisation, Collingwood, Victoria,
Australia; ††Aboriginal Medical Services Alliance Northern Territory,
Darwin, Northern Territory, Australia; ‡‡Kirby Institute, University of
New South Wales, Kensington, New South Wales, Australia; and
Sydney Sexual Health Centre, Sydney, New South Wales, Australia.
Acknowledgments: We acknowledge each State and Territory Health
Department for their in-kind and cash contributions to this project.
The project was coordinated by National Aboriginal Community Controlled
Health Organisation and the State and Territory Based Affiliate
organizations, which agreed to participate and be a strategic partner in
the research. Particular thanks to the survey coordinators based within
these organizations who were responsible for the coordination of logistics
and data collection in their respective jurisdiction: Mark Saunders,
Katherine Dann, Rekisha Eades, Hayley Mathews, Kassandra Graham,
Lucy Mills, Daniel Mcaulley, Paige Dowd, Sofia Lema, Dina Saulo,
Mathew Fields, Kristie Harrison, Darryl Gardiner, Sallie Cairnduff,
Nerelle Poroch, Kacey Boyd, Neville Atkinson, Clinton Dadleh, Amy
Kerr, John Solar, Sarah Betts, David Scrimgeour, Liz Moore, Dy
Kelaart, David Adams, Andrew Bamblett, Peter Waples-Crowe, Kat
Byron Sid Williams, Tony Coburn, Troy Combo, and James Tully Nala
Mansell-McKenna.
This research would not have also been possible without the 3000
Aboriginal and Torres Strait Islander people who participated in the
survey. Thank you!
We thank Andrew Nakhla, Imogen Green, and Dr Clint Arizmendi, who
have all provided support at different time points for this project. We
thank Peter Hull of the Centre for Social Research in Health for his
assistance in establishing and supporting the programming of the
personal digital assistants.
Finally, we express our sincere thanks to the late Professor Anthony Smith,
who was critical in shaping the questionnaire and answering many of
our questions in the development of this project. He was instrumental
in establishing this survey, and we express sincere thanks for his efforts.
This project was funded by the Australian Research Council Linkage Grant
No. LP0991274.
Correspondence: James Ward, BA, South Australian Health and Medical
Research Institute, PO Box 11060, Adelaide, SA 5001, Australia. E-mail:
james.ward@sahmri.com.
Received for publication September 5, 2015, and accepted November
27, 2015.
DOI: 10.1097/OLQ.0000000000000417
Copyright © 2016 American Sexually Transmitted Diseases Association
All rights reserved.
ORIGINAL STUDY
Sexually Transmitted Diseases •Volume 43, Number 3, March 2016 177
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

testing patterns and rates. It can be difficult to determine whether
STI notification data are a true reflection of the burden of disease
within communities, rather than an indication of who is being
tested. However, recent clinic-based studies have been undertaken
to determine testing rates, prevalence, and incidence of STIs, par-
ticularly in remote settings, and confirmed the highly elevated
rates of STIs in comparison to nonindigenous young Austra-
lians.
8,9
These studies have further shown testing rates to be higher
in Aboriginal women than men, probably related to more regular
health service attendance providing more opportunities for testing
in women.
10
There remains a gap in that no community-based data col-
lection has ever been reported on STI testing and diagnoses in a
sample of young Aboriginal people. We therefore analyzed data
on self-reported STI testing and diagnoses and their correlates,
using data from the first national survey of sexual health and
blood-borne viral infections in this population.
METHODS
The GOANNA study has been described in detail else-
where.
11
In brief, we used convenience sampling at 40 Aboriginal
community events across Australia between 2011 and 2013 to ad-
minister self-completed questionnaires to Aboriginal people aged
16 to 29 years. Most events were either 1- or 2-day community
events comprising cultural celebrations (18/40), sports carnivals
(15/40), annual regional show days/weekends (5/40), or Aborigi-
nal community health events (2/40).
