Dr Marcos Davi G. Sousa Specialist in Infectology, Federal Hospital of the Servants of the State of Rio de Janeiro presented a case history of a male, unfortunately he didn't state how long the patient had been HIV +.

* 51 years of age

* COPD

* alcohol dependant 

* very poor ARVT compliance

He had previously been treated for Tuberculosis, mycobacterium kansasii and mycobacterium avium, but continued to experience poor health, and poor compliance on ARVT.

He was tested and treated for M. intracellulare in Jan 2015, then tested positive for "atypical mycobacteria" in Sep. 2015.

In Nov 2015 a positive culture identified M. colombiense, the first isolate of this species in Brazil. It is a slow growing  type of  mycobacterium that infects both immunocompetent and immunocompromised people and was first isolated in Bogota, Columbia in 2006. Importantly, infection can mimic tuberculosis.

Treatment provided was the same for tuberculosis and should have continued for one year after the last negative test, but the patient continued to be non compliant with treatment and apppointments. Resistance testing was not yet available, and the outcome for the patient was not presented. 

My focus today was on Mycoplasma Genitalium as it has been a topic of many discussions recently. 

Several presenters discussed this topic

Dr Catriona Bradshaw, Melbourne Sexual Health

Dr Jorgen Jensen, Statens Serum Institute, Copenhagen

Prof. Charlotte Gaydos, John  Hopkins Centre

Dr Lisa Manhart, University of Washington 

Mycoplasma Genitalium (MG) causes symptoms similar to C. Trachomatis & N. Gonorrhoea 

Sequelae in women include pelvic inflammatory disease, spontaneous abortion, preterm birth and infertility. 

Diagnosis is limited to NAAT as culture lacks sensitivity and takes a long time. It is however recommended that NAAT testing should include resistance assay.

First line treatment regimes have included azithromycin and doxycycline, individually or in varying combinations, but doxycycline has a low efficacy rate and macrolide resistance has developed after 20 years use of azithromycin for other STI's. 

Moxifloxacin has been used as second line treatment but the past 10 years has seen emerging failure rates in some countries with rates as high as 15% in Asia-Pacific regions. Recent warnings from FDA and Europe, high cost and side effects make this option unpopular.

Funding for testing and trials of new classes of antmicrobials include

* solithromycin

* lefamulin

* diafloxacin

* zoliflodacin

* gepotidasin

The emergence of dual class resistance to both macrolides and  quinolones means there is no highly effective class of antimicrobials currently available to treat  MG. 

Prof. Basil Donovan from the Kirby Institute Sydney in his discussion of treatment of chlamydia, advocates for alternatives to azithromycin. This concerns me, as my experience in a sexual health clinic is that poor compliance is a major factor for using single dose treatments. I hope that new antimicrobial treatments will include single dose. 

The day started with a presentation from Prof. Jeanne Marrozzo, Professor of Medicine and Director of the Division of Infectious Diseases, University of Alabama, Birmingham.

Key points - 

* colonisation of a newborns gut is dependant on the type of birth

       ^ Caesarian births result in the newborns gut being colonised with skin flora eg staph aureus

       ^  Vaginal birth results in the newborns gut being colonised with healthy lactobacillus     

       ^ With the high rates of Caesarian births in developed countries, the practice of introducing the mothers           vaginal secretions into the mouth and nose of the caesarian born neonate may need to be seriously considered.

* Women with Bacterial Vaginosis (BV) have a 60% higher risk  contracting HIV through vaginal sex

* HIV neg men whose HIV+ female partner has BV are more likely to contract HIV

* one outcome of the VOICE study revealed that women using tenofovir vaginal gel who had a lactobacillus dominant vaginal biome had a lower risk of contracting HIV, compared to those with a lactobacillus non-dominant vaginal biome.

* maintenance of a healthy vaginal environment might reduce the risk of contracting STI/HIV, further research is required to establish how this is achieved, particularly to establish the pathogen that causes BV

The afternoon continued along the vaginal microbiome theme with several presentations:-

Dr Ricardo Diaz, University of San Paulo Brazil

* Gardnerella Vaginalis reduces the levels of TDF-DF in vaginal fluid

Olimade Jarrett MD

* The presence of P. amnii and S. sanguinegens in vaginal miceobiome was associated with a 3.5 to 4-fold increase in rates of Trichomonas vaginalis infection

Charlotte Van Der Meer

* The Dutch study on Effect of intra-vaginal douching on the vaginal mucosa suggests that use of intra-vaginal douching has no effect on vaginal microbiome, but may increase the risk of developing a candida infection. 

