As part of the closing plenary, there was a panel on the role for STI prophylaxis and it's potential use in Australia. The concept of bacterial STI prophylaxis is similar to that of PrEP in preventing HIV infection, however the use of antibiotics instead of anti-virals (of course).

The consideration of this raises several differing points of view among panel members from a number of backgrounds. I myself initially considered the use of antibiotics in an age of increasing resistance to our current frontline antibiotics to be a potential issue. This was an eye opener into what could be a potentially very effective tool for prevention of bacterial STI's.

Facilitated by

Associate Prof. David Templeton, Senior Staff Specialist, RPA Sexual Health Clinic, HARP Unit, Kirby Institute.

Panel Members

Craig Cooper, CEO Positive Life NSW.

Dr Bridget Haire, Research Fellow, Kirby Institute, UNSW.

Dr Jeffrey Klausner, Prof of Medicine, Division of Infectious Diseases University of California.

Prof David Lewis, Director of Western Sydney Sexual Health Centre, NSW.

Chris Williams, Co-founder of PrEP'd for Change, Victoria.

Dr Kathryn Daveson, Staff Specialist, Canberra Hospital, ACT.

As with my previous reporting to panels, I will not attempt to assign particular quotes to people, lest I lose their ability to articulate their point, being from their particular backgrounds and expertise. Rather I will paraphrase the panel and draw attention to particular themes raised.

Pro

That there is great potential for a range of populations ie. MSM, but should be used in combination with other treatments.

Con

There may be issues with accessibility for clients to medications (rural/remote, clinics, ? GP's) and feasibility of executing programs effectively (time sensitive large scale dosing, organisation and adherence).

Pro

Targeted groups with Doxycycline could be effective. It has been proven to be safe for use (ie. treating acne in teenagers). There has been no documented resistance to Chlamydia or Syphilis (to doxycycline). The potential for doses post high risk episode has potential (ie. single dose 200mg doxycycline).

Con

From an antibiotic stewardship point of view, this can have issues. Already significant change in bacterial resistance to antibiotics, noted in some strains of STI's. Largely, Australia is yet to see this but it is becoming more of an issue.

Pro

There is a lot of interest from people in the PrEP community to opt into this type of treatment. Treatments such as this would help to diminish the stigma associated with STI infections.

Con

Outside of Sexual Health, antimicrobial resistance has already become a significant issue. Skin and soft tissue infections are becoming more significant and risks of sepsis from resistant bacteria causing significant issues in other areas of health.

Okay, I'll change my rule on quotes because there were two that were great.

"We think we're smarter than the bugs but we're not!" and (if you're concerned about microbial resistance "STOP EATING FACTORY FARMED MEAT AND FISH".

-------------------------------------------

This brings me to the end of my reporting from the ASHM HIV & AIDS Conference in Canberra, 2017.

I would like to thank ASHM for the opportunity to have attended this conference and recognise the efforts of all the organisers and presenters this conference. It was a fantastic conference with much learnt and I look forward to the conference next year in 2018 to be held in Sydney.

Thank you.

The Implications of HIVSTI on Sex Workers

Udesha Chandrasena - Policy Officer at Scarlet Alliance, Australian Sex Workers Association

This was an very interesting session focusing on the accessibility of "self-test" HIV test kits that are currently available online and that have been made available to people in rural areas of Australia. With the changes and increase in availability of technologies that will allow for fast results, with some accuracy, to determine someone's HIV status, Udesha presented that this has potential to impact positively and negatively on sex workers.

The ability to have people attend tests at non-clinical locations can have great potential benefit in allowing for confidential testing in a private setting but can also have potential for significant issues.

Sex workers in Australia have been shown across Australia to have lower rates of HIV than the general population and also when compared to rates of sex workers overseas. This has been made possible through strong peer group programs in Australia and can only be measured in this population as a success, something that should be recognised. However this is not new data and across Australia every state and territory has it's own legislation regarding sex workers and a persons HIV status. This has potential to impact this population at risk with emerging new technologies that laws may not be keeping up with.

The advent of technologies with the ability to test a person on site or that need to be sent elsewhere for results may lead to an increase in the number of people tested but could also open workers up to potentially dangerous practices in their workplace. This could lead to bullying within brothels to be tested, to have workers be coerced by other workers, clients or brothel owners or managers to test in their presence. This has potential to impact on the workers safety, ability to work or force people to change practices or even be stopped from working. With differences between testing kits, techniques and potential technical issues with these technologies, this could lead to issues with false negative outcomes which would be managed differently in a clinical setting or with more "traditional" testing techniques.

Udesha argues that the current high rates of voluntary testing among the sex worker population be acknowledged and that changes to legislation across the country be made to ensure safety for workers.

