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.

Laura Cunningham

Laura Cunningham

Laura is a Clinical Nurse Specialist from the Kirketon Road Centre, which is a Primary Health Care clinic in Kings Cross. The aim of the service is to prevent, minimise and treat HIV and other transmissible infections and hepatitis. Laura’s role involves health education and co-ordinating youth clinics in the Kings Cross area.

Day 4- Increasing the demand for HIV testing

Mark Stoove discussed innovative ways to improve HIV testing.  50-70% of HIV transmission among GBM are attributed to undiagnosed infection. There were policy and regulatory changes in 2012, which revolutionised HIV testing in Australia. Rapid HIV testing was introduced and there was an increase in HIV testing in community settings. The uptake of rapid HIV testing has been modest. Barriers may include funding, lack of government subsidy and some services feel testing can be time and resources heavy. The majority of HIV testing continues to occur in primary health care settings using serological laboratory testing

Community based HIV testing services such as ACON provide a comfortable, peer based service which clients find very acceptable.  ACON in Sydney provides a peer based testing model, which is supported by nursing staff. Peer based clinics have successfully attracted first time testers that were classified as ‘high risk’. Rapid HIV testing has increased testing in urban areas but more needs to be done for those living in rural areas. We need to expand the geographical reach of HIV testing. The Terence Higgins Trust provided funding to increase testing in the UK. In a 14-month pilot study over 17,500 testing kits were posted and 10,410 specimens were returned. There was a positivity rate of 1.4% and this testing was welcomed by participants with 97% reporting that they would test this way again. Self-testing kits are available in the UK and the uptake has been excellent with over 27,000 units sold between April 2015 –Feb 2016. Half of the test kit users have never had a HIV test before.

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

-Funding may be a barrier for services offering HIV testing. Government subsidies could improve rates of HIV testing

 Vickie Knight spoke about the effect a[TEST] clinics has had on HIV testing among gay and bisexual men. It was found that the clinic on Oxford Street in Sydney has increase testing and also increased the frequency of testing. Factors that make this clinic user friendly include short wait times, the service is free, CASI is used which means intrusive sexual health histories are not taken by health professionals.

 

Key messgaes

This model works and has increased testing among GBM.

 

James Ward presented evidence about the increase in HIV notifications in Aboriginal communities in 2015- 38 cases. The rate of diagnosis has more than doubled in 1 year. HIV is increasing in remote communities. There has been an overall increase in HIV testing, especially in MSM populations but more needs to be done to increase testing and promote treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) in Aboriginal communities.Ward stated that the syphilis outbreak in Northern Australia is a national shame with over 900 new infectious syphilis cases and 3 neonatal deaths.Harm minimisation services such as needle syringe programs should be expanded. In the past 5 years there has been a 43% increase in hepatitis C diagnosis, which are largely attributable to injecting drug use. Young Aboriginal clients are particularly at high risk.

Key messages

-HIV testing should be offered as part of a routine sexual health screen

-Community engagement is needed to improve the uptake of TasP and PrEP

-Timely surveillance data is needed.

-Some GPs may not be offering full BBV/STI screening as the consults may be lengthy. Work is underway to Medicare items specific toBBV/STIs

-More NSPs are needed

 Caitlin Douglass from the Burnet Institute conducted study on the sexual behaviours and Tinder usage among young Australians.

Tinder was found to be the most popular dating site. An online study of 1001 revealed that 690 participants had been sexually active in the past year and 40% (266) had used Tinder in the past 12 months-35% women and 45% men. Douglass questioned whether Tinder could be used to promote sexual health services and noted that there was a lack of sexual health content on dating apps. Grindr is the exception as there are ‘sexpert’ willing to offer health advice at the click of a button. Grindr also has a portal which can advise users of their nearest sexual health clinic.

Gemma Hearnshaw of the NSW STI Programs Unit discussed the Playsafe website. Playsafe is an interactive engagement tool, which can inform young people about safer sex practices and testing. Peer educators are trained to deliver informal education to festivalgoers and provide free condoms and advice. There has been repeat exposure of safe sex messages on the Ticketek and Live Nations website.

Viv McGregor grabbed everyone’s attention with the fabulous music video –Close: Lady Sings it better. This playful video leaves room for the imagination. I would recommend everyone have a wee look! Click on the link below.https://vimeo.com/157020994

Research by Albury and Noonan in 2001 revealed high levels of same sex sexual interactions among women, despite the fact women often identified primarily as heterosexual. The study found that there was often a lack of sexual health knowledge among this group and they often participated in riskier sexual practices such as impact play, blood play and fisting.

Key messages

More targeted, culturally appropriate information is needed. Clinicians should opportunistically invite all patients to complete sexual health screening irrelevant of sexual orientation or practice.

Claude packs are available in NSW-‘Play packs’ and ‘Blood Play Packs’.  More information is available at www.iloveclaude.com

Alison Coelho spoke about a comic based resource for young people from refugee and migrant backgrounds. It was acknowledged that change and unsettlement can cause huge upheaval among this population and many people accessing their services have had significant interruptions to their education. It was found that there was limited information regarding sexual health and a surprisingly high number of young people accessing the service had participated in transactional sex.75% of humanitarian intake is young people and a large proportion are young males. They are often unaccompanied minors and often do not have female role models in their family. Sexual health is often not a priority for this marginalised population group. Issues like housing, employment and language acquisition often seek precedence over sexual health information.