Such an exciting area of research, where so much more knowledge is needed to reduce risks of acquiring HIV, STIs, and those pesky vaginal conditions. 

The new WHO STI Treatment Guidelines were released August 2016 after 3 years of a very complex process, this was the first update since 2003. The recommendations were mostly based on very low - low quality levels of evidence but resulted in 'Strong Recommendations' or 'Conditional Recommendations'. 

Target populations were based on the same as Australian target groups but I was surprised to see the adolescent group include 10 - 19 year olds compared to Australia's young people aged 15 - 24 year olds. 

N. Gonorrhoea 

Recommended treatment 

* 250mg ceftriaxone IMI + 1gm azithromycin oral stat

When asked why 250mg ceftriaxone IMI as opposed to 500mg ceftriaxone IMI as recommended in may developed countries including Australia, Prof Magnus Unemo explained that there were no adequate RCT to support the larger dose worked any better than the recommended. 

Also they advised a 'Strong Recommendation' for all neonate to receive prophylactic treatment for prevention of gonococcal and chlamydial ophthalmia neonatorum, a practice abandoned in Australia with no subsequent increase in occurrence of infection or childhood blindness.

C. Trachomatis

* Azithromycin or doxycycline remain the treatment of choice for CT

* Anogenital CT - treatment changed to 7/7 of doxycycline 100mg BD.                                                                       Australian STI Guidelines recommend 7/7 of doxycycline 100mg BD if asymptomatic and 21/7 if symptomatic

Prof. Nicola Low advocated that the doxycycline regime of 7/7 of treatment still cures CT as well as if not better than azithromycin even if the course is not completed in non compliant people. 

* There is no evidence that repeating or lengthening the course of treatment is any more effective. 

Syphilis

* Nothing has changed in Rx recommendations for syphilis

* There is very low quality evidence to support the recommended treatment

* Treatment is based on 70 years of successful treatment.

I enjoyed Dr Francis Ndowa's analogy that there were no RCT proving the use of parachutes when jumping out of a plane greatly improved survival over not using one, so proving benzathine penicillin successfully treated syphilis didnt require RCT. 

* There is a pending global shortage of benzathine penicillin so alternatives include

        * doxycycline, ceftriaxone and in special circumstances azithromycin 

Genital Herpes

The only change recommendation for treatment is to increase treatment of the first outbreak of genital herpes to 10 days as most first outbreaks are prolonged. 

Martin Holt presented interesting results from the Australian PrEPARE Project.

Overall the results seemed to lean towards willingness to use PrEP being amongst the minority of people in the MSM population, with the willing parties mainly being in the high risk group of contracting HIV.  These high risk men most willing to use PrEP are with those with HIV positive partners and inconsistent condom users.

Interestingly, the study also looked at men who were willing to have sex with a PrEP taker. People in this group were mainly those who were positive themselves, or who had a HIV positive partner, rather than those who are having casual sex with multiple partners. 

Really interesting! I can't wait to see what happens as more people start taking PrEP as it becomes more freely available! Maybe it will become more widely accepted. 

Mondays sessions on contraception and abortion contained many topics and key points I will take back to my work place and will make a difference to the Indigenous communities I work in.  

Living in a remote and isolated setting rules out certain options for local people with regard to abortion and family planning options. Learning of the telehealth options that are now available for early abortions gives young women another choice in this regard. 

I am interested in the future of this particular model and it's evolving service and how it can benefit those living in these remote settings. 

Thursday morning Lisa Fitzgerald presented a memorable overview of patients living with HIV. She outlined the importance of biomedical information, however also stated that real life complexities are sometimes marginalized. 

Living with HIV as a disease is difficult enough, but for those people in the community that have no social or familial support those issues are emphasized. 