11
Data were collected via self-administered surveys using
hand-held personal digital assistants (PDAs) or hand-held com-
puters that participants completed themselves. Questionnaires in-
cluded data on (i) demographics, (ii) participants' knowledge of
STIs, (iii) sexual and drug-taking behavior, and (iv) health service
access, including experience with testing and diagnosis for the fol-
lowing STIs—chlamydia, gonorrhea, syphilis, or trichomonas—
chosen because they are the most commonly notified STIs preva-
lent among this population. In this last category, we collected infor-
mation regarding where the test/diagnosis was done: an Aboriginal
medical service, local doctor at a general practice clinic, or at a
family planning clinic/sexual health clinic.
Finally, we asked participants what they considered to be
the single best way for a person to get help for an STI, with possi-
ble responses being one of several categories of clinical services
or friends/family.
More than 96% of surveys were completed by participants.
No surveys were excluded from analysis irrespective of the com-
pleted status of the survey. Around 8% of participants refused to
complete the survey. Refusals were defined as not willing to com-
plete the survey after survey collectors had explained the study to
the participant. Survey collectors collected basic information on
the number of refusals during set periods at each event to gauge
an understanding of the proportion of refusals overall for the study.
The PDAs enabled us to monitor data quality after each event in-
cluding the completeness status of the surveys.
The questionnaire took on average 8 minutes (range,
7–13 minutes), because of the inbuilt auto-skip functions
within PDAs.
Statistical Analyses
Descriptive statistics were used to summarize the character-
istics of the study population, overall and by sex. The χ
2
test was
used to compare these factors between women and men. The pri-
mary outcome variable was self-reported history of any STI diag-
nosis (chlamydia,gonorrhea, syphilis, or trichomonas). Univariate
logistic regression models were used to examine the associations
between possible risk factors and self-reported history of any
STI among participants who reported ever having had vaginal or
anal sex and who reported STI testing in the past. Multivariate
models were created using the forward stepwise approach manu-
ally; all variables found to be statistically significant (P< 0.1) in
univariate analyses were used in the forward stepwise methods.
Covariates were entered into the multivariate model if they had
P< 0.10 in the univariate analysis. The final model was identified
using a forward stepwise approach and included statistically sig-
nificant covariates. Unadjusted and adjusted prevalence ratios
(PRs) and their 95% confidence intervals (CI) are presented.
All analyses were conducted using STATA software version
12.0 (Stata Corporation, College Station, TX).
Ethics
Ethics approval for the study was received from Aboriginal
Human Research Ethics Committees in relevant jurisdictions
and the UNSW and La Trobe University Human Research Ethics
Committees.
RESULTS
Of 2877 participants in the GOANNA study, 2320 reported
ever having had vaginal or anal sex. Of these, most women (60%)
reported 1 or 2 sexual partners in the previous year compared with
56% of men who reported 3 or more partners (P< 0.001). Com-
pared with women, a higher proportion of men reported their last
sexual partner as someone they had just met (41% vs. 33%;
P< 0.001). Around a half of women's and men's last sexual partner
was someone who identified as Aboriginal. A higher proportion of
men than women at last sex reported using a condom (54% vs.
43%; P< 0.001) and being drunk or high (33% vs. 21%;
P< 0.001; Table 1).
STI Testing and Diagnosis Among Sexually
Active Participants
Of the participants who had ever had sex, 68% (n = 1589)
reported ever having had an STI test, and within this population,
the proportion who self-reported a positive diagnosis was 25%
(n = 391) comprising 26% of women and 22% of men
(P= 0.073). The most common STI diagnosis reported by women
and men, respectively, was chlamydia (16% vs. 11%), gonorrhea
(2% vs. 3%), syphilis (<2%), and trichomonas (<1%). More than
half (51%) of those who had been tested for an STI reported being
single and less than a half of participants(48%) reported their sex-
ual debut before the age of 16 years. Among people who reported
ever being tested for an STI, 50% reported that their last STI test
was done at an Aboriginal Medical Service, 30% at a private gen-
eral practice clinic, and 8% at family planning or sexual health
clinics (Fig. 1). No differences in place of testing were observed
between women and men. More than half of all participants
(59%) felt that Aboriginal medical services were the best place
to have an STI test, followed by sexual health/family planning
clinics (24%) and general practice clinics (15%; Fig. 2).
