ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

In the Gollow lecture Rebecca Guy discussed the important role of new technology for STI prevention including interventions such as: -

-CASI an electronic self-registration tool has proven acceptable reduced waiting times and improved data collection.

- ACCEPT showed the need for opportunistic Sexual health screens in primary care for young people due to high prevalence of CT and presenting complaint often not being sexual health related simple computer prompts increased testing by 30%

- SMS and postal test kits have been used to improve re-testing rates

 

Mark Hayter called for collaborations within sexual health with other specialities such as family planning and drug and alcohol services. Incorporation of family increased consult time but decreased unintended pregnancy, without increasing STI rates.  In addition inks with family planning could even go someway to dispel contraception myths held by Australian men as highlighted in Mary Stewarts lecture ‘contraception and the Australian male’.

 

Craig Rigney, CEO Kornar Winmil Yunti spoke about the KWY community based response to high rates of Aboriginal family violence and a lack of accessible culturally appropriate services. The Aboriginal family violence program maintained client safety through ‘women’s business’ and ‘men’s business’. Men’s business included a perpetrator program, which was aimed to unpack perpetrators own held trauma so that they can be accountable for their own violence.  Although initially many attendees were mandated from court self-referrals are on the increase. Rigney discussed that undoubtedly valuable outcomes are hard to evaluate.

 

In ‘rethinking testing and management of sexually transmissible infections’ Catriona Bradshaw drew attention to the lack of guidelines internationally for rectal MG with treatment shifting towards doxycycline. She called for a reduction in macrolide use and improved contact tracing and TOC rates.

Jane Tomnay analysed PDPT in the Australian context drawing attention to challenges in primary care such as who will pay for PDPT? And how do you write a script for the partner if the partner has never attended the practise.

PDPT was criticised in NT in 2012 when it coincided with child abuse allegations as a way that abuse could remain hidden – something to think about especially in relation to pick up rates of family violence/ domestic violence. 

Daniel Richardson proposes HCV testing should be considered in relation to sex in certain groups even if heterosexual (namely women) and in HIV negative MSM on PrEP – when asked about increased cost due to Australian labs only performing HCV RNA, Richardson suggested lobbying for HCV antigen tests he denied value of LFT’s as a screen, referring to the MSM in PROUD and EPIGAY whom contracted HCV through sex having had no change in transaminases.

In the sexuality lectures Hilary Caldwell Challenged gender based narratives about the Australian sex industry stating that its no longer sustainable to claim only men command and objectify bodies when buying sex or that that power dependent activity is inherently oppressive. She described how women buying sex (WBS) In Australia are more likely to do so from women than men and that these women were diverse with any ethnicity and any income. WBS stay for longer and buy sex less often prioritising safety and a sexpert. Angela Davies looked at the impact of pornography on young peoples sexual lives. There are concerns that porn can normalise risk behaviour promote harmful attitude. An Online survey of 15-29y revealed both male and females used porn. Porn was considered a more detailed sex resource compared to formal sex education where pleasure is the goal instead of risk. There were positive and negative impacts. Positives impact included – positive body image, sex positive, normalising taboos, ‘a safe space to sexplore’, in some males prevented other risk behaviour. Negative impact included  - negative body image, unrealistic expectations, and limited representation of sexuality, harmful attitude and behaviour. A significant portion reported no impact of porn. Do this group have protective factors preventing impact or are these most at risk who lack insight?

 

A huge thank you to Gracelyn Smallwood who gave an inspirational talk around the importance of involving appropriate people in a community to deliver culturally appropriate health promotion that engages communities as a whole.

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Khadija was born in Sierra Leone and arrived in Australia in 2001. There is an impressive list of projects and organisations in which she is heavily involved including her long-standing involvement with ShineSA and No FGM Australia - a not-for-profit Australian organisation where she is currently the Executive Director.

She gave the opening address at the 2016 Australasian Sexual Health Conference in Adelaide and also provided a second presentation titled 'Sexuality and Female Genital Mutilation - The Psycho-Social Impact of Sexual Dysfunction due to Female Genital Mutilation'.  

Today she kindly spoke with me about FGM in the context of health settings with a particular focus on sexual health clinics.  It is with her generous permission, and that of ShineSA, that this audio interview is able to be shared.

Due to the size of this 12 minute audio file, it is hosted on the external link below:

https://soundcloud.com/user329177428/khadija-gbla

For more information on FGM and FGM in the Australian context see the following link: http://www.nofgmoz.com 

 

FAMSACA - is Forensic & Medical Sexual Assault Clinicians Australia. 

www.famsaca.org.au

Today commenced with FAMSACA breakfast which was very well attended.

The organisation is small group nationally and meets up every 2 years. It welcomes new members and provides clinical educational updates. 

The Australian media has increased its reporting on Domestic Violence (DV) in Australia.

DV has become a major topic and focus nationally, especially since Rosie Batty education campaigns and advocacy.

FAMSACA presenters discussed 4 different and highly complex Client cases.

