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Abstract:
Objective:  To increase available information about rates of sexually transmitted infections (STI's), Pap smear abnormalities and pregnancy outcomes among homeless and at risk young people.
Method:   Retrospective review, covering the period August 1991 to June 1996, of casenotes of 559 clients aged 12 to 25 years of a primary health care clinic targeted at homeless or at risk young people.
Setting:  Brisbane Youth Service in inner-city Brisbane.
Results:   Results from fully or partly screened clients (181/559 = 32.4%) suggest increased prevalence of several infections, and included two cases of syphilis (2/123 clients = 1.6%), one case of past exposure to hepatitis B virus (1/29 clients = 3.4%), and 11 cases testing positive for genital Chlamydia trachomatis (11/82 clients = 13.4%).  Reported Pap smear changes were common (30/72 smears = 41.7%), including inflammation (21/72 = 29.2%), human papilloma virus infection (6/72 = 8.3%), atypia (5/72 = 6.9%), and CIN 1 (2/72 = 2.8%).   Over 17% of female clients were seen when pregnant, and the rate of termination of pregnancy was relatively low.  The results suggest that this group may have an increased rate of certain STI's, Pap smear abnormalities and pregnancies requiring antenatal care.  Further studies are needed.

Introduction:
Brisbane Youth Service (B.Y.S.) operates a primary health care clinic staffed by a full time nurse practitioner, with a general practitioner attending two sessions per week.  The clinic is aimed at 12 to 25 year old young people who are homeless or at risk of becoming so.  This group includes young people sleeping on the streets, in squats or temporary accommodation, and those still living with parents or guardians but lacking the personal supports normally provided by a family.  There is little specific data published on the sexual health status of this group.  This paper reviews B.Y.S. casenotes to provide information on rates of sexually transmitted infections (exposure may also occur via intravenous drug use), Pap smear abnormalities and pregnancy outcomes.

Methods:
A retrospective review of casenotes covering the period from the clinic's inception in August 1991 up until 30th June 1996, was performed.  A group of 559 clients (see Table 1) were identified from their casenotes as homeless or at risk and aged between 12 and 25 years inclusive.

The casenotes were reviewed for:  the results of STI testing by serology for human immunodeficiency virus (HIV), syphilis and hepatitis B virus, and genital tract swabs for Chlamydia trachomatis, Neisseria gonorrhoeae and other organisms;  the results of Pap smears; and pregnancy outcomes.  These were the outcomes of pregnancies which had been recorded in the clinic files (i.e. the woman was known to be pregnant at the time of a clinic consultation).  The review only included investigation results which had been ordered through the clinic and were recorded in casenotes.

Results:
The results of STI testing by serology for HIV, syphilis, and hepatitis B virus are detailed in Table 2.  The results of genital tract swabs for C. trachomatis, N. gonorrhoeae and other organisms are found in Table 3.  Pap smear results are given according to age in Table 4.

The clinic provided care during 58 pregnancies in 52 women (52/293 = 17.7%).  There were no multiple pregnancies but some women were pregnant more than once.  Table 5 shows pregnancy outcomes within age groups.

Discussion:
These results need to be interpreted in the context of methodological problems.  Casenotes were only generated during formal consultations in the clinic.  Many clients were seen informally and/or outside the clinic, and it is unknown how this group compares with those seen in the clinic.  Of the 559 clients whose casenotes met the criteria for inclusion in this review, only 181 (181/559 = 32.4%) had any or all of the above serological, microbiological or cytological investigations performed.  Universal screening of all 559 clients was not possible for many reasons including the following:

First, some clients were not yet sexually active.  Second, it was not uncommon for clients to be impaired by alcohol or drugs when seen and hence unable to give informed consent for testing.  Third, 41.1% of the clients were seen in the clinic on one occasion only.  If they presented with an unrelated health crisis this allowed little opportunity to explore sexual health issues.  Fourth, many clients did not want to discuss sexual issues whether due to embarrassment, denial or lack of rapport despite appropriate counselling.  Fifth, even clients prepared to discuss sexual health issues often declined testing.  Concerns regarding discomfort during sample collection or fear of a positive result were commonly expressed, and some clients may have believed that testing could allow authorities to trace them.

Also, only investigations ordered through the clinic have been included in these results.  This means conditions diagnosed clinically and/or referred without investigation are not included.  For instance, this data could not include instances of presumptive diagnoses of C. trachomatis in males who refused investigation, and recently a 22 year old Caucasian woman with a primary chancre was referred prior to investigation to a specialised sexual health clinic.  In addition, the results do not include conditions already adequately confirmed and not in need of retesting, such as three HIV positive clients within the study group.