Correlates of Self-Reported STI Diagnosis
Among Women
Table 2 presents the results of univariate and multivariate
logistic regression analyses for the 1589 participants who reported
both having had sex and ever having an STI test.In univariate anal-
yses, for women the following factors were significantly associ-
ated with a past STI diagnosis: being single not finishing high
school, sexual debut before the age of 16 years, having 3 or more
sexual partners in the past 12 months, ever having had oral sex,
Ward et al.
178 Sexually Transmitted Diseases •Volume 43, Number 3, March 2016
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

TABLE 1. Demographic Characteristics and Selected Risk Behaviors of Sexually Active Participants Who Have Ever Tested for an STI by Sex
Female (n = 1381; 60%) Male (n = 939; 40%)
Not Tested Tested PNot Tested Tested P
Region 0.119 0.149
Urban 197 (55.81) 525 (53.25) 205 (57.10) 292 (53.68)
Regional 139 (39.38) 381 (38.64) 134 (37.33) 203 (37.32)
Remote 17 (4.82) 80 (8.11) 20 (5.57) 49 (9.01)
Age groups, y <0.001 <0.001
16–19 201 (55.22) 275 (27.04) 230 (62.67) 165 (28.85)
20–24 92 (25.27) 383 (37.66) 93 (25.34) 215 (37.59)
25–29 71 (19.51) 359 (35.30) 44 (11.99) 192 (33.57)
Relationship status 0.262 0.012
Living with a partner or in a relationship 169 (46.43) 507 (49.85) 145 (39.51) 274 (47.90)
Single 195 (53.57) 510 (50.15) 222 (60.49) 298 (52.10)
Education level 0.674 0.887
High school or more 175 (48.08) 502 (49.35) 167 (45.50) 263 (45.98)
Less than high school 189 (51.92) 515 (50.64) 200 (54.50) 309 (54.02)
Sexual identity 0.312 <0.001
Straight/Heterosexual 356 (97.80) 984 (96.76) 357 (97.28) 515 (90.03)
Gay/Bisexual 8 (2.20) 33 (3.24) 10 (2.72) 57 (9.97)
Prison ever 0.689 <0.001
No 348 (95.60) 967 (95.08) 338 (92.10) 477 (83.39)
Yes 16 (4.40) 50 (4.92) 29 (7.90) 95 (16.61)
Age at sexual debut, y 0.189 0.232
16+ 228 (62.64) 597 (58.70) 164 (44.69) 233 (40.73)
< 16 136 (37.36) 420 (41.30) 203 (55.31) 339 (59.27)
Alcohol intake in the past 12 mo 0.888 0.424
< Once a month 157 (43.13) 443 (43.56) 141 (38.42) 205 (35.84)
At least 1+ mo 207 (56.87) 574 (56.44) 226 (61.58) 367 (64.16)
Cannabis use in the previous 12 mo <0.001 <0.001
No 271 (74.45) 654 (64.31) 264 (71.93) 331 (57.87)
Yes 93 (25.55) 363 (35.69) 103 (28.07) 241 (42.13)
Meth/Amphetamine use in the previous 12 mo 0.057 0.001
No 343 (94.23) 926 (91.05) 334 (91.01) 475 (83.04)
Yes 21 (5.77) 91 (8.95) 33 (8.99) 97 (16.96)
Ecstasy use in the previous 12 mo 0.034 <0.001
No 341 (93.68) 915 (89.97) 330 (89.92) 455 (79.55)
Yes 23 (6.32) 102 (10.03) 37 (10.08) 117 (20.45)
Injected drugs in the previous 12 mo 0.302 <0.001
No 359 (98.63) 994 (97.74) 358 (97.55) 526 (91.96)
Yes 5 (1.37) 23 (2.26) 9 (2.45) 46 (8.04)
No. sexual partners in the past 12 mo 0.162 0.002
1 229 (62.91) 606 (59.59) 183 (49.86) 248 (43.36)
2 71 (19.51) 184 (18.09) 65 (17.71) 75 (13.11)