I have learned a lot about HIV as an illness, however understanding the linkages beyond the treatment cascade into the day to day social lives have been highlighted again. 

A great reminder to clinicians that a patient is at the heart of these illnesses we all learn about. Thanks Lisa! 

This session on Wednesday morning was entertaining and informative. 

It outlined that health promotion is imperitive and very effective in the music/concert arena, sporting events as well as online via dating sites and various other informative websites. Great results have come from increasing accessibility and anonymity of access to both education and screening tools. 

The importance of clinicians and educators utilising an 'as required' method of health promotion and screening programs rather than a blanket, one size sits all approach was emphasized.

Very interesting to hear about various communities and audiences success rates with their various approaches. 

Thank you to all of the passionate presenters! 

What a great session!! 

The importance of STI screening post sexual assault, the relevance and role of technology in violence, and the great initiatives in response to violence in Aboriginal communities. 

My future practice will definitely change to incorporate conversations around violence to both potential victims and perpetrators of sexual violence.  Often questions are not routinely asked of potential perpetrators regarding behaviors that are unacceptable. 

Incorporating technology and its potential risks has been highlighted as an often forgotten element of health and sex education to the younger generation. Emphasizing the risks of private photos and events being shared needs to be stressed when delivering health education in an attempt to encourage people to think about the potential consequences before sharing photos or film clips seems simple, however is frequently not discussed when delivering education. 

Great presentations by everyone and very moving personal stories shared. 

ASHM Conference 2015 – Take home messages from a GP

The 2015 ASHM conference displayed all the teamwork I saw at the first conference which I attended 21 years ago.  Great presentations and choices in themes. There was friendliness and a range of stakeholders and an ongoing respect for the roles and hopes of the different parties. The meaningful involvement of all the stakeholders and especially those most affected by blood borne viruses is unique to ASHM stakeholders and I have not seen such teamwork in all the branches of medicine I know.

In a nutshell, the big message for GPs from this conference is PrEP, PrEP and PrEP. PrEP means pre exposure prophylaxis. GPs will need to get ready for what appears to be a huge ground swell of demand for PrEP. They will need to know the use of Truvada for HIV sero negative gay men.  Truvada for PrEP is not currently approved by the TGA and the PBS. So, GPs working in the MSM health area will need to know what mechanisms exist for current access.

Some issues will exist for a GP who considers prescribing PrEP, but the figures offered at this conference strongly suggest the outcome for ser negative MSM at high risk of HIV infection and  on  Truvada will be a lowering of new HIV cases.

The United Nations 90%:90%:90% goal concerning HIV was often referred to  in presentations. The UN goal is:-

- 90% of people living with HIV will know their HIV status.

- 90% of people living with HIV will receive sustained anti retroviral therapy.

- 90% of people receiving antiretroviral therapy will have durable viral suppression.

A big message was that early ART treatment is recommended - start at the time of diagnosis. Regardless of CD4 count. Many presentations supported this. The START (Strategic Timing of AntiRetroviral Treatment) Study presentation concluded that:-

=Combination antiretroviral therapy (ART) should be recommended for all HIV -persons regardless of CD4+ count.

= The START Study results align the benefits of ART to the HIV-positive individual to the benefits of ART in reducing the risk of viral transmission from HIV – positive persons to non- HIV- infected individuals. So, clinicians should regularly discuss the current state of knowledge regarding when to start ART with all individuals with HIV who are not yet on ART.

 The conference presentations reviewed current recommended ART treatment and some of their toxicities. An issue resulting from this is that all decisions to start ART should be made by the individual with HIV, in consultation with their healthcare providers and on the basis that they are fully informed and supported in their decision making. Patients makes the decisions and doctors give  good advice  for the  patients to  base their  decisions on.

The conference highlighted the importance and difficulties in long-term follow-up of people with HIV. The option in the future of a national notification system might help in this regard, but there are currently greater efforts to evaluate past and current treatments.

 Data at the conference strongly showed that mucosal damage from STDs lead to more easy HIV infection and the vigilance to treat STDs to decrease HIV spread cannot be over emphasised.

 The new treatments for Hepatitis C genotypes 1 and 3 with daclatasvir and sofosbuvir have been approved by the TGA and are awaiting PBS approval.

