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.

Kaija Talviharju

Kaija Talviharju

I made a shift from the social welfare field to nursing in 2009, and have worked as a nurse at the Kirketon Road Centre in Kings Cross since early 2014. This role includes a mix of sexual health, drug health and general nursing care. My professional interests including providing quality health care to marginalised people.

Presentation by Maria Dulce Natividad

Maria gave a disturbing presentation about the current state of HIV prevention work in the Philippines. There has been a frightening shift in the landscape since President Duarte took the reins in June 2016.

Between 2010 and 2016 the Philippines has seen a doubling of HIV infections from 4300 to 10500. Maria noted that prior to that time progress on HIV prevention in the Philippines was “low and slow”. While most of the rise is seen to be amongst young MSM, there is also concern for those who inject drugs. Prevention for this group under the current Government will be very difficult.

After taking office President Duterte declared a ‘war on drugs’ , which has been marked by harsh condemnation of drug users and Presidential ‘permission’ to punish and kill drug users. Maria presented several quotes from the president, which including the words “free to kill idiots” (IV drug users). The impact on the ground was the beginning of extra judicial killings which have led to an estimated 13000 deaths. Maria described this as a “shoot first, ask questions later” approach.

She noted that the political message represented a harnessing of fear and social discontent, with its roots in social inequality. It has enabled the institutionalisation of fear through promises of cleaning up society. Maria argued that for Duterte it has led to a consolidation of political support.

The resulting discrimination means that drug users have been driven further into the shadows, with people avoiding health care because they fear for their safety. Harm reduction has become much more difficult. Programs such as clean needle distribution have been discontinued, drug use is poorly documented, and activists/advocates are afraid to get involved.

Drug use and HIV interventions are treated separately, so there is no cross linking.

The situation in prisons is very concerning, with greater overcrowding and a subsequent rise in health issues, which is likely to include blood borne infections.

Overall it appeared to be a grim picture which does not present much room for optimism, however Maria discussed some areas of hope. While dialogue is not possible nationally, change may be initiated at the community level. Some communities and smaller organisations are stepping in to help despite the risks.

IV drug users have the most to fear in the current climate. Perhaps Australian health workers and their peak bodies can find ways to support those communities which are brave enough to help people affected by these depressing government policies, and through this keep alight the flame for HIV prevention. 

Posted by on in Public Health and Prevention

Presentation by Professor Monica M Lahra

Monica gave a fascinating and thorough summary of global concerns relating to anti microbial resistance [AMR]. Resistance is predicted to be a big problem by 2050, and is considered to threaten health and health care provision.

AMR is essentially a problem of overuse. Bacteria which come into contact with antibiotics, but are not killed have various means of developing resistance. Resistant organisms are now global and endemic in some countries. Some organisms have become resistant to last line antibiotics. AMR presents a threat to medical procedures and treatment, including chemotherapy, complex surgery and transplants.

Factors leading to resistance include:

  • Mass food production. Antibiotics are needed to control disease, particularly where large numbers of stock are raised in minimal space as happens with large scale fish and pig farming. This is considered a major contributing factor.
  • Large scale antibiotic dumping by manufacturers.
  • Inappropriate prescription /overuse where antibiotics are not necessary /availability of non prescription antibiotics. The latter uncontrolled use is estimated to be even greater than current studies indicate as many countries do not collect data on non-prescribed supply.
  • Travel. Global travellers are colonised with resistant bacteria which they bring home with them. (here Monica threw in a comment that we should avoid eating pastry or ice cream when travelling ).
  • Lack of data. Inadequate surveillance has led to an inadequate understanding and response to the problem.

Peak global health organisations see AMR as a real threat as evidenced by a 2016 UN high level meeting on the subject and subsequent global planning to stem resistance. WHO have released a list of priority organisms and these have been categorised according to their threat level as urgent, serious, or concerning.

Responses required for tackling the problem include:

  • Improved knowledge and awareness of the issue at all levels. This should include building awareness amongst industries such as food production.
  • A solid global and national policy response, including workable frameworks and accountability.
  • Optimisation of antibiotic use through stewardship, and reduction of antibiotic use through lowering infection rates.
  • Investment in research and development.