≥3 64 (17.58) 227 (22.32) 119 (32.43) 249 (43.53)
Last person you had sex with was 0.873 0.025
Current girlfriend/boyfriend 242 (66.48) 682 (67.06) 202 (55.04) 339 (59.27)
Someone just met 29 (7.97) 87 (8.55) 61 (16.62) 114 (19.93)
Other 93 (25.55) 248 (24.39) 104 (28.34) 119 (20.80)
Last person you had with was 0.336 0.336
Other than ATSI 185 (50.82) 487 (47.89) 185 (50.82) 487 (47.89)
ATSI 179 (49.18) 530 (52.11) 179 (49.18) 530 (52.11)
Last time you had sex
Did you use condom? <0.001 0.003
Yes 195 (53.57) 436 (42.87) 123 (33.51) 231 (40.38)
No 123 (33.79) 497 (48.87) 203 (55.31) 309 (54.02)
Missing 46 (12.64) 84 (8.26) 41 (11.17) 32 (5.49)
Were you drunk/high? 0.537 0.049
Yes 70 (19.23) 211 (20.75) 268 (73.02) 383 (66.96)
No 294 (80.77) 806 (79.25) 99 (26.98) 189 (33.03)
Ever tested for HIV <0.001 <0.001
No 327 (89.94) 250 (24.58) 327 (89.10) 114 (19.93)
Yes 37 (10.16) 767 (75.42) 40 (10.90) 458 (80.07)
Ever tested for HCV <0.001 <0.001
No 335 (92.03) 391 (38.45) 329 (89.65) 203 (35.49)
Yes 29 (7.07) 696 (61.55) 38 (10.35) 369 (64.51)
ATSI indicates person of Aboriginal and or Torres Strait Islander descent; HCV, hepatitis C virus.
STI Among Young Aboriginal People
Sexually Transmitted Diseases •Volume 43, Number 3, March 2016 179
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

inconsistent condom use in the past 12 months and at last sex,
having sex with someone that they had just met,last sexual partner
an Aboriginal person, being drunk or high at last sex, and using
meth/amphetamines, ecstasy, or injecting drugs in the previous
12 months (Table 2).
At the multivariate level, the following factors remained
significant correlates of a past STI diagnosis: sexual debut before
the age of 16 years (PR, 1.53; 95% CI, 1.16–2.81, P< 0.005), hav-
ing ever had oral sex (PR, 2.66; 95% CI, 1.47–4.82, P<0.001),
inconsistent condom use in the past 12 months and not using a
condom at last sex, having sex with someone that they had just
met, last sexual partner being Aboriginal, and being drunk or high
at last sex were all independently associated with a past STI diag-
nosis. Among the drugs used in past 12 months, only using ecstasy
(PR, 1.81; 95% CI, 1.16–2.81, P< 0.009) remained as a signifi-
cant factor in the multivariate model (Table 2).
Correlates of Self-Reported STI Diagnosis
Among Men
Among men in univariate analyses, being 25 to 29 years of
age, identifying as gay or bisexual, having 2 or more partners in
the past year, inconsistent condom use in the past 12 months,
and not using a condom at last sex correlated with a past STI diag-
nosis. Among men who reported being drunk or high at last sex,
and who had used cannabis, meth/amphetamines, ecstasy, or who
had injected drugs in the past 12 months, associations with a past
STI diagnosis remained significant in the univariate model (Table 2).