 Victorian data suggests that in Victoria, HIV and STD notifications are rising. There is evidence of ongoing increase in condomless anal intercourse with casual partners. There are also additional risk reduction practices in use in the community.    

 Geoff Symonds gave a presentation on gene therapy treatment for HIV. I found this fascinating and wonder how the role of gene therapy will pan out in the future. Great potential there.

 At the ASHM AGM an overwhelming number of members voted to change its formal name and affirm its current role in covering HIV, viral hepatitis and sexual health. The new name is the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine.  The good news is the logo and the associated word ASHM stays there as well.

 ASHM delivered a great conference.

 Darcy Smith

Day 2 of the conference was informative, fun and interactive. Opportunities to use smartphone technology to interact using live polls added to the experience. Here are my key GP take home messages from day 2.

1. Hepatitis C is curable and can be eradicated! At present only 1% of people with Hepatitis C are offered treatment. There is an urgent need for more community prescribers. The new DAA should be PBS listed by the end of this year. These drugs offer 8 week treatment times, are well tolerated, and have minimal drug interactions. Regimens will be interferon free. These drugs are highly effective (over 90-95% cure rates, even in advanced cirrhotics and HIV/Hep C coinfected populations).

GPs will play a major role in the eradication of Hep C. Treatment needs to be accessible and affordable globally.

2. Integrase inhibitors should now be first line agents of choice for ARV naive patients. They have outperformed EFV, DRV, ATV and just about everything else. They are well tolerated, suppress viral load rapidly, have few drug interactions and have a good metabolic profile. They are also increasingly available in 'one pill daily' regimens.

3. We need to include the transgender community in our sexual health campaigns and research (see my blog "PASH" 17/9/15)

4. We should be open to HIV self testing, in the US HIV self testing kits were well received by patients, and available by voucher, post, sex on premises venues, and even from vending machines in car parks! Patients who tested positive did link in with care, and these tests offered a convenient, out of hours testing opportunity, potentially reducing barriers to HIV testing.

Looking forward to day 3!

QuAC Launch of PrEP Campaign and why cant my fellow GPs always help MSM patients?

It was  heart warming  and praiseworthy to  see the  Queensland AIDS Council (QuAC)  launch what one QuAC employee told me was Australia’s first PrEP public  education  programme in  Australia..

 In a segment of the AFAO Community and Advocacy Hub forum, QuAC passionately and convincingly launched their education programme aimed at HIV sero negative gay men who consider they want or need extra protection to minimise HIV infection.

Blue and black PrEP T-shirts were prominent and panel members gave personal accounts of their use or desire for PrEP.

 I am a GP and sadly for me one panel member vividly told of the difficulties he was encountering with his GP to achieve PrEP. The panel member recalled the concern of the GP to prescribe a medicine outside “government recommended” principles. The panel  member said he  provided written  material  to the GP  and in  the end he was referred to  a Sexual  Health physician  for a definitive decision – but  not without being warned the  Sexual  Health  physician decision  would be final and after that decision,  the panel  member/ patient “should let the matter rest”. My goodness!

 I had hoped his GP and all the 25,000 GPs of Australia could manage such a request.

 Another panel member said MSM patients have had to “drag” GPs along to an “acceptable point of view” for many years.

 The dilemma of gay men seeking appropriate treatment from GPs needs further attention and debate and education in GP circles.

 The issue of how to find a GP who is sensitive to gay men was highlighted. Just how do a MSM client/ patient know they will receive modern, non judgemental, aware and informed advice?

 This is an ongoing problem, especially for remote and rural men.

 There is much education going on. It might be best to take GPs along with this swell.

 Well done, QuAC.  I admire your programme which sends the PrEP message to gay websites including SameSame, Recon, Gay News, Grindr and other popular gay internet locations frequented by gay and bisexual men.

PrEP has the potential to minimise the spread of HIV so all efforts to ease access need to be canvassed and supported.  The TGA and PBS should move their processes along – and hopefully they will, despite the bureaucratic processes and the inevitable pundits.    

Congratulations to Teddy Cook (ACON) and Jeremy Wiggins (VAC) for an important talk today about PASH, the Peer Advocacy network for the Sexual Health of trans masculinities. 

