BACKGROUND: Acute rheumatic fever (ARF) is an abnormal immune reaction following Streptococcus pyogenes (Strep A) infection of the throat, and likely the skin. Primary prevention is the prompt and appropriate antibiotic treatment of Strep A infection, and it can reduce the risk of developing ARF and subsequent rheumatic heart disease. OBJECTIVE: This article explores current recommendations for primary prevention of ARF in Australia. DISCUSSION: People at increased risk of ARF should be offered empirical antibiotic treatment of Strep A infections to reduce this risk. People at increased ARF risk include young Aboriginal and Torres Strait Islander people in remote Australia as well as those with a personal or family history of ARF and people from migrant communities in urban areas, including Māori and Pacific Island people. Risk-stratified primary prevention can reduce the inequitable burden of ARF and rheumatic heart disease in Australia.