At the multivariate level, among men, older age (25–29 years)
compared with 16 to 19 years of age, being gay or bisexual (PR,
1.64; 95% CI, 1.15–2.32, P< 0.005), having 2 or more partners
in the past year (PR, 1.60; 95% CI, 1.10–2.53, P< 0.047), having
last partner being an Aboriginal person (PR, 1.31; 95% CI,
0.92–1.87; P< 0.135), and using ecstasy in the last 12 months
(PR, 2.02; 95% CI, 1.50–2.72, P< 0.001) were all independently
associated with previous STI diagnoses among men (Table 2).
DISCUSSION
In this community-recruited sample of Aboriginal people
aged 16 to 29 years,
11
around 68% those who had ever had sex re-
ported ever having an STI test, and of these 25% reported ever
having a past STI diagnosis. These data are the first to report on
correlates associated with STI diagnoses in a community sample
of young Aboriginal people and show multiple independent risk
factors as well as differences between women and men.
Among women, early sexual debut, ever having oral sex,
inconsistent condom use, having sex with a casual partner, having
last partner being Aboriginal, being drunk or high at last sex, and
ecstasy use in the last 12 months were independent factors associ-
ated with an STI diagnosis. Among men, independent factors asso-
ciated with an STI diagnosis were sexual identity as gay or bisexual,
having 2 or more partners in the past 12 months, having last sexual
partner being Aboriginal, not using a condom at last sex, and using
ecstasy and injecting drugs in the previous 12 months.
These data provide important information for clinicians
working in Aboriginal health and when offering testing for STIs.
Current clinical guidelines recommend doctors working with young
people provide a nonjudgmental environment that will maximize
patient disclosures on sexual matters.
7
Given that some of these risk
factors are also indicated in HIV transmission, it is important to
screen for these risk factors to avoid ongoing transmission and
HIV outbreaks in communities which to date has been avoided.
Similar to other studies, our study has shown higher rates of
STI diagnosis among women than men. A study conducted in Ab-
original Community Controlled Health Services (ACCHSs) in ur-
ban and regional areas used electronic patient management
systems to extract data to monitor annual STI and blood-borne vi-
rus (BBV) testing among Aboriginal people aged 15 to 54 years,
and found the mean number of annual visits was 7 for women
and 5 for men. Annual chlamydia testing rates for women and
men were 22% and 10%, respectively,
10
with positivity rates of
9% and 14%. In another study in 68 remote Aboriginal communi-
ties in northern Australia, women comprised 60% of all clients at-
tending primary care and annual testing rates were greater than in
men (24% vs. 15%). Retesting rates within 5 to 15 months were
also greater among women (41%) than among men (27%).
12
Given the high prevalence of STIs in many Aboriginal com-
munities,
13
it is important to identify strategies that not only better
engage men in primary care services but also ensure STI testing is
carried out at rates at least comparable to those in women.
The high proportions of people who reported their last sex-
ual partner as a casual partner are of concern, with more than 40%
and 30% of males and females, respectively, reporting their last
sexual partner as someone they had just met. In other Australian
studies, the prevalence of this behavior is similar to other groups
in Australia. In the most recent survey of Australian school stu-
dents in Years 10, 11, and 12, nearly 40% of sexually active partic-
ipants reported having intercourse with more than 1 person in the
past year and 23% reported having intercoursewith 3 or more peo-
ple in the sameperiod,
14
and among gay men, just less than a quar-
ter reported having sex with casual partners in the previous
FIGURE 1. Type of health service where last STI test was
taken by gender.
FIGURE 2. Type of health service to access for STI testing by gender.
Ward et al.