It took me a long time browsing through the ASHM program to find any content or posters addressing sexual health in the Trans community.

As health providers we need to lift our game and take action to prevent further discrimination and negative health outcomes for this often neglected group.

A great presentation, informative and concise. Thanks!

Excessive intellectual property protections for HIV  treatments:  the momentum  for reform

What a clear and informative presentation  Charles Chauvel , Team leader, Inclusive Political  Processes, Bureau for Policy and Programme Support, United Nations Development Programme, New York, USA delivered towards  the last end of Day One of the 2015Australasian  .HIV and AIDS conference

The ethics of patents has long troubled most health practitioners, and none more so, than those wanting  affordable  access to antiretrovirals  at  rates that will not deter people receiving,  needing or wanting HIV  treatment or prophylaxis.

Charles outlined that disease and poor health remain major barriers to sustainable development in  many countries. HIV and malaria and viral  hepatitis  continue to  kill  more that 5  million  people every  year and  most of the deaths occur in  low or middle income families. Even in rich countries, drugs like sofosbuvir are largely unaffordable to all the citizens. He also outlined that there are also non patent factors affecting access to medicines.

 Charles outlined that a patent is a type of intellectual property. It is a social contract between an inventor and society.  It gives the inventor the temporary and exclusive right to make use, export or market an invention in the country where the invention is patented.

 Patents affect access by creating protection on existing drugs, and the patents give exclusive control to  licence, manufacture and distribute the product. It also influences the kind of innovation which in undertaken in  the first  place.

 The Agreement on Trade – related Aspect of  Intellectual Property Rights was agreed to  in  1994 and came into  force in  1995. There was also another agreement setting minimum standards of IP protection and enforcement for countries to follow.

TRIPS Agreement Objectives (Article 7) states” The protection and enforcement of IPRs should contribute to the promotion  of technological innovation  and to  the transfer and dissemination of technological knowledge and in a manner conducive to social and economic welfare, and to the balance of rights and obligations.”

TRIPS Agreement  Principle (Article 8) indicate “ Members ……(should) adopt  measures necessary to  protect public health  and  nutrition, and to  promote the public interest in sectors of vital  importance to  their socio- economic and technological development, ………”  But the rights of the inventor Should also be protected.

Furthermore, there is IP “creep” and practices and measures since the original  Agreement have consolidated the Agreement.

Charles outlined the high  costs of ARVs. He said second  generation  ARVs cost 3.4  times more than  first  generation drugs.  Third generation ARVs cost 23.4  more than  the first generation  ARVs. He indicated India make over 80% of ARVs and their legislation  has enshrined the TRIPS agreement.

It also  seems TRIPS may be  further broadened and the term of patent protection  extended and create barriers to  medicines registration by “linking” IP to  marketing requirements.

The  Human Rights Commission  called for reform  in  2009 . It said “  …. Take into account the right o f everyone to the enjoyment of the highest attainable standard of  physical and mental health …..and supports public  health policies that  promote broad access to safe,  effective and affordable medicine.”

In  December,  2014, a resolution was put to the Secretary - General  of the UN calling for reform.  “We must continue to remedy the policy incoherence current in modes of international governance in matters of trade, finance and investment on one hand, and our norms and standards for labour, the environment, human rights and sustainability on  the other.”

Great!

For many people, changes to  TRIPS would be welcome and could not come too soon.

Charles Chauvel – thank you for your address and please keep up  your good work.

Darcy Smith

Good evening everyone! Here are some ‘take home’ points from the conference today:

1.     The HPTN052 trial did not stop in 2011 - contrary to popular belief. This landmark study published interim results in 2011 showing a marked (96%) decrease in HIV transmission rates in discordant heterosexual couples when ARV therapy was commenced early versus delayed therapy.The study continued, but in light of the new data all participants were offered ARVs.There have only been 8 HIV transmissions since then on the study. 4 of these were people who acquired HIV at the same time as commencing ARVs. The other 4 cases were in the context of treatment failure with detectable viral load.In other words no transmissions have occurred when HIV replication is suppressed – exciting news!

