Mpox and emerging STIs: the Australian general practice approach

Sexual health in Australian general practice has changed substantially since 2022. Mpox joined an already crowded landscape of evolving threats — antibiotic-resistant gonorrhoea, rising Mycoplasma genitalium treatment failures, a syphilis resurgence reaching congenital cases, and emerging prevention tools including Doxy-PEP. The GP’s role is triage, testing, notifiable disease reporting, vaccination, PrEP prescribing, and culturally safe non-judgemental care. This article covers the essential clinical framework.

A. Core clinical — the AU general-practice framework

Mpox — clinical features and diagnosis

Mpox (monkeypox) is caused by an orthopoxvirus. The clade IIb variant driving the 2022 global outbreak spread predominantly through direct skin-to-mucous-membrane contact during sexual activity, primarily affecting men who have sex with men (MSM). Several hundred Australian cases were notified in 2022–2023 via the National Notifiable Diseases Surveillance System.

Clinical presentation. The prodrome — fever, lymphadenopathy (characteristically inguinal, unlike smallpox), myalgia, malaise — precedes the rash by 1–4 days, though in the 2022 outbreak some cases had no prodrome. The rash progresses macule → papule → vesicle → pustule → crust, taking 2–4 weeks total. Key 2022 features: anogenital, perianal, oral, or palmar lesions; often few in number (1–10); deep and painful. Proctitis with tenesmus and rectal bleeding is a common and severely painful presentation in MSM with receptive anal exposure.

Complications include secondary bacterial infection, severe proctitis, pharyngitis, and, in immunocompromised individuals, encephalitis or disseminated disease. Pregnancy increases severity and carries risk of vertical transmission.

Diagnosis. PCR from a vigorous swab of a de-roofed vesicle or pustule is the gold standard, per the CDNA Series of National Guidelines. Throat swab if pharyngeal; rectal swab if proctitis. Notify your state public health unit on clinical suspicion — do not await laboratory confirmation for a high-probability presentation.

Differential diagnosis includes varicella, herpes simplex, primary syphilis (chancre), genital warts, bacterial folliculitis, and hand-foot-mouth disease.

Mycoplasma genitalium and antibiotic resistance

Mycoplasma genitalium has no cell wall, rendering beta-lactams ineffective. It causes urethritis in men and cervicitis or pelvic inflammatory disease in women. Azithromycin resistance now exceeds 50% in Australian MSM cohorts, with rising moxifloxacin resistance also documented.

The Australasian Sexual Health Alliance (ASHA) recommends:

1. Macrolide resistance testing (reflex 23S rRNA mutation detection) at the time of NAAT
2. Doxycycline 100 mg twice daily × 7 days first (reduces bacterial load; improves subsequent macrolide success)
3. Then resistance-guided antibiotic: azithromycin extended course if macrolide-sensitive; moxifloxacin 400 mg daily × 7–14 days if macrolide-resistant

Routine asymptomatic screening is not recommended — asymptomatic carriage is common and treatment selects resistance without meaningful clinical benefit.

Drug-resistant Neisseria gonorrhoeae

ASHA guidelines currently recommend ceftriaxone 500 mg IM single dose as first-line gonorrhoea treatment, with some jurisdictions using ceftriaxone monotherapy 1 g. Always check local protocol as this area is evolving rapidly. Test of cure at 7–14 days is mandatory for pharyngeal gonorrhoea, which has the highest treatment failure rate. Report all cases to public health — the Australian Gonococcal Surveillance Programme tracks resistance patterns nationally.

Critical clinical note: test pharynx and rectum at every MSM STI screen. Single-site (urethral only) testing misses approximately 50% of gonorrhoea infections.

Australian syphilis resurgence

Australia has experienced rising syphilis notifications since approximately 2010. The Aboriginal Health Multi-Jurisdictional Syphilis Response Strategy addresses a particularly concerning outbreak in remote communities including congenital syphilis cases and neonatal deaths. eTG complete provides the current treatment framework — benzathine penicillin remains first-line. Enhanced antenatal screening at first visit, 28 weeks in high-risk areas, and at birth is standard.