180 Sexually Transmitted Diseases •Volume 43, Number 3, March 2016
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

TABLE 2. Univariate and Multivariate PRs Among Sexually Active Participants, by Sex, of the GOANNA Survey Who Had Been Previously Tested for STIs
Factors
Female (n = 1017) Male (n = 572)
Univariate Analysis Multivariate Analysis Univariate Analysis Multivariate Analysis
PR (95% CI) PPR (95% CI) PPR (95% CI) PPR (95% CI) P
Age (quartiles)
1st quartile (<18 y) 224 (14.10) 1 —1—
2nd quartile (18–19 y) 216 (13.59) 0.72 (0.45–1.14) 0.165 —1.24 (0.63–2.43) 0.574 —
3rd quartile (20–24 y) 598 (37.63) 1.10 (0.77–1.55) 0.624 —1.20 (0.70–2.07) 0.504 —
4th quartile (25–29 y) 551 (34.68) 1.21 (0.86–1.71) 0.280 —1.95 (1.17–3.26) 0.011 —
Marital status
Living with partner/in relationship/other 781 (49.15) 1 —— 1—
Single 808 (50.85) 1.30 (1.05–1.60) 0.015 —0.89 (0.65–1.21) 0.462 —
Education level
High school or more 765 (48.14) 1 —— 1—
Less than high school 824 (51.86) 1.23 (1.00–1.52) 0.050 ——1.03 (0.76–1.40) 0.850 —
Age at sexual debut, y
16+ 830 (52.23) 1 1 1 —
< 16 759 (47.77) 1.52 (1.24–1.87) <0.001 1.32 (1.08–1.63) 0.008 1.12 (0.81–1.54) 0.496 —
Sexual identity
Straight/heterosexual 1421 (89.43) 1 —— 11
Gay/Bisexual 168 (10.57) 1.04 (0.59–1.85) 0.871 ——2.02 (1.41–2.89) <0.001 1.64 (1.15–2.32) 0.005
No. sexual partners in the past 12 mo
1 854 (53.74) 1 —11
2 259 (16.30) 1.24 (0.94–1.64) 0.122 ——1.53 (0.95–2.47) 0.081 1.60 (1.01–2.53) 0.047
≥3 476 (29.96) 1.56 (1.24–1.97) <0.001 ——1.60 (1.13–2.27) 0.008 1.49 (1.07–2.07) 0.0190
Ever had oral sex
No 147 (9.25) 1 1 1 —
Yes 1445 (90.75) 2.40 (1.45–3.97) <0.001 2.17 (1.31–3.58) 0.003 0.99 (0.48–2.04) 0.980 —
Condom use in the past 12 mo
Always 505 (31.78) 1 1 1 —
Not always 1084 (68.22) 1.75 (1.33–2.29) <0.001 1.70 (1.30–2.22) <0.001 1.47 (1.03–2.10) 0.034 —
Last person you had sex with was
Current girlfriend/boyfriend 1021 (64.25) 1 1 1 —
Someone just met/other 568 (35.75) 1.47 (1.19–1.80) <0.001 1.57 (1.27–1.93) <0.001 1.20 (0.88–1.64) 0.243 —
Nonindigenous 548 (34.49) 1 1 1 1
Aboriginal 812 (51.10) 1.40 (1.10–1.78) 0.007 1.44 (1.14–1.81) 0.002 1.22 (0.84–1.77) 0.293 1.31 (0.92–1.87) 0.135
Don't know/not sure 229 (14.41) 1.16 (0.82–1.66) 0.396 0.91 (0.63–1.31) 0.607 1.87 (1.24–2.86) 0.003 1.83 (1.23–2.73) 0.003
Continued next page
STI Among Young Aboriginal People
Sexually Transmitted Diseases •Volume 43, Number 3, March 2016 181
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

TABLE 2. (Continued)
Factors
Female (n = 1017) Male (n = 572)
Univariate Analysis Multivariate Analysis Univariate Analysis Multivariate Analysis
PR (95% CI) PPR (95% CI) PPR (95% CI) PPR (95% CI) P
Last time you had sex
Did you have a condom?
Yes 765 (48.14) 1 —— 1—
No 824 (51.85) 1.40 (1.13–1.74) 0.002 ——1.22 (0.90–1.66) 0.203 —
Did you use condom?
Yes 745 (46.88) 1 —1—
No 844 (53.12) 1.56 (1.25–1.96) <0.001 —1.38 (1.01–1.88) 0.0424 —
Were you drunk/high?