In conclusion, there is potential for an increase in the numbers and scope of testing, however this can also negatively impact on sex workers. Changes in legislation across Australia is necessary to accompany this new technology.

Day 2: Afternoon Session Joint Symposium

Chaired by Teddy Cook and Ange Davidson.

So I'm going to be jotting ideas and themes as I go, paraphrasing.

Trans populations are and are becoming more so a at risk population in multiple areas, including violence, socioeconomic disadvantage, but also within HIV and sexual Health.

Teddy goes to say that despite your personal thoughts towards trans and gender diverse people, today is about your clinical practice, and this is what counts. "Lets consider this a call to action" "Because we need you. We have been erased over the last 30 years. We are not considered as a priority population in any state and except for the most recent statement".

The capture of data using sex, gender or identity is has been holding back ability to identify and treat. This has become so that people consider rates of trans and gender diverse people within risk populations to be low. This is false and unless people identify or area identified within data, we cannot make decisions on providing services to this population.

Furthermore, within the grouping MSM, trans men or trans masculine have been forgotten and erased.

Trans and gender diverse (GD) people area a VERY diverse group. Some define themselves within a multitude of different ways, a handful of examples being Trans, non--binary, brother-boys and sister-girls, queer... I could go on.

Trans men are men, and trans women are women. I would qualify this statement however trans and GD people do have some particular needs met (such as identifying that trans men may still need pap tests or trans women will need to consider prostate checks as they age).

Teddy asks, Will you stand with us to stand with us to move toward meaningful steps towards trans inclusion and recognition in this area of clinical care?

Panel Members (apologies if I don't go into everyone's CV's, believe me they've an interest and investment in this area).

Ange Davidson is a Sexual Health Nurse at Gateway in Wodonga, Victoria

Mish Pony, Gender Diverse and Trans sex worker representative for Scarlett Alliance, Australian Sex Worker Association

Dr Ayden Scheim, Global Public Health at University of California

Lisa O'Brien, Sistergirls and Brotherboys Australia, NSW

Jeremy Wiggins, Victorian Aids Council, EQUINOX Clinic, Vistoria

Dr Stuart Aitken, Sexual Health Physician, Gold Coast, Qld.

Dr Vincent Cornelisse Sexual Health Physician, HIV, PrEP and Transgender medicine, Melbourne SH Centre

Q: What does trans and GD inclusive clinical care look like to you?

The underlying theme here is that currently, in Australia, trans and GD people have fragmented care. Multiple panelists recognised this and that integration within primary care is needed to provide holistic care to this population.

Specific healthcare needs such as ARV treatments may be attended by GP's with experience and knowledge in this area, much in the same way as hormone therapy for trans people. The specific need to see an endocrinologist is not always necessary and some panelists make reference to "gatekeeping" within the medical profession, where patients require clinicians approval and guidance in this area, which may not always be the case.

Another theme that arose was the lack of experienced clinicians in rural or remote areas, even in cities outside the East Coast, meaning that people seeking medical transition (ie. hormone therapy) will need to travel for these healthcare needs, often away from their families and communities. In particular this is raised as a potential issue with Aboriginal or Torres Straight Islander people away from their mob, moving to larger centres or cities and the increased risk of socioeconomic disadvantage when moving to areas of higher cost, less support and increased isolation.

Another point made by the panelists is that there is significant difference from state to state (or territory) in regards to models of care, legality, requirements in particular to gender marker recognition. Informed consent is a healthcare model that removes particular onus from clinicians and allows trans and GD people to engage in their own healthcare and needs. It is not always necessary that someone be deemed "Trans" by a psychiatrist or psychologist before being allowed to commence on hormone therapy.

One great quote was "We don't send gay people off for sexuality assessments anymore, why should we do so for trans people?".

Q: Trans-specific healthcare is not specific healthcare, it is general, simple healthcare. How does this play out in your practice?

One panelist referred to their own practice and the normalisation of providing care to trans and GD people is paramount, that many of the clients they see have grown up in a society and culture hostile towards them and historically a medical model pathologising them. From a social justice point of view, one panelist made the statement that workings with trans and GD people was "very clinically satisfying" for these reasons, helping people through providing comprehensive general practice care.

One idea that was brought forward, that the concept of Evidence based practice is particularly binding to us as clinicians. Not all areas are so bound to the requirement that we must have hard available evidence in studies before we change practice. This in my opinion is an interesting concept, as on one hand I agree that we must be guided by scientific methodology that has been proven to be what makes "best practice" however the thought from the panelist(s) that we should strive to be more open to other forms of practice whilst evidence and studies are conducted in this area.