B. Prevention — vaccination, PrEP, and Doxy-PEP

JYNNEOS vaccine for mpox

JYNNEOS (MVA-BN, marketed as IMVANEX) is a modified vaccinia Ankara live replication-deficient vaccine, per ATAGI / Australian Immunisation Handbook. It is state-funded for high-risk MSM including PrEP users, HIV-positive individuals, those with recent bacterial STIs, and trans or gender-diverse individuals with high-risk exposures. Two doses 28 days apart subcutaneously. Observational data show approximately 70–80% reduction in symptomatic disease. Being replication-deficient, it is safe in immunocompromised individuals and those with atopic dermatitis.

As post-exposure prophylaxis, JYNNEOS should ideally be given within 4 days of exposure (efficacy maintained up to 14 days). Coordinate with your state public health unit for contact tracing and vaccination of contacts.

HIV PrEP

Tenofovir disoproxil fumarate / emtricitabine (TDF/FTC) is PBS-listed under Streamlined Authority for HIV-negative high-risk individuals, per ASHM guidance. Approximate cost is ~$30/month general or ~$7/month concession. Daily dosing provides greater than 99% reduction in HIV acquisition with good adherence. On-demand (2-1-1) dosing — 2 tablets 2–24 hours pre-exposure, then 1 tablet at 24 and 48 hours — is an acceptable alternative for receptive anal sex in MSM. Quarterly reviews include HIV/STI screening, renal function, and hepatitis status.

Long-acting cabotegravir IM 8-weekly (CAB-LA) has superior clinical trial data but limited funded access in Australia; refer to infectious diseases for consideration.

Doxy-PEP

Doxycycline 200 mg single dose within 72 hours of condomless sex was shown in the 2023 DoxyPEP NEJM trial to reduce chlamydia, gonorrhoea, and syphilis combined by approximately 65% in MSM and transgender women. ASHA is developing formal guidance. Current position: consider for high-risk MSM with recurrent bacterial STIs after discussion with a sexual health specialist. It is off-label and not PBS-funded for this indication. Essential counselling includes antimicrobial resistance implications, particularly for Mycoplasma genitalium and gonorrhoea.

C. Chemsex, harm reduction, and special considerations

Chemsex — sexualised drug use involving methamphetamine, GHB/GBL, and mephedrone — increases STI transmission, HIV seroconversion, and hepatitis C. A non-judgemental enquiry approach is essential. Harm reduction includes: sterile equipment via needle and syringe programmes, naloxone access (GHB CNS depression risk), HIV PrEP, hepatitis C testing and direct-acting antiviral treatment, and Doxy-PEP discussion. Refer to alcohol and other drug services for ongoing support.

Hepatitis A outbreaks in MSM have been documented in Australia. Hepatitis A vaccination is recommended for MSM in state-based programmes — ask about vaccination status opportunistically. Hepatitis B vaccination should be offered to all sexually active adults if not already immune.

LGV (lymphogranuloma venereum) — chlamydia serovars L1–L3 causing rectal proctitis — is rising in Australia. Treatment is doxycycline 100 mg twice daily × 21 days per eTG, longer than standard chlamydia therapy.

D. Australian operations

Notification requirements. Under state Public Health Acts, mpox, syphilis, HIV, gonorrhoea, and chlamydia (and hepatitis A/B/C) are notifiable. Notify on suspicion for mpox — do not await PCR results. The National Notifiable Diseases Surveillance System (NNDSS) tracks aggregate national data.

MBS items. Standard GP consultations (items 23, 36, 44) apply to sexual health assessment, STI counselling, and PrEP review. Aboriginal and Torres Strait Islander Health Assessment (item 715) should always include STI and hepatitis B/C screen, vaccine status, and PrEP discussion. Mental Health Care Plan (items 2715/2717) is appropriate for distress associated with STI diagnosis, chemsex management, or relationship impacts. Telehealth equivalents apply for follow-up, results, and repeat scripts.