No 1189 (74.83) 1 —— 1—
Yes 400 (25.17) 1.54 (1.23–1.91) <0.001 ——1.57 (1.16–2.13) 0.004 —
Used cannabis in the past 12 mo
No 978 (61.55) 1 —— 1—
Yes 611 (38.45) 1.30 (1.06–1.60) 0.014 ——1.61 (1.18–2.19) 0.003 —
Used meth/amphetamine in the past 12 mo
No 1395 (87.79) 1 —1—
Yes 194 (12.21) 1.55 (1.17–2.06) 0.003 —2.20 (1.61–2.99) <0.001 —
Used ecstasy in the past 12 mo
No 1360 (85.59) 1 1 1 1
Yes 229 (14.41) 1.79 (1.39–2.29) <0.001 1.40 (1.10–1.78) 0.006 2.31 (1.72–3.12) <0.001 2.02 (1.50–2.72) <0.001
Injected drugs in the past 12 mo
No 1520 (95.66) 1 —1—
Yes 69 (4.34) 2.23 (1.53–3.24) <0.001 —2.97 (2.18–4.05) <0.001 —
Ever tested for HIV
No 365 (22.91) 1 —1—
Yes 1225 (77.09) 1.22 (0.94–1.57) 0.137 —0.83 (0.58–1.19) 0.319 —
STIs include chlamydia, gonorrhea syphilis, and trichomonas.
Ward et al.
182 Sexually Transmitted Diseases •Volume 43, Number 3, March 2016
Copyright © 2016 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

6months
15
and another28% reported both casual and regular part-
ners in the past 12 months. These data support the need for in-
creased STI awareness among this aged population.
Early sexual debut was an important indicator for a previ-
ous STI diagnosis in this population. Early sexual debut has been
consistently associated with more recent, lifetime, and concurrent
sexual partners as well as engagement in a wider range of sexual
practices.
16–18
The median age of sexual debut in this study and
of other young Australians is less than 16 years.
19,20
Arecent
study of 189 sexually active Aboriginal young people in Western
Australia also reported a similar age of sexual debut (15 years
for males and 16.5 for females, with 30% reported having had
sex before the age of 14 years).
21
In light of these data, earlier
school-based education that is culturally appropriate about healthy
sexual lives should be a priority. In addition, guidelines for case
detection and management of STIs in sexually active people youn-
ger than 16 years should be reviewed and strengthened. Current
guidelines restrict STI testing to people identified as “at risk,”or
are restricted to the population older than 15 years.
6,7
Given the
risk of developing pelvic inflammatory disease
22
and infertility
in undiagnosed cases of STI,
23
considerations should be given to
amending current clinical guidelines to ask young people at an ear-
lier age about their sexual history and associated risk behaviors
such as alcohol and other drug use which have a known correlation
with sexual risk taking.
Among those who reported that they were “drunk or high”
the last time they had sex, a significant association was found with
a past ever self-reported STI diagnosis. Recognizing that the last
time they had sex was not necessarily associated with a past STI
diagnosis, we believe that this group are characterized as a high-
risk group, with multiple risk factors contributing to potential
STI diagnosis. For example, those who said they were “drunk or
high at last sex”weremore likely to have reported a higher number
of sexual partners in the last year (71% vs. 38%, P< 0.001), were
also more likely to use illicit drugs (70% vs. 37%, P< 0.001), and
were more likely to use alcohol on a regular basis, for example, 7+
drinks on a regular basis (62% vs. 37%, P< 0.001).
Alcohol and other drug use have previously been reported
as risk factors for inconsistent condom use and other sexual risk
behaviors, STIs.
21,24,25
This concurs with our study, in particular
the use of ecstasy and injecting drugs in the last 12 months were
important factors associated with a self-reported STI diagnosis,
as was a pattern of risky alcohol consumption. These data under-
score the need for more comprehensive approaches to address
drug and alcohol use among young Aboriginal people. These as-
sociations are particularly important given the overrepresentation
of Aboriginal people in national drug and alcohol statistics in
Australia.