2.     We now have irrevocable evidence that all people with HIV should be offered antiretroviral therapy regardless of CD4 count. However the WHO have yet to update their guidelines, and the logistics of global access to ARVs are massive.

3.     Doxycycline “syphylaxis” is effective and well tolerated.  In a small study of people taking doxy 100mg daily for 48 weeks, there was a 77% retention rate and a 73% decrease in STI acquisition (gono, chlamydia and syphilis). Worth considering in high risk patients.

4.     For early syphilis only one dose of benzathine is required for HIV pos patients (not 3 as previously recommended).

5.     5-15% of pregnant women worldwide have a curable STI, but only 5-6 countries have a documented policy of screening for STIs during pregnancy. Globally many women attend a health care provider just once during their pregnancy, and symptomatic STIs are treated on the spot. Given that 80% of STIs are asymptomatic many are missed and can cause adverse pregnancy outcomes and MTCT. We need to improve pregnancy outcomes in high burden low income settings, including making point of care testing for STIs readily available and affordable.

Really enjoyed today's informative and cutting edge sessions, ASHM have set the bar high!, looking forward to tomorrow.

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Helen Tyrrell, Hepatitis Australia, provided a progress report on the targets from the 2012 Auckland statement on viral hepatitis. Helen Tyrrell described the “national shame”, that 1,000 people will die from hepatitis related liver disease in Australia in 2014. These rates are higher than those at the height of the HIV/AIDS mortality in 1994 in Australia.  Viral hepatitis requires the same action and response which HIV/AIDS mortality rates elicited in order to reverse the “rising death toll from viral hepatitis”.

Target progress:

Target 1: by 2016, halve the incidence of hepatitis C infections by doubling the amount of new injecting equipment distributed in the general community and implementing NSPs in prisons. 

Limited progress has been made in achieving this target thus far. In 2012 the ACT announced a trial of the distribution of sterile injecting equipment in a prison, however the trial has not yet commenced.  Contrary to this target, the 4^th National Hepatitis C Strategy does not include a priority action area which encourages trial needle and syringe programs (NSPs) in prisons. This is a backwards step as this priority action area was included in the previous strategy. Veering off the path of prioritising the need for NSPs in prisons undermines the development of an enabling policy environment to assist with preventing HCV transmission in high HCV prevalence settings.    

Target 2: Apply consistent funding of Hepatitis B vaccines for all those at greatest risk

A national policy commitment to this target is reflected in the 2^nd National Hepatitis B Strategy. Tyrrell highlighted that there has been inequitable access to funded vaccination programs for key populations.

Target 3: Ensure at least 80% of people living with Hepatitis B and C are diagnosed

April 2014 saw the announcement of $4.6 million in funding to increase the uptake of hepatitis B testing and treatment, however the planned distribution of this funding has not been publicised. This target largely related to hepatitis B as estimates suggest that 80% of people living with hepatitis C have been diagnosed.    

Target 4: Ensure 5% of people living with hepatitis C receive anti-viral medication each year

This target is reflected in the 4^th National Hepatitis C Strategy. This target requires accelerated PBAC and Cabinet approval process for new HCV drugs and promotion of new treatment options.

Target 5: Guarantee that 10% of people living with hepatitis B receive antiviral treatment each year

This target is again reflected in the 2^nd National Hepatitis B Strategy target, aiming for 15% of people living with hepatitis B to be on treatment.  

Whilst there has been some progress in the target areas, significant prioritisation of viral hepatitis will be required to meet the targets by 2016. The minimal progress is a call to action for state and federal governments to upscale the response required to both meet targets and reduce numbers of avoidable viral hepatitis related liver deaths. 

I’ve just had the privilege of attending the stream this morning on Community & Social Research – Preventing Viral Hepatitis.  All of the sessions were very valuable, however, I particularly enjoyed the session titled “Peer Link”, this was presented by Yvonne Samuels, Yvonne presented on behalf of Fiona Poeder who was unable to be present. 

Yvonne was a vibrant and passionate presenter who succinctly and clearly made the point that, while often overlooked, peer education is a powerfully effective tool for fighting viral hepatitis in injecting drug using communities. 

