“There has probably never been a population both more heavily impacted and less discussed at scientific meetings than the transgender population around the world” Dr Tonia Poteat CROI 2016

This was a recurring theme at the ASHM conference this year and not before time!  Zahra and Teddy spoke to a paper that they plan to launch on World AIDS Day this year.

As background, trans people have been severely underserved in HIV/AIDS responses worldwide, and in Australia, with Victoria as the only state listing trans people as a priority population.

There is a lack of data on the prevalence of trans people living with HIV worldwide, however figures presented were:  19.1% of trans women, limited data for trans men, and no data for non-binary people. Australian figures from the Kirby ACCESS data showed of 696 people, 5.2% were HIV positive - 8.9% for trans women and 4.5% for trans men. However 40% had no gender identity recorded.

An interesting comment was the lack of knowledge by health professionals about trans gender issues and how, as a patient, they end up educating their health providers about trans gender issues, especially when having to meet narrow medical models for care which doesn't always sit well.

I thought this presented quote summed up further risks for HIV for trans people very well:

“Other barriers to health and health care are the numerous socioeconomic determinants of health that legally, economically and socially marginalize trans people. These include discrimination in employment, education, housing, and relationship recognition: police harassment, often as a result of actual or assumed association with sex work; and identity document policies that deny many trans people legal recognition in their true gender. They also include aspects of structural violence such as racism, violence against women, and poverty.”  Open Society Foundation, 2013

So what can we do to support trans people in the HIV response?

•  Include trans and gender diverse people as priority populations in HIV strategies
• Start collecting gender and sexuality data better! See attached photo of a suggested way of collecting gender data
•  Positive interactions with medical community
•  Access, informed consent
• Meaningful inclusion in health promotion campaigns
• Meaningful engagement and decision making by communities

I’ve also included a photo of the fab presenters. Thank you for an articulate and engaging presentation and panel discussion. 

Warning: this report deals with torture, trauma and rape/sexual violence so a trigger warning is provided.

Lauren gave a strong, emotionally challenging presentation regarding the setting up of a specific service to cater for the needs of women who are refugees from the Democratic Republic of the Congo.

Wodonga in regional Victoria began receiving refugees via women at Risk Visa 204 of the Humanitarian Refugee Resettlement program in 2015.

Lauren spoke about the history of trauma, torture and rape that these women had experienced in their former lives and how this impacted on the service delivery model established. She spoke of how these women have been unwilling to engage and maintain engagement in care, and strategies used to resolve this situation.

The Democratic Republic of Congo (DRC) is incredibly unstable with wars that have been ongoing for more than 20 years. There are up to 70 separate militia, with internal mini-wars frequently occurring. DRC has the world’s largest UN peacekeeping force and is described as ‘dangerously unstable’.

Traditional cultural values regarding women’s status are vastly different to our own. For example,  DRC has legislated that a wife ‘owes obedience to her husband’ and  that marital rape is not an offence. Marital rape is common, with 1 in 3 women reporting this. Women have no right to own property or wealth.

Rape has occurred to many of the girls and women of women of the DRC regardless of marital status. The reasons for rape are many reflect both the incredible instability created by war and the powerlessness of the women in the society. These include: punitive rape – to punish or silence; status rape; ceremonial rape; exchange rape as a bargaining tool; theft rape –abduction; and survival rape.

All of the women in the service acquired HIV as a result of rape. Many witnessed the murder of their husband and other family members; kidnapping, rape and loss of their children; were subjected to extreme physical violence and often fled with children other than their own e.g. nieces and nephews. Families fleeing were separated with no knowledge of the whereabouts or outcome of family members.

Attitudes to HIV were very fearful in this community. Fears included disclosure, death, transmission, ostracism and discrimination. Women with HIV are often blamed for the infection. This leads to lack of understanding for reasons both for ongoing monitoring of health but also engagement at all due to fears of being seen at any of the points of care. Some of the strategies to encourage the receiving of healthcare included: not having specific HIV clinics so that clients would not meet each other; flexible walk in model; not noting HIV on medical notes – the generic ‘immunocompromised’ was used instead; and care with interpreters – using only trusted phone interpreters, not using names nor using the term HIV.

Lauren talked about issues around pregnancy; so far they have had one baby born and another baby is due. This involved upskilling of staff – both community health and maternity staff. One GP decided to get her S100 prescribers approval which was a great outcome for the community. However pregnancy and parenting has provided further issues for the women such as questions about why they are bottle feeding,  questions about why the child is receiving medication and having blood tests, as well as fears of disclosure during the contact with health workers.

Lauren saw the future as education involving all those involved: Women living with HIV, men from the DRC, the community and healthcare professionals.

I was very keen to attend this presentation as I work in a sexual health service in a nearby town and state, and this service has offered further choice for HIV care in the regional community.  I congratulate Gateway Health staff – Lauren, Catherine and Ange on this successful ground-up initiative, which is inherently very difficult to achieve. I look forward to refugee women finding a voice to tell their own stories at future events.

Anna McNulty presented about the New South Wales initiative of posted self collected HIV dried blood spot testing. This is of interest to me as I work in a sexual health clinic in a regional setting and I'm aware of how isolated some people are who could benefit from a HIV test.  In my setting I'm aware of isolated MSM who are not out in the local community and/or don't want to be seen at a sexual health clinic or are unable to travel to a local sexual health clinic. Some feel unable to discuss this with their GP or may not even have access to a GP.