26
For example, the 2013 National Drug Strategy House-
hold Survey reported that Aboriginal people were 1.6 times more
likely to use any illicit drug in the last 12 months, 1.9 times more
likely to use cannabis, and 1.6 times more likely to use (meth) am-
phetamines compared with nonindigenous people.
26
As expected, men who identified as gay or bisexual were
found to be more likely to have reported a previous STI diagnosis
than other men. Men who sex with men (MSM) are identified as a
priority population group in Australia for HIV and other STIs.
Other studies have confirmed high-risk sexual and injecting drug
use behaviors among Aboriginal MSM,
27,28
and this study fur-
thers the understanding of this population and the need for im-
proving targeted interventions. A meta-analysis of behavioral
interventions among MSM has shown that effective interventions
can result in a significant decrease in unprotected anal intercourse
(odds ratio [OR], 0.77; 95% CI, 0.65–0.92) and number of sexual
partners (OR, 0.85; 95% CI, 0.61–0.94) and with a significant in-
crease in condom use during anal intercourse (OR, 1.61; 95% CI,
1.16–2.22).
28
The main types of interventions that have been suc-
cessful in reducing risky sexual behavior were based on theoretic
models and included interpersonal skills training, incorporated
several delivery methods, and were delivered over multiple ses-
sions spanning a minimum of 3 weeks.
29
However, a limitation
of these studies is that significant reductions in STI prevalence
or incidence have not been achieved because of these interven-
tions. Currently, very little of this type of intervention occurs
among Aboriginal MSM in Australia. Introducing these types of
interventions can provide an efficacious means of reducing STI
and HIV risk, especially if coupled with incidence or prevalence
data to assist in the effectiveness of the trialed interventions.
Our study confirmed that ACCHSs are the preferred health
service for most and place where most STI testing and diagnosis
occur among young Aboriginal people. Aboriginal Community
Controlled Health Services are controlled by a local, representa-
tive Aboriginal board and are governed to be responsive to the
needs of their community and plan delivery to suit these needs.
30
This study also confirms findings from the pilot study for this
study that showed young Aboriginal peoples' preference for test-
ing in ACCHSs and for seeking advice for STIs and other related
health issues.
31,32
Aboriginal Community Controlled Health Ser-
vices often focus on preventative health, early intervention, and
improving access to services. Strengthening STI prevention issues
within ACCHS should occur to deal with the burden of risk and
disease that exists within young Aboriginal people.
This study has some methodological limitations. First, the
representativeness of participants recruited from community
events is unknown because those who attend these events may
be different in some ways from those who do not, including in
the way they are connected to their communities, their knowledge
about STI and BBV, and use of health services compared with
other Aboriginal young people. However, we deliberately sampled
from community events rather than from clients attending Aborig-
inal health services to reduce bias in our sample of young people.
We are not aware of other means of recruiting a large, diverse pop-
ulation of young Aboriginal people, as strategies based on house-
hold or telephone recruiting will be likely to underrepresent
Aboriginal people. Second, the data are self-reported which can
lead to underascertainment of specific behaviors, particularly
those that are stigmatized. Conversely, there may be overreporting
of characteristics that participants view as socially desirable. How-
ever, the proportion of participants who self-reported ever having
an STI diagnosis is consistent with available epidemiological evi-
dence on STI positivity in the population. For example, a range of
studies reported between 8% and 15% annual positivity on chla-
mydia testing and between 1% and 9% for gonorrhea.
11,12
In conclusion, this study has important implications for
health programs and strategies, particularly in primary care for
the control of STIs. Much work needs to be done to ensure all sex-
ually active young people are being tested for STIs as well as
screened for other sexual health and BBV risk behavior each year
as per Australian guidelines. Screening among Aboriginal MSM
should be done so in accordance with screening guidelines
in Australia.
7,33
This study suggests that community-based surveys of sen-
sitive issues are possible with young Aboriginal people. It also
provides an important baseline to guide evaluation of the impact
of future sexual health programs and clinical care.
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184 Sexually Transmitted Diseases •Volume 43, Number 3, March 2016
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