One hundred and thirty clients (130/559 = 23.3%) were tested for HIV antibodies.  There were no positive results, although some high risk clients declined testing.  The experience in the clinic suggested there may be a group with high risk lifestyles disinterested in being tested, and a more concerned group who place themselves at little risk but want testing for reassurance.  Three clients were known to have been previously confirmed HIV positive.  If these three were in fact the only HIV positive people in the review group then this suggests a prevalence of 0.5% (3/559).

Two clients had positive serology for syphilis.  One was an asymptomatic 15 year old Aboriginal female (TPHA +; FTA-ABS +; RPR 1:256), who was treated, contact-traced and reviewed with the co-operation of a local Aboriginal Medical Service.  The second case was a 21 year old heterosexual Caucasian male (TPHA +; FTA-ABS +; RPR -) with no past history suggestive of Treponemal infection or intramuscular penicillin.  A presumptive diagnosis of late congenital syphilis was made.  The client moved interstate but treatment with benzathine penicillin and follow-up were arranged.

One hundred and forty-five clients (145/559 = 25.9%) were tested for at least one hepatitis B virus marker (HBsAg tested in 94 clients; HBcAb 29; HBsAb 124).  No hepatitis B carriers were detected (0/94).  One client was core antibody positive indicating past infection (1/29 = 3.4%).  This was a 20 year old male injecting drug user who also tested positive for hepatitis C.  Surface antibodies indicating immunity were present in nearly half the clients tested for them (57/124 = 46.0%).  Twenty-four clients with surface antibodies had not been given hepatitis B immunisations at the clinic.  It is believed that the majority of these would have had immunisation elsewhere, for instance youth detention centres and prisons, rather than experienced past infection.

Ninety-three endocervical Chlamydia trachomatis swabs, mostly antigen tests, were taken from 69 women (69/293 = 23.5%).  Ten women tested positive (10/69 = 14.5%).  Fourteen urethral C. trachomatis swabs were taken from 13 males (13/259 = 5.0%), with one antigen test positive (1/13 = 7.7%).  This compares with a prevalence of C. trachomatis estimated to be less than 2% in 1995 at the Sydney Sexual Health Centre (1).

Endocervical and male urethral swabs detected no cases of gonorrhoea.  The prevalence of vaginal Gardnerella and/or Bacteroides infections was just under 30%, within the reported range of 10 to 45% found in the general female population (2).

Seventy-two Pap smears were performed on 57 women (57/293 = 19.5%).  Reported Pap smear changes were common (30/72 smears = 41.7%), including inflammation (21/72 = 29.2%), human papilloma virus infection (6/72 = 8.3%), atypia (5/72 = 6.9%), and CIN 1 (2/72 = 2.8%).  This compares with reported total rates from a major local pathology laboratory of 2.8% atypical and 0.6% CIN 1 smears (3).  Abnormal Pap smears were found even within the youngest age group, and included an atypical smear in a 13 year old who also tested positive for C. trachomatis.  She had been sexually active since age 10 and unfortunately was lost to follow-up.  Performing investigations which require vaginal penetration of girls under the age of consent without involvement of guardians may raise untested legal questions, but does occasionally appear justifiable.

The casenotes of 52 women recorded that they had been pregnant when seen in the clinic (52/293 = 17.7%).  This suggests that unsafe sex is common.  It has been reported that about 40% of pregnant Australian 15 to 19 year olds have a termination (4), and this compares with a rate of around 20% in women attending the clinic.  This is consistent with previous observations that lower socio-economic groups have reduced rates of termination of pregnancy (5).

Conclusion:
The results of retrospective casenote review suggest that this group may have an increased rate of certain STI's, Pap smear abnormalities and pregnancies requiring antenatal care.  Further studies in this population are needed to examine this.

References:
1.  Donovan B., Management of Genital Chlamydia Infections. Current Therapeutics 1997 vol 38 no5 47-53.
2.  Henahan, Sean, Bacterial Vaginosis: The missing link of pelvic inflammatory disease? Current Therapeutics 1995 vol 36 no6 105-6.
3.  Drs JJ Sullivan, NJ Nicolaides and Partners, Taringa Qld. Cervical Smear Analysis 1/1/96 to 30/6/96.
4.  Robertson Suzanne, Adolescent sexuality: guidelines for GPs. Modern Medicine 1996 vol 39 no6 112-123.
5.  Siedlecky S.,  Adolescent Pregnancy in Australia.  Practice Management. August 1988; 19-32.

Acknowledgements:  Many thanks to Theo van Lieshout, Tracy Schrader and Ann Harrison for their assistance preparing this paper.

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			This page was last updated on 10th February, 2003.
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