Q: In regards to HIV and Sexual Health care, where does this place trans and GD people?

Not all panelists agree that TGD people should be a priority population for HIV! Controversy!

One panel member refers to data showing that approximately half tans women in the last 12 months were not sexually active. Although limited accurate data exists, there is evidence that trans and GD people are both at higher risk and not at higher risk of HIV.

The panel then discussed how appropriate training for care of trans or GD people can and should be implemented. A general concensus that training should commence early in the career, preferably at university, to explain the basics of transgender and GD persons and their healthcare needs. There is experience within the trans and GD community that when meeting a practitioner who has a gap in experience or knowledge that they then need to themselves educate the practitioner in "trans 101" type information and this is not seen as ideal, particularly when a client themselves is not in a position to do so.

Final Thoughts, in no particular order.

- Training to include trans and GD issues, particularly for specialists

- Changes to data collection to include trans and GD persons

- Trans healthcare is simply healthcare. It should not be only for Psychiatrists or Sexual Health practitioners.\

- Increase in culturally appropriate healthcare for trans and GD persons

- Opportunity for trans and GD inclusive programs for Sexual Health and HIV medicine.

- That systems can and should change to adapt to new models of care (for screening, SH and HIV care and general healthcare for trans and GD persons).

Day 2 Morning Session.

Good morning folks, welcome back. The sun is shining, its still a bit cold in Canberra but you wouldn't recognise the place. I started the morning with the Opening plenary for the Sexual Health Conference, some fantastic speakers with valuable insights. Prof. Kit Fairley from Melbourne Sexual Health Centre was a highlight (fantastic speaker) as was Prof. Gracelyn Smallwood speaking on Indigenous HIV and sexual health with her career highlights numerous. Not just an informative session but also very entertaining. Wonderful speakers.

Our last speaker for the morning was Dr Ayden Scheim from the University of California speaking on Trans Rights, sexual health and HIV, referring to the studies, or lack thereof, in regards to Trans people in HIV and Sexual Health research. This as another area where work needs to be done and the way in which we as clinicians or researchers attend this will greatly impact on our ability to be proactive and effective. If I say something from personal and professional experience, work with us, not on us.

I will get off my high horse now and am currently sitting in the next session with Leah Williams, a Nurse Practioner from Perth Hospital speaking on the REACH Programme where maintaining clinical contact with at risk patients more likely to not be presenting.

Normally where referred patients would be discharged from care after two missed appointments, the Immunology clinic sought a change in the structure of clinic visits which is REACH. Candidates were identified as living in metropolitan area, with a detectable viral load and who would avoid or miss clinical appointments.

A cohort of 108 patients was found for the programme, consisting of 65% men, 32% women and 3% people identifying as trans. The research found that the most hard to reach people were Australian and not  born overseas. Interestingly a number of these people were identified as attending the clinic weekly despite no appointments, an indicator that people felt safe to be within this clinical area and with staff. Collaborating with other services, such as Emergency Department presentations by REACH clients being notified to the clinic and staff being able to take the opportunity to engage with the client.

Once i the programme, REACH patients could turn up whenever they like, which was no different to many of their previous attendance. No appointments were made on the books and so no data on "Did Not Attend" was recorded, a huge plus to the clinics KPI's. Focus was on the presenting issues of the patient rather than making visits specifically HIV focused. Another important change was having clinic Administration staff aware of the clients being part of the REACH programme and no reason for a visit was necessary, another way of making clients feel welcome and the clinic appear more accessible.

The "Virtual Clinic" was one innovation of REACH where patient case files were reviewed weekly by a multidisciplinary team and any changes in care or needs were identified in order to facilitate the above changes and give appropriate patient care.Ensuring more support was avaialble to patients commencing new treatments early on and after diagnosis was identified as an effective strategy and client medications were also made available to be picked up from the clinic daily or weekly and use of webster packs to keep things simple and accessible again were effective changes.

In total, DNA rates were halved, patients were happy and were no longer discharged by the service and quality care was given to the patients. The take home message was that we make small tweaks ourselves to make things work becuase patients less likely to do so. Hahaha, so true.

Thanks for following me and looking forward to the second part of the day.

Day 1: Afternoon Session

Welcome back to the afternoon (evening really, my laptop ran out of juice). In case you were wondering, it did eventually stop raining. Also, apologies for the formatting error in my last post, I'm sorry you had to see that.

The afternoon session in the main theatre was PrEP and was fascinating. I chose share with you the EPIC-NSW analysis done by Associate Professor Rebecca Guy from the Kirby Institute at UNSW.