Peerlink, is a program run by NUAA (NSW Users and Aids Association).  It is a peer education project which has been developed and is delivered by people who use drugs.  It has recently been delivered in Nowra, Toronto and Mt Druitt.  The model is a holistic model that tackles Hepatitis C via education and prevention. It is based on the view that each individual community knows its own needs and own also contains the strategic information that that community needs for prevention.
 
Compellingly, Yvonne quoted, when you arrive in a community,  “What you do …. is shut up….You never arrive in a community with any ideas.”  Rather you need to arrive in the community ready to learn what the community needs.
 
The Peerlink program has three phases.
 
Phase 1
Making contact with the community, find a core group of people who use drugs and who are interested in being trainers in their own community (peer recruitment).  In this phase service partners are also identified and recruited.  In this phase there is initial training, the project outlined and planned.
 
Phase 2
In this phase Peerlink peer educator activities take place with individual contacts of the peer educator and also in groups.  If appropriate refresher training takes place. There are also health promotion activities and collaboration with service partners.  There is ongoing peer facilitator training.
 
Phase 3
Is working out how to withdraw the peer-link program while sustaining the gains that have been made.
 
The results have been impressive. In Mt Druitt there were 10 peer educators. In two years NUAA expected 800 peer education interactions. In actual fact, there were over 7,000  peer interventions.  In Toronto, there were seven peer educators.  It was expected that 800  interactions would occur in two years.  In actual fact over 9,000 conversations took place. In Nowra, there were nine Peer Educators. It was expected that in two years there would 400 interactions.  However, in two years there were more than 6,000 total peer interventions.
 
In summary, it was concluded that Peerlink demonstrates effectiveness in disseminating education to communities and reducing Hepatitis C.
 

On Monday, 15 September 2014, at the World Indigenous Peoples’ Conference on Viral Hepatitis, the Centre for Social Research in Health (CRSH) launched the results of a study examining the experiences of Aboriginal Australians living with hepatitis C (henceforth HCV) and their experiences of healthcare. A study of Aboriginal people in NSW living with hepatitis C: A report to community was conducted with 203 participants across NSW.

Professor Carla Treloar outlined the key findings of the research at yesterday’s launch, primarily the impacts of stigma and discrimination, with specific reference to the entangling nature of racism and HCV. Participants of the study described their experiences of health care workers expecting Aboriginal patients to have “these things”, referring to HCV.

Treloar explored the notion of ‘overlapping stigma’: Aboriginal Australians living with HCV can experience a combination of stigmas, such as the stigma of living with HCV, which can be linked to the stigma attributed to being  a person who injects drugs (based on assumptions regarding the mode of transmission) and additionally associated stigmas that society projects on Aboriginal people. Stigma influences patient decisions to disclose their HCV status to family and friends. Deciding not to disclose denies patients potential support networks which are vital during treatment.

The detrimental effects of stigma are evident at an individual and societal level. Treloar identified that experiences of stigma increase the burden of disease for the individual, and stigma on a population level increases health inequalities for minority groups.

Findings indicate that participants who thought that their diagnosis was delivered in a culturally appropriate manner were more likely to consider and commence treatment. These findings reinforce the need for health professionals to have culturally appropriate pre and post test discussions in order to increase rates of Aboriginal and Torres Strait Islanders receiving HCV treatment. Similarly, participants emphasised the need for health care professionals to adequately discuss HCV when diagnosis is delivered rather than numerous reports of being given pamphlets and denied an opportunity for further discussion.

According to WHO, 15% of the world's population are living with disability. People living with disability are at increased risk of exposure to HIV, more dependent on the welfare system, more likely to live in poverty and less likely to have access to HIV education.

People living with disability are also more likely to engage in risky sexual behaviours and are at increased risk of sexual abuse. Importantly, HIV infection and treatment can actually cause disability—a double-edged sword for people living with disability. We cannot afford to ignore the relevance of disability to HIV prevention, treatment, care and support.

So began the preliminary presentation for a disability community skills development workshop at #AIDS2014 "The world's biggest minority left behind: National HIV responses need to and can include disability."

The goal of the workshop was to gain insights, feedback and input from delegates for the UNAIDS Strategy on HIV and Disability 2015-2017.