 Background to this project:

• HIV New South Wales strategy identifies GBM and CALD  as priority populations for testing
• 11% of people with HIV in New South Wales are undiagnosed
• GBN are interested in self testing however currently not available
• Those from CALD communities are more likely to be diagnosed late 

 How it works: 

•  Dried blood spot test (DBS) test ordered via website
•  Person uses small lancet to prick finger and apply blood to small circles on blotting paper, 5 drops preferred
•  Sample is returned in the reply paid envelope to SVH lab
•  Negative results SMS via Sexual Health Infolink (SHIL)
•  Positive results via phone 

 Promotion: 

•  Promoted through social media and local initiatives
• Translated into 10 languages 

Results:

• November 2016 to end of September 2017 there were 505 registrations
• 77% MSM, 32% had partners from Asia or Africa, 26%  were from Asia or Africa, 14% CALD MSM, 11% CALD heterosexual, 4%had ever injected drugs or  5% Aboriginal. Note people could be for more than one group
• 58% kit return rate
• 54% have never tested or tested greater than two years ago
• Median kit return time was 18 days
• Reactive results: 1 confirmed and the person linked to care, another recent reactive result
• There were 39 repeat testers

Feedback from users of the test  in a post test survey:

• Test participants  were very supportive of HIV testing done this way and we're very happy they had the opportunity to test.  Feedback included: They  could test  in private, the test was was quick, free, convenient, no need to go to GP,  allows me to test ahead, it is less embarrassing, easy to do

Conclusions: 

•  Successful implementation however slowper uptake than anticipated
• Difficult to reach heterosexual CALD
•  Expected 1% HIV positivity
• Marketing is the key to uptake

Future:

• Phase 2 site specific projects including addition of hepatitis C RNA testing and Aboriginal and PWID added as populations to be targeted
• SOPV
• NSPs
• D&A services 

Dr Adam Bourne from La Trobe University in Melbourne spoke to four statements about safe sex drawn from his experience working in many countries.

1.  Sex is safe if it feels safe 

In some countries e.g. the Netherlands, HIV is being transmitted within regular sexual relationships rather than casual sex due to beliefs around the person being a risk rather than the type of sex being had. Familiarity, trust and a romantic halo effect led to more unsafe sex whereas perceptions about a person led to safe or no sex at all - e.g. in the U.K., 70% of men are not willing to have sex with a positive person.

2. Safe sex is what is possible

A world map of countries providing PrEP highlighted how PrEP is not an option in much of the world for safe sex. In some countries there is poor access to viral load testing making it not a tool for decision making. In some African countries water based lube is not available and it gets confiscated at customs due to association with gay sex.

3. Safe sex is about safe environments

Safe sex is non-threatening.  What does safe sex mean when there is lack of consent or threats to physical safety? Nearly one in 5 MSM in Southern Africa have experienced blackmail, entrapment or rape. What about safe sex when under the influence of drugs or alcohol?

4.  Safe sex is what I understand or appreciate 

For many condoms still equals safe sex.  For example in the UK only 30% of people have heard of PrEP and only 50% would use it if it was available. Other questions included can a pill really protect against HIV? Or what does undetectable mean? 

Dr Bourne commented that Australia is ahead of many countries in Europe and UK with MSM knowledge about PrEP and also knowledge about safe sex within relationships i.e. talk test trust together. 

EPIC-NSW  commenced in March 2016 and provides free access to prep for high-risk people at 27 sites in NSW.

The question posed in this presentation is: are EPIC-NSW  participants representative of people at high-risk of HIV?  

A comparison was made of participants against data of HIV notifications in New South Wales. For age groups (young men were slightly underrepresented), areas of residence, and Aboriginal and/or Torres Strait Islander the enrolment data was closely aligned to HIV notification data.

However for region of birth, NE and SE Asia born men were underrepresented, 2.5x and 2.4x lower respectively. In response, ACON developed specific initiatives to engage with men from NE and SE Asia using culturally appropriate engagement initiatives such as resources in 6 languages eg posters at train stations. In response, in the 3rd quarter 2017 there has been an increase in enrolments from men born in NE Asia of 103% and SE Asia of 83%.

The comment was made by the presenter that there Is more work to be done.  

However it was very interesting to see how close EPIC-NSW participants demographics correlated to HIV notification data.

As people living with HIV age, the risk of  polypharmacy due to comorbidities rises. This presentation discussed whether medication review  by experienced HIV pharmacists would assist GPs to manage the complexities of drug interactions, adverse affects and adherence issues of ART and other co-medications.

PROM-GP study  is an ongoing nonrandomised prospective open study of 100 patients recruited from February 2016 to August 2016. The criteria was that patients had to have one or more of the following: be above 50 years old, on five or more medications including ARVs, have adherence issues or a recent hospital admission. A single 20 to 30 minute pharmacist/patient consultation occurred in the GP clinic. A report outlining medication related problems (MRP) and recommendations was provided to the GP. About 10% were reviewed by a panel. There was a follow-up at 3 to 4 months to assess whether the MRPs were resolved.

Results: 542 MRPs identified; 262 high/mod risk and 280 low risk. At 3-4 months 159 high/mod risk resolved and 162 low risk resolved. MRPs were varied with drug interactions, monitoring, education, toxicity, undertreated and compliance being the most common issues cited.

Panel review of 15 randomly selected patients (89 MRPs). Panel agreed with or even rated higher 73% of MRPs. 

Summary: PROM-GP study identified 2 mod/high risk MRPs and 3 low risk MRPs per patient.  62% of high moderate risk MRPs were resolved at 3 to 4 months. 

 Patients were very satisfied with the service.

The speaker commented that pharmacists love answering questions so encourage patients to ask away!