PBS and SAS items. HIV PrEP (TDF/FTC) is Streamlined Authority PBS. Tecovirimat (TPOXX) is available only via TGA Special Access Scheme (Category A or B) for severe or immunocompromised mpox — not on PBS. JYNNEOS vaccine is state-funded through sexual health clinics and some general practices. Doxycycline, ceftriaxone, azithromycin, and moxifloxacin are all General Schedule PBS. Moxifloxacin for macrolide-resistant Mycoplasma genitalium requires Authority.

Referral pathways. Refer to a sexual health clinic for: complex or refractory STIs, mpox, extensively drug-resistant gonorrhoea, suspected LGV, chemsex with significant AOD comorbidity, and HIV management initiation. Aboriginal Community Controlled Health Services provide culturally safe care and community testing programmes. Needle and syringe programmes are essential harm-reduction infrastructure.

E. Special populations

Aboriginal and Torres Strait Islander peoples. The syphilis outbreak in remote communities has caused tragic congenital cases. Enhanced point-of-care testing, culturally safe care through ACCHS, and the Aboriginal Health Multi-Jurisdictional Strategy are the response framework. 13YARN (13 92 76) provides crisis support. Item 715 health assessments should integrate sexual health comprehensively.

Immunocompromised individuals. HIV-positive people with low CD4 counts, organ transplant recipients, and those on immunosuppressive therapy are at risk of severe or disseminated mpox. JYNNEOS is safe in immunocompromised patients. Early assessment and low threshold for tecovirimat consideration applies. NPS MedicineWise provides prescribing guidance for this group.

Pregnancy. Mpox in pregnancy carries risk of vertical transmission, preterm birth, and fetal loss. JYNNEOS use in pregnancy is a clinical decision to be made with an infectious diseases specialist. Most antibiotic regimens for bacterial STIs are safe in pregnancy with appropriate selection — consult AMH and eTG for pregnancy-specific dosing. Enhanced antenatal syphilis screening is standard.

Culturally and linguistically diverse (CALD) communities. Do not assume sexual orientation or practices. Ask sensitively about partners and practices. Interpreter services improve assessment quality and patient trust. Consider region-specific risks for patients from areas with higher HIV or STI prevalence.

When to escalate

Escalate or refer to a sexual health clinic or infectious diseases service when:

• Suspected mpox with severe proctitis, pharyngeal involvement, ocular involvement, or immunocompromise
• Mpox in pregnancy
• XDR gonorrhoea or treatment failure despite guideline-compliant therapy
• Multi-resistant Mycoplasma genitalium (failed doxycycline + moxifloxacin)
• Congenital syphilis concern or antenatal syphilis in third trimester
• HIV diagnosis requiring antiretroviral initiation
• Chemsex with significant substance use disorder requiring AOD co-management
• Patient distress or mental health impact requiring psychology or psychiatry

What this article is and is not

This is general health information drawn from current Australian guidelines — ASHA STI Management Guidelines, Therapeutic Guidelines (eTG), ATAGI Australian Immunisation Handbook, ASHM, NPS MedicineWise, and RACGP. It is not personal medical advice and does not create a doctor–patient relationship. Clinical decisions about specific treatments, including Doxy-PEP eligibility or antiviral prescribing, are made with your own GP and treating clinicians.

For consumer-friendly information: HealthDirect — Mpox, Better Health Channel — STIs. For Aboriginal and Torres Strait Islander community support: 13YARN 13 92 76. For sexual health support: Scarlett Alliance, Living Positive Victoria, ACON.

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Sources cited

1. Australasian Sexual Health Alliance — STI Management Guidelines
2. CDNA Series of National Guidelines — Mpox
3. ATAGI / Australian Immunisation Handbook — JYNNEOS
4. Therapeutic Guidelines (eTG) — Sexually transmitted infections
5. ASHM — HIV PrEP and sexual health
6. TGA Special Access Scheme — Tecovirimat
7. NPS MedicineWise
8. Australian Medicines Handbook
9. RACGP — Sexual health resources
10. HealthDirect — Mpox
11. Better Health Channel
12. Luetkemeyer AF et al. — DoxyPEP NEJM 2023