In breakout groups, participants discussed stigma and discrimination against people with disability (PWD) who are living with HIV, barriers to HIV/STI education, access to prevention programs and treatment, co-morbidities including intellectual disability and mental health issues.

Key Points - Peer Support breakout session facilitated by Matthew Bowden - PWD Australia

• Need to respond to the diversity of the disabled community - disability takes many forms
• Positive people with disability to have a leadership role in policy development and peer response
• Realign all HIV policy frameworks to be inclusive of disability
• Peer counselling is a powerful tool for HIV support and education in the disability space
• Disability must move beyond the concept of charity into the the light of a mainstream response to HIV

Workshop convenors, UNAIDS along with their key partners UNESCO and WHO have made it their goal to define specific disability-related targets for the UNAIDs Strategy on HIV and Disability 2015-2017 by December 2014. It was a privilege to be involved in a workshop with a direct line of communication to HIV/AIDS policy makers.

In 2010, young people aged 15-24 accounted for 42% of new HIV infections in people aged 15 and older.¹

The adolescent HIV population presents a unique set of challenges when it comes to education and behaviour change. Adolescence is a time for exploring sexuality, experimenting with risk-taking behaviour and finding new ways to connect that sets them apart from the adult world.

How can we reach young people to prevent new HIV infections?

Moving health messaging into the digital gaming space, says Lynn Fiellin and colleagues at Yale University who presented their results at the Young People Epidemiology and Prevention Strategies oral abstract session at AIDS 2014 today.

Digital health technologies are growing at an unprecedented rate, particularly in the smart phone and tablet space. Mobile phone networks are now reaching up to 85% of the global population and the World Health Organisation estimates close to 5 billion mobile subscriptions worldwide.²

A recent infographic reported the State of the Mobile 2013:

•      91% of all people on earth have a mobile phone

•      56% of people own a smart phone

•      80% of time on mobile devices is spent inside games or apps

•      Majority of teens play video games as long as they have access to them.³

And the largest audience of apps and video games?  Adolescents - the digital natives or our techno world.

'Serious Gaming' is an emerging platform for imparting health messages and delivering health education. Serious gaming holds the promise of delivering HIV prevention messages to teenagers through game-based learning.

Anyone who has talked to a teenager lately knows that gaming experiences can be engaging, immersive and educational. Many Australian schools now set homework where students are using video gaming platforms and apps to entice and encourage literacy and numeracy and to connect and collaborate with remote schools.

Applying health messages to video games has the potential to improve health literacy around HIV and STI and may go some way towards prevention.

Studies into serious gaming cite neuroplasticity improvements, faster processing, increased cognitive flexibility and a deeper creative learning experience as just some of the results reported by young people who took part in serious gaming compare to those who played non-educational games.⁴

Today, Fiellin and colleagues showed that when teens were randomly assigned to 10 hours of gaming sessions that included: HIV knowledge, self efficacy, risk perception scenarios, short vs. long term priorities and an epilogue illustrating the consequences of their choices, their HIV risk knowledge had improved at 6 weeks, with knowledge levels maintained at 3 and 6 months.

Participants enjoyed the gaming experience, found it challenging, and reported that they felt responsible for the decisions made during game. 

During question time, criticism of the study was aimed at the game's apparent representation of heteronormative and gender-based stereotypes. Ms Fiellin agreed that the video game was limited in its choice of characters and diverse sexual orientation but that the research group now have proof of concept to develop the game further including the potential for a multiplayer platform.

References

1.  UNAIDS Fact sheet Adolescents, young people and HIV www.unaids.org/<http://www.unaids.org/en/media/unaids/contentassets/documents/factsheet/2012/20120417_FS_adolescentsyoungpeoplehiv_en.pdf>
2. World Health Organisation (WHO) Website. Tobacco Free Initiative. www.who.int/tobacco/mhealth/<http://www.who.int/tobacco/mhealth/en/index.html>
3. www.digitalbuzzblog.com/State of the Mobile<http://www.digitalbuzzblog.com/infographic-2013-mobile-growth-statistics/>
4. Glass BD, Maddox WT, Love BC (2013) Real-Time Strategy Game Training: Emergence of a Cognitive Flexibility Trait. PLoS ONE 8(8): e70350. doi:10.1371/<http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0070350>