The SHARE project has published many cartoons with important sexual health information messages with little written dialogue. Fact sheets are also available.

Key messages 

This website is a must for people working with young people. Check it out @ www.ceh.org.au

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Professor Rebecca Guy from the Kirby Institute delivered a talk on how new technologies are important for STI prevention. Media technologies allow young people to 24-hour access to information on sexual health. Computer assisted survey instrument (CASI) is an efficient way for clinics to collect information and triage clients. It is acceptable to both patients and clinicians. Studies have found women are more likely to report higher numbers of male partners via CASI than during a face to face consult with a clinician.

ACCEPt is a prevalence study, which aims to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing among 16–29 year olds in the general practice setting. Findings from the study include: 73% of chlamydia cases in the study were asymptomatic patients attending for non-sexual health reasons. This highlights the importance of offering all young people chlamydia treatment at GP visits. 

Point of care testing (POCT) in rural areas has been successful. POCT can significantly reduce the time from diagnosis to treatment in many clients-especially marginalised populations who are often transient.

 Professor Mark Hayter from the University of Hull spoke about integrated sexual health services and highlighted the need for school based sexual health clinics. There is some evidence to show a reduction in births to teenage mothers and a reduction in chlamydia rates among young men in young people who have access to school based sexual health clinics.

More focus is needed on alcohol misuse interventions and services. Alcohol consumption can reduce inhibitions and can lead to unsafe sexual practices. Clinicians should include alcohol and drug history as well as the patients sexual health history and provide brief interventions and referrals to appropriate services as needed.

It was also highlighted that whilst PrEP is very important for HIV prevention we also need to counsel men around safe drug use when they engage in “chemsex” as this can pose further r

 Christopher Fairley postulated that pharyngeal gonorrhoea could be transmitted by saliva-via deep kissing and by using saliva as lubricant; which stirred great interest among the attendees in this morning’s session.  Anti-bacterial mouthwashes may be the way forward in substantially reducing gonorrhoea prevalence. Watch this space!

 Catriona Bradshaw discussed Mycoplasma genitalium (MG) and Chlamydia trachomatis (CT) infections in the rectum. There is no standardised treatment for rectal chlamydia. The Centre for Disease Control guidelines does not distinguish between urogenital and rectal chlamydia.

Doxycycline appears to be the best treatment for rectal chlamydia. A randomised control trial is underway and this will inform treatment guidelines for rectal chlamydia.

MG has been less studied that CT and the data available on rectal MG is limited. MG testing is unavailable in many settings and may take 2 or more weeks to get a result.

There have cases of macrolide resistance, which have meant that this clever bacterium may need dual antibiotic therapy to treat and there is a great need for more antibiotics to be developed.

Key messages

-Doxycycline should be used over azithromycin for rectal chlamydia while awaiting RCT evidence

-Rectal MG is commonly asymptomatic and more common in HIV positive males

-MG is predominantly macrolide resistant

-Better treatment guidelines and treatments are needed

 Jane Tomnay- Patient-delivered partner therapy for STIs: the current state of play in Australia

Patient delivered partner therapy (PDPT) describes the practice in which treatment is prescribed for the sexual partner/s of an index patient diagnosed with a sexually transmissible infection, as well as the index patient. The patient then delivers a prescription, or the treatment, to their partner/s. PDPT aims to target those partners who are unwilling, unlikely or unable to consult a health professional in a timely manner.

Jane presented about the difference between a ‘provider referral’ versus ‘patient referral’ for the treatment of STIs. PDPT can be less resource intensive and was found to be acceptable to many. PDPT is already happening in Australia and the NT has taken the lead with this initiative.

Key messages

-PDPT works

-PDPT for chlamydia using azithromycin is safe

-Pharmacist’s knowledge regarding PDPT was low therefore education is needed

-In trials there has been no difference in partners followed up between medication PDPT and prescription PDPT

 

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Posted by on in Social and behavioural research

Khadija Gbla is an inspirational woman who settled in Adelaide after attaining refuges status via the United Nations Refugee Program. In 2004 she became a peer educator in the Women’s Health State Wide program ‘Female Genital Mutilation’ (FGM) and is now the Director of 'No FGM Australia'.

Khadija raised an interesting point about the different values some cultures put on sexual health. For some CALD communities’ sexual health is not a priority as they have competing factors such as poverty or homelessness. Another interesting point made is clinicians need to consider women’s safety when discussing contraceptive options as partners may not be supportive of contraception and this could lead to violence.

 

Take home message:

Women should be asked about FGM and appropriate referrals can be made. Sexual health is a human right and we should support people to make informed decisions about their sexual health.

Khadija has an interesting Ted Talk available from https://www.ted.com/talks/khadija_gbla_my_mother_s_strange_definition_of_empowerment

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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