Sexual health is at the frontline of the global antimicrobial resistance (AMR) crisis. Sexually transmitted infections (STIs) are some of the most common diseases worldwide.
Clinicians and researchers are raising the alarm about STIs becoming untreatable, with the inappropriate use (overuse, underuse, and misuse) of antibiotics in the community and in sexual health as a major contributing factor.
Without immediate action, we risk losing the ability to treat these common diseases, posing a public health crisis in Australia and globally.
Here are the most critical steps needed to curb AMR in sexual health:
What are STIs, and why should we care?
STIs are a critical global health issue. More than 374 million new STIs are diagnosed globally.
According to Professor Alex Broom, Director of the Sydney Centre for Healthy Societies, Faculty of Arts and Social Sciences, The University of Sydney, STIs are common – one in six Australians will receive a diagnosis of an STI over their lifetime.
According to WHO data there are around 1 million new cases of the four most common treatable STIs in adults aged 15 to 49 – chlamydia, gonorrhoea, syphilis and trichomoniasis – per day. More than 30 pathogens (disease-causing microorganisms) can be transmitted sexually, and a person can have multiple infections at the same time.
STIs can cause severe, long-term and potentially fatal health consequences, including infertility, chronic pelvic pain, ectopic pregnancies, neonatal complications, cancer and increased susceptibility to HIV.
A person can have an STI without any symptoms and be unaware of their infection but can transmit the disease to their sexual partners, and can later develop long-term health outcomes. STIs can also be transmitted from mother to infant during pregnancy or at delivery with potentially adverse consequences for the infant.
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We must shift public and professional attitudes toward a more judicious use of these drugs.
Professor Alex Broome
The challenge of AMR in STI treatment
The risk of AMR increases with more frequent usage of antibiotics. In sexual health, this is particularly relevant for people who are frequently tested for STIs.
Groups with high rates of partner change and lower rates of condom usage are more likely to have more frequent use of antibiotics for STIs.
We are already seeing some STIs that are superbugs
Currently, most microorganisms that cause STIs are treatable, but these bugs are becoming increasingly resistant to antibiotics because of our overuse of these diminishing resources.
According to Professor Catriona Bradshaw, a clinician scientist and Head of Research Translation and Mentorship at the Melbourne Sexual Health Centre, Alfred Health and School of Translational Medicine, Monash University, “Mycoplasma genitalium is an STI that has resulted in untreatable infections thanks to AMR.”
Clinicians globally, including in Australia, are now encountering infections that are resistant to all available antibiotics.
Like Mycoplasma genitalium, gonorrhoea has developed resistance to many drugs over the years. Although it is susceptible to one last antibiotic, ceftriaxone, in most people, we have seen rising levels of reduced susceptibility to ceftriaxone and some high-level resistant strains emerging over the past few years.
“There is now a real emergence of gonorrhoea that is resistant to ceftriaxone in parts of SE Asia, particularly Vietnam and Cambodia – and this is a huge problem for them and obviously a big risk for us in Australia,” Professor Bradshaw says.
We can tackle STI AMR with awareness and education
Experts like Professors Bradshaw and Broom are urging the need for a highly visible, effective, nationwide public awareness campaign to educate Australians about AMR as a national threat. Each year, around one in three Australians (9.8 million people) have at least one antibiotic dispensed.
“We have tended to throw antibiotics around like confetti and are creating bugs that are more difficult if not impossible to treat,” says Professor Broom.
The public needs clear messaging about the costs and benefits of the routine use of antibiotics, including harmful effects on the gut microbiome and the rise of treatment-resistant infections.
In sexual health, the public needs messaging that STIs are becoming untreatable due to rising antibiotic resistance, and we can take steps to change that by using antibiotics more judiciously.
And acknowledging that sometimes, infections may resolve without intervention, saving antibiotics for future scenarios and preventing any collateral damage to the body.
Practicing antimicrobial stewardship in primary care
Healthcare providers must be trained to strike the right balance between appropriate antibiotic use and maintaining high cure rates, also known as “antibiotic stewardship”.
“We must shift public and professional attitudes toward a more judicious use of these drugs. We must understand the potential collateral damage to the gut and oral microbiomes – the message must be that antibiotics cannot be used without other health impacts,” says Professor Broom.
To do this, we need to refine our approach to track not only infection rates but also AMR, the direct consequence of antibiotic use.
Antibiotics should not be prescribed purely based on STI symptoms or potential exposure. Testing should guide treatment decisions, ensuring antibiotics are only used when an infection is confirmed and that it is sensitive to a specific drug.
Every unnecessary, premature, or inappropriate antibiotic prescription for an STI speeds up resistance, making once-reliable treatments ineffective. Healthcare practitioners must balance appropriate use with the need to conserve existing treatment options, and provide effective patient care.
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To stem the tide of resistance, we also need to break down the stigma around sex and STIs.
Professor Catriona Bradshaw
Messaging and consumer engagement
Public health messaging about antibiotic use in sexual health should be carefully crafted to educate without alienating individuals through shame or blame.
To do this, we need to break down the stigmas associated with sexual health and educate the public about the misconceptions about STIs.
The idea that STIs are related to promiscuity is untrue. The public needs messaging to understand that STIs are incredibly common and do not mean that someone has had risky behaviours or has not been monogamous.
“To stem the tide of resistance, we also need to break down the stigma around sex and STIs, challenging cultural taboos to encourage a more open dialogue about the risks involved in enjoying sex,: says Professor Bradshaw.
Addressing self-medicating prophylactic antibiotic use
The overuse, underuse, and misuse of antibiotics in society and sexual health, including antibiotics for the prevention of STIs, exposes beneficial bacteria that reside in the body to antibiotics, which contributes to antibiotic resistance.
Rather than relying on indiscriminate antibiotic use, we need a system that prioritises safety through evidence-based prevention and treatment strategies.
Without a clear national awareness strategy, people may continue to self-medicate as a misguided safety measure, unknowingly or inadvertently fuelling AMR.
Promote community-driven approaches
AMR is accelerated by the overuse of antibiotics. In sexual health, this is particularly relevant for people who are being given multiple antibiotics a year due to frequent STI screening and treatment.
Groups with high rates of partner change or lower rates of condom usage are more likely to have higher usage of antibiotics for STIs.
Community-driven approaches to negotiating safety and risk in sexual practices can help people navigate the complex landscape of sexual health more effectively. Safe sex messaging, driven by community practices and care, is likely to be the most effective approach.
The battle against AMR in sexual health demands urgent attention from all of us to conserve the antibiotics we have before it’s too late.
Melissa Waine swapped Petri dishes for prose, transforming her love of science into compelling health and medical writing. She is passionate about antimicrobial resistance (AMR) and communicating the looming threat it will pose if we exhaust our supply of effective treatments.
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