Quickly a bit of information for those not from NSW or familiar with this program. Expanded PrEP Implementation in Communities in New South Wales (EPIC-NSW) is a study commenced in March 2016 and was designed to provide free access to PrEP to people at high-risk of HIV infection for free. This is the result of an active partnership between NSW Health, the Kirby Institute, ACON and clinical services involved in the study. The study was planned to have a rapid rollout and high clinical coverage within target populations and now has enrolled over 7,500 participants.

Rebecca spoke to the study, highlighting the similarities and disparities in demographics of people enrolled in the study and with data for new HIV notifications in MSM. The data for HIV notifications was taken from 2015 and the EPIC-NSW data up to and including September 2017.

Rebecca told us how the data shows mostly similarity in the capture of population at risk within the age, locality (urban vs. regional and remote) and to a somewhat lesser degree people identifying as Aboriginal or Torres Straight Islander (ATSI). However the one area demonstrated to have a disparity between the data and HIV notifications is that of people born overseas. Rebecca’s analysis has shown that in particular, people born in South East Asia (SEA) and North East Asia (NEA) are not reflected within the EPIC-NSW enrolments. From the data above, the rate of HIV notifications for persons born in NEA or SEA are 2.5 and 2.4 times respectively compared to the numbers reflected within the EPIC-NSW data.

In 2017 ACON increased the number of culturally appropriate programs, advertisements and information was released, targeting these populations. Examples such as posters in other languages and programs and information targeted to particular language groups has coincided with a marked increase in the population reflected within the study.

Rebecca concluded that although we mostly have participation that reflects the population targeted, we still have work to be done in order to reach the goals of the EPIC-NSW study.

Through my position in a sexual health clinic, I have been involved with this study, although I am well and truly at the lower end of the food chain than Rebecca. It is worth recognising the impacts on changing information available and making culturally appropriate services available to engage an under represented population. This is a great example of how changes in strategy can have a significant effect, although as Rebecca said, there is more work to be done.

I will be back tomorrow and hopefully won't be writing so late, I am now more prepared for batteries running out mid session. See you tomorrow!

Follow the Conference on Twitter with @ASHMMEDIA and with #ASHM17.

Day 1 ASHM HIV & AIDS Conference 2017 - Canberra

Day one, it's wet. Bring an umbrella. It is worthwhile to mention to the conference bag from SEW Conference bags, made by women in Tanzania living with HIV, they are made from recycled wheat flour sacks. It's a fair trade set up where employees are paid a fair wage, which is fantastic as well. They're pretty funky, I tried looking up their website but the domain expired a couple of weeks ago, so hoping it's only temporary. 

First up is the Opening plenary with Martin Holt and Denise Kraus chairing.

Acknowledgement of the Ngunnawal people on whose lands we meet with a welcome to country by Wally Bell, a Ngunnuwal man. Wally reminds us that if you take care of the land, the land takes care of you. I can't agree more with that sentiment.

A welcome from the government from Senator Richard Di Natale was next with a reflective Senator considering his own previous work in public health and HIV prevention in India prior to his career in politics. Senator Di Natale then spoke to how Australia was once leading in many ways for it's response to the emergence of HIV, the care and dedication of healthcare workers and how early implementation of Needle Syringe Programs helped stem infection rates. However we have more work to do as a nation, with examples given specifically as the still anticipated approval by the PBAC for PrEP on the PBS and that of our collective position as a leader in our region from a funding and policy standpoint with ending HIV. A final sobering example was given; the disparity between the Indigenous population and non-Indigenous persons. Among other indicators, preventable disease being five times greater in the ATSI population compared to the people not of indigenous background remains a stark reminder that we have far to go.

The Acting CEO of ASHM Scott McGill followed with his opening remarks and paying respects to Levinia Crooks who recently passed, who will be sorely missed. Later, In memoriam of Levinia Crooks will be conducted by Edwina Wright at the end of this session.

Dr Bridget Haire, President of Australian Federation of AIDS Organisations AFAO also welcomed us with again further reminders that work is yet to be done across the nation, highlighting that "Best practice depends on where you live". City to country, we have large gaps within our reach as clinicians despite the hard work we all do. A few take home messages for me, that advances in the field of HIV treatment, prevention and screening are not always technology based (such as the advent of home testing), but community based programs can be of even greater significance. Also, that we need to ensure equitable action to ensure proper prevention, screening and treatment.

The last welcome of the morning was from Cipri Martinez, President of the National Association of People with HIV Australia (NAPWHA). The important news that undetectable viral loads in people living with HIV means it is sexually untransmissible. This still has not resonated across society and the stigma associated with HIV still remains, to quote "letting go of our fears and the modern reality of U equals U".

I will end this post with Cipri's last quote, "People deserve our care, and our best. Thank you for continuing to care and welcome to ASHM 2017".