Monica argued that now was not a time for complacency. We need to be careful about how we use this precious commodity. We need a workable road map of what to do, and commitment from business, which is likely to require strong governmental policy. 

At a clinic level, it raised questions for me about the wisdom of contact treatment where risk is low, and the contact indicates their willingness and ability to abstain from sex until results are received. We currently advise contact treatment, so is it too controversial to wait?

It also raises questions about any rollout of antibiotic prophylaxis for high risk groups

The presentation was a confident and engaging call to action.

On the throw away line regarding the risks of global dining, a friend who I informed about the presentation commented “deliciously infected by an Italian Gelato”.

 

 

 

 

Posted by on in Workforce Development

Presenter – Joanne Leamy

Joanne led an enthusiastic presentation about the implementation of a large scale screening program in Far North QLD which adopted a peer education model to encourage STI and BBV screening among young people.

The scale of the project appeared somewhat daunting at the start. Fortunately, with much energy, and a strategy which put local communities at the centre, a significant improvement in testing rates has been achieved.  Aspects of the project included:

  • Screening in 10 remote communities and 2 towns in Far North QLD, targeted at young people.
  • Traditional owner groups were included in consultations.
  • Adequate staffing and ongoing staff training gave the project a real chance of success.
  • Peers were recruited with the help of local employment agencies and given basic STI training. They received wages for their work. All peers were residents in the communities.
  • Focus on workplace culture. It was acknowledged that working as a peer was not always easy. Support for peers was built in.
  • An understanding of attrition. Young people may change priorities, and new peers may need to be recruited.
  • Appropriate ‘branding’ of the screening drive in order to have cultural integrity.
  • Incentives, e.g. daily prizes such as footy jumpers.
  • Well planned outreach with adequate equipment.
  • Continuous quality improvement was included. While the reaction to feedback by clinilinic staff was not always initially enthusiastic, it has been an important factor in developing the program.

The program led to a clear increase in screening rates across the area, rising from 24% in 2013 to 53% in 2017. Interestingly, syphilis rates were not found to be as high as expected (10%). As an example of resources required, at one of the sites which had a target population of 130 to 170 15-29 year olds, 7 staff members were present for 4 days of testing.

Joanne acknowledged that without the peer workers providing targeted messages, hope, and support, the project was unlikely to have been as successful. An example of their contribution included being able to bring local language to the testing setting. The presentation demonstrated that improved access can be achieved with a lot of energy and the right mix of resources.

 

 

Presenter - Ms Danielle Collins, Nurse Practitioner Candidate, Alfred Health

Danielle walked the audience through some of the important considerations and challenges involved in establishing nurse led models of care. Her presentation highlighted the need for rigorous step by step planning, which requires organizational commitment and solid partnerships.

Danielle used two Victorian practice examples to draw attention to these key messages, one being a nurse led rural clinic focused on HIV prevention and the other a combined medical/nursing model aimed at increasing client participation in HIV care in a metropolitan hospital.

A brief summary of the ongoing evolution of nursing roles was given, with an acknowledgement that with planning, nurses are well placed to provide various aspects of care which can improve HIV prevention and treatment, particularly with the slow but steady breakdown of barriers to advancing scope of practice.

The rural example involved the roll out of PREP to a regional area via the establishment of a monthly nurse led clinic within an existing health service in Bendigo. The visiting Nurse Practitioner Candidate is supported in her role by access to an ‘on call’ physician, and the sexual health nursing staff at the clinic.

The metropolitan project began from an understanding that many people living with HIV were presenting to tertiary hospitals with issues that were not directly HIV related. Management of these issues could have been potentially coordinated through an advanced nursing role. A specialist HIV nurse role was established, where the practitioner offers a health assessment and follow up for patients who have multiday admissions.

 Danielle noted a number of important points in relation to the planning and set up of these services.