Physical Assessment of Woman and Girls after an assault can be re-traumatising.

There is clear Pathways to E.D and Medically investigation. 

FAMILY PLANNING - Copper IUD is 1 of the most effective form of contraception. 

New Emergency Contraception Pill, Ulipristal acetate is 99% effective. Ideally to be administered ASAP and within 4 days of an event. After this time it's efficiently declines rapidly. Cost is approximately $50.00 AUD and will become available over the counter in 2017. Please refer to  www.ellaone.com 

Reporting Violence to Police and relevant Authorities in relation to Children.

We spoke about the potential difficulties of reporting if the victim refuses to consent in providing this information and requests confidentiality. 

Woman may often feel unsafe reporting to Police due to fears of retribution from men/boys. This can include threats to their children. Victims dislike reporting directly to the Police, an option would be to report this on-line, but the Police require the victim (witness) to provide details, otherwise they lack powers to investigate. 

Other challenges to services and clinicians are re-current presenters. This often presents in context of people with an Intellectual Disability or mental health, with a history of childhood sexual abuse. It is hard to establish safety with ongoing abuse. 

Under age children/young people with abuse, even under Guardianship present particularly difficult challenges. When they become of legal age of sexual consent the police are not so interested. 

Drugs and Alcohol are frequently seen but it’s also can be common not remember things/details. 

Clinicians need to celebrate small changes to cope and manage working in this area of trauma. 

It is important for Clinicians and Community Workers to know where to refer Clients and Patients to these Specialised Services. 

 

 

 

 

 

 

 

 

 

Day one of the Australasian Sexual Health Conference 2016 included presentations showing: advances in resistance testing and POCT for common STI’s, novel treatments of MG, possible reasons why Australia lags behind in LARC uptake, Australia-specific barriers to termination of pregnancy, as-well as issues such as the importance of a multi-layered representation of aboriginal men to aid with engagement around sexual health and how policy is protective of LGBTIQ young people in Australia.

 

Associate Professor Rebecca Guy discussed the challenges of STI testing amongst aboriginal communities in remote areas. She reported the average time to treatment being 21 days due to population mobility and distance to lab, with 1 in 5 not receiving treatment at all. 

In 2011 12 rural health services trained aboriginal nurses and health-workers to perform a POCT for CT/NG (‘Xpert’). This meant results could be given within 90 minutes. Treatment uptake increased to 96.2% (treatment uptake for the standard was 88.3%). The mean time to treatment reduced from 19 to 4 days with 80% being treated within 7 days (compared with 48.5% previously). Future studies will look at POCT for NG/CT cost effectiveness.

 

MG remains a concern with increasing resistance to azithromycin and moxifloxacin. Associate Professor Catriona Bradshaw explained how Pristinamycin could not be considered an alternative treatment in those where azithromycin had already failed due to a disappointing cure rate of only 75%. However, Pristinamycin may have a role in special circumstances such as pregnancy as it is safe with few side effects.

 

Dr Elina Trembizki proposed PCR resistance testing could individualise NG treatment by accurately predicting ciprofloxacin susceptibility through TCC/ TTC wild type detection. It possible NG resistance to ciprofloxacin may by over represented through traditional culture methods though this should only be interpreted in an Australia context.

 

In the reproductive health lectures Mary Stewert highlighted the need for contraception education in men as although survey through a dating website revealed high rates of contraception use there was a lack of awareness of LARC’s and many believed hormonal contraception especially the ECP to be harmful which could negatively influence female partner decision.

 

Australia still lags behind in LARC with only a 3.2% uptake compared with 13.9% worldwide. Dr Amy Moten dispelled myths about IUDs explaining that PID rates are now <1-2% regardless of age and only in first 20 days post insertion after which time risks go back to baseline. Studies have even shown that there is no benefit of removing IUD in PID unless there is no improvement in clinical status after 48-72hours. Therefore PID should not be a barrier to IUD’s. Gabrielle Lodge looked at GP perspectives towards IUD insertion revealing barriers to include cost to train, minimal Medicare rebate and de-skilling due to small patient load.

 

There was a call to make MTOP de-centralised and so more accessible and affordable.  As despite misoprostol being available on PBS professor Angela Taft found many women find cost a significant barrier. Spontaneous discussion highlighted women’s experiences can vary widely depending on the state. Lauren Coelli described a successful nurse-led approach used in Victoria and emphasised importance in training all members of the MDT including receptionist staff to de-stigmatise.

 

Other interesting lectures included Dr Deborah Bateson speaking about POP (75mcg desogesterol  - not available in Australia) as a treatment for migraine possibly due to anovulation. Associate professor David Templeton who presented the increased follow up of victims of sexual assault due to improved relationship between sexual assault and sexual health services, councillors calling individuals to make appointment, separate waiting room, councillor obtaining sexual history, and personal phone call with negative results. >10% of these patients had an STI showing the importance and benefit of proactive follow up.  Todd Fernando discussed how the media/ literature fuelled view of aboriginal men either being heterosexual or hyper-sexualised MSM needs to be remedied to aid engagement with sexual health services and Tiffany Jones talked about how policy made LGBTIQ young people feel safe. Lack of policy and poor education in schools around LGBTIQT leads to increased bullying, days off school, self harm and suicide whereas promoting activism can me protective.  