  • Organizational support was key to achieving a workable model.
  • Funding can be difficult. Projects need a solid business case behind them. In a bulk billing setting financial modeling which takes into account slow clinic times must be factored in. Projects need to be viable if they are to be sustained.
  • Scope of practice also needs to be carefully thought out, with planning for all contingencies. Ask ‘what if?. Recognise the limits of practice as well as opportunities for autonomy. 
  • Collaboration is vital, particularly when moving into community settings. Projects need to be wanted by the client group and supported by the community. Find local leaders.

 

Danielle’s presentation demonstrated that the journey to innovation requires the enthusiasm of many players, sustained effort, and business acumen. It was also an optimistic take on the future contribution of nursing in the area of HIV related chronic illness management.

 

 

People from Sub-Saharan Africa and South East Asia have the highest rates of HIV diagnosis in Australia in relation to country of birth, and people are often diagnosed late. Victoria Sande and her colleague Corie Gray presented an engaging talk about a collaborative study which aimed to identify barriers and enablers for testing among these high risk groups.

The study involved focus groups across four states (Western Australia, South Australia, Victoria and New South Wales), and included 77 participants. Questions were centered around HIV knowledge, access and barriers to testing, and ways to increase testing.

Generally, results showed a lack of knowledge in relation to testing across the groups.

Identified barriers to testing included:

  • ·         Ideas about why people attend health services. Health services were seen by some as only for those who are sick.
  • ·         Some indicated they preferred not to know about an illness which was feared.
  • ·         The cost of attending health services.
  • ·         Fear of homophobia.
  • ·         Participants identified gaps in knowledge about where to get tested.
  • ·         HIV was not seen by some as an issue in Australia. They felt that they had been tested on arrival and were therefore in a ‘safe’ country. This was reinforced by the perceived invisibility of HIV in Australia. They did not see much information or concern about it in their surroundings.
  • ·         Some older participants had negative experiences of HIV in their country of origin and this impacted on their engagement.
  • ·         Fear of having to return to their country of origin if receiving a positive diagnosis.
  • ·         HIV was seen by some as associated with people different to themselves, people who engaged in activities such as drug use or sex work.

Some of the motivators for testing were:

  • ·         GP initiated testing
  • ·         Influence of peers

The presenters suggested that alternative testing methods, including self testing and home testing could be attractive to people from these high risk countries.

HIV testing as part of a regular health check was considered a more acceptable approach, as this did not entail identification as someone at higher risk.

Health promotion targeting the broader community might also be more successful, as opposed to targeted campaigns that these groups do not identify with.

 

The presentation highlighted the importance of a culturally sensitive approach when encouraging testing for people from these high risk backgrounds.  

Epidemiologist Barbara Telfer presented the findings of a cross sectional study which used NSW HIV notification data to identify predictors of late diagnosis.  Of the potential risk factors examined, the study found the following four factors to be associated with late diagnosis:

  • ·         being over 50 years of age
  • ·         being  female
  • ·         being born outside Australia
  • ·         residing in regional /rural areas

 

Late diagnosis is an important problem because it delays treatment, enables ongoing transmission, and can lead to poorer health outcomes.  If we are to continue progression towards virtual elimination, we need to identify the more elusive gaps in detection.

The study included data from 1465 notifications between January 2013 and June 2017, of which 38% (550) were considered late notifications. Late notification was defined as a CD4 count of less than 350 or an AIDS defining illness or death within 3 months of diagnosis, in the absence of a negative HIV test in the preceding 12 months.

Barbara noted that the study relied on data provided by the clinician giving the notification.  Some notifications could not be included due to missing information, which draws attention to the need for accurate data collection.

The study concluded that greater efforts needed to be made in the earlier detection of HIV amongst the groups found to be at high risk. The findings highlight the need for testing efforts to be inclusive of those who may not readily identify as needing a screen, to think both broadly about testing, and to be aware of those patients who we may have neglected to consider in terms of their risk. It is also a reminder for those clinicians working in rural and regional areas that they may be key players in earlier detection.

 

 

RT @hepqld: Curing #hepatitis C is easy, and no longer needs a specialist to prescribe treatment. Community doctors play a pivotal role in…

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