 

 

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Reproductive Health: Contraception, Access and Equity

 

Amy Moten from ShineSA dispelled some myths regarding intrauterine devices (IUDs) causing pelvic inflammatory disease (PID). Amy explained the reasons behind the poor uptake of IUDs in Australia in comparison to other countries.

The legacy of the Dalkon Shield has cast a shadow on the use of IUDs in Australia. The Dalkon Shield was an intrauterine device manufactured in the 1970’s. It became infamous for its serious design flaw-a porous, multifilament string upon which bacteria could travel into the uterus causing sepsis, miscarriage and in some cases death.  There are three intrauterine devices available in Australia- the progesterone IUD called Mirena and the non-hormonal IUD’s-copper T 380A and Multiload. IUDs are extremely effective long acting methods of contraception, which are under utilised in Australia. Only 3.2% of Australian women use IUDs V 35% of Vietnamese women.

Data from 12 randomised studies revealed that modern IUDs showed an overall rate of PID of 1.6 cases per 1,000 woman-years of use.

 There is strong evidence to indicate PID is related to the insertion process. 20 days post insertion the risk of having PID is the same as a non IUD user.

 Take home messages

·      There is no difference in outcome for women with PID who retained the IUD compared to those who had it removed

·      All women who are diagnosed with PID should be reviewed in 24-72 hours

·      IUDs can be used in nullips and there is no increased risk of complications in younger women

·      IUDs are a cost effective method of contraception and clinicians can help by dispelling myths regarding side effects

·      Contraception is very much a very personal choice. It is important that clinicians suggest appropriate contraceptive options for their patients/clients. Long active contraceptive options can be a great choice for women of all walks of life, especially those with chaotic lifestyles. I often suggest LARC for our ‘at risk’ young clients who are often homeless and using drugs.

      Angela Taft (La Trope University)-Medication abortion: access and equity following Mifepristone on the PBS

Medical termination of pregnancy (MTOP) has become more available Australia since restrictions were lifted on mifepristone. Mifepristone can be taken for 63 days/9 weeks after conception. Women can now choose their preferred method and the MTOP can be preferred over surgical interventions for many reasons. Taft explores access and equity in obtaining a termination, including reported challenges, preferred methods and out of pocket expense. The data was from Marie Stopes clinics from November 2014 to April 2015.

Demographics @ Marie Stopes clinics-

·      49% nulliparous but 35% had previous abortions

·      Over 83 % attended for TOP within the first trimester

·      Little difference in the cost of surgical terminations and medical terminations at  Marie Stopes clinics- non Medicare holders can pay up to $1160

·      Identified factors associated to late presentations include distance to clinic, not aware that MTOP was available, and financial difficulties

      Take home messages

Mifepristone is now available in Australia but there can be a significant cost involved which reduces access to lower income earners. 1 in 5 study participants expressed concerns about the cost of abortion and relied on the financial assistance of others. 

35% of clients attending for TOP have had previous abortions. It would be great if contraceptive advice and free LARC could be offered on the day women attend for terminations.  Angela Taft’s talk sparked some debate on why the price of medical termination of pregnancy (MTOP) was so expensive.

 KRC can offer free contraception to ‘at risk’ young people and other target populations. Free contraceptive options include the combined contraceptive pill, emergency contraception, implanon and mirena or copper IUD. Clinicians at KRC often refer clients for TOP and with the clients permission can liaise with the clinic and make a plan regarding contraception options post procedure.

 This session was followed on nicely by the amazing initiative of Lauren Coelli who established Clinic 35 in the Hume region. Her work has undoubtedly improved access for marginalised population groups.

 Increasing access to medical terminations of pregnancy through nurse-led models of care/Decentralising abortion services: The Integration of Medical Termination of pregnancy into a Rural Primary Health Care Setting-Lauren Coelli

Commenced MTOP in 2015

·      Accessible and equitable service-no Medicare required

·      Nurse-led model excellent opportunity to increase access to MTOP

·      Requires good working relationship with GP + Pharmacy who has undertaken MS2Step Training

·      Few GPs complete training as consultations associated with MTOP are lengthy (>45 mins) and there is suboptimal remuneration for GP.

·      The nurse’s role includes triage, pregnancy options, holistic assessment, investigations and referrals for ultrasound and specialist referrals.

·      The cost of MTOP at Clinic 35 costs between $0 and $38.20

·      In-depth planning process and ongoing communication is essential for the program to be successful

 Take home messages

This service is awesome. It is a step forward in the movement for sexual and reproductive empowerment of women in Australia and hopefully it can be emulated in other countries worldwide

 

 

 

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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