Australia has led the way in many HIV activities so why are we so behind when it comes to self-testing? Marginalised groups have been a focus of this conference, and rightly so. We know that self testing will be a part of the response to closing this gap in hard to reach groups but so far, no home test has been approved in Australia and access is currently limited to research.

Sarah Bell from the University of Queensland presented data on a peer led pilot to increase access to high risk men in rural and remote communities. They had a high uptake by infrequent/never testers with self-perceived risk and convenience being the main reason for participation. 93% didn’t want the optional pre-test counselling and most participants stated they were willing to pay for a test given the option to. 

ASHM President Dr Mark Block reminded us that HIV testing doubles when self tests are available and reported that the ATOMO test, currently under TGA review, is an accurate test with high usability. 

Dr Anna McNulty presented findings from the NSW Health dried blood spot self-sampling initiative targeting hard to reach groups.  Resources have been translated in 10 languages and the project has been promoted by multicultural health. Privacy was the most commonly stated reason for participating.

Key points from the HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2017

• Gonorrhoea and syphilis are increasing while HIV is stable for the fifth year in a row.
• the biggest increases in gonorrhoea rates are in young, urban heterosexuals
• The HIV notification rate is rising in Aboriginal and Torres Strait Islander people while decreasing in the non-indigenous Australian born population. 
• Asian born MSM were disproportionately diagnosed with HIV in 2016
• Over 30 000 people were cured of hepatitis C last year
• 63% of people living with chronic hepatitis B in Australia were diagnosed in 2016. Only 17% were receiving care and 7% were receiving treatment.
• Rates of STIs in the Aboriginal and Torres Strait Islander population compared to non-indigenous populations: gonorrhoea (7 times as high), infectious syphilis (5 times as high) and chlamydia (3 times as high)
• The number of newly diagnosed hepatitis B cases has halved in Aboriginal and Torres Strait Islander people over the past five years but has remained stable in non-indigenous populations

Like the Partners study, Opposites Attract has demonstrated that undetectable equals untransmittable. There were no linked HIV transmissions after 591.2 couple years and 12000 acts of condomless sex protected only by viral suppression. Three incident HIV infections during the study were not linked to the positive partner on phylogenetic analysis highlighting the importance of PrEP for those having sex with other partners.

The true role of STI’s in HIV transmission requires further investigation says Dr Ben Bavinton of the Kirby Institute, noting that there were very high rates of STIs detected during the study despite no linked HIV incident infections.

The question of how soon is ‘safe’ to have condomless sex after ART initiation also requires further study.

The take away messages from Ben’s talk are the importance of regular STI screening in this group, PrEP for those having sex with other partners, and condoms or PrEP after starting ART.

Opposites Attract was a prospective longitudinal study of serodiscordant homosexual couples in Australia, Brazil and Thailand. Couples had testing and completed behavioural surveys at least twice per year during the study.

NSW HIV diagnosis and care cascade 

Sweden and Denmark are the only countries so far that have met the UNSAIDS 90-90-90 targets. Yesterday, Phillip Keen from the Kirby Institute demonstrated that NSW has also reached this goal ahead of schedule with an estimated 91.3% of NSW residents living with HIV diagnosed, 92% receiving ART and 94.5% virally suppressed. Enhanced data collection and quality methods that have been introduced in NSW could be adopted elsewhere.

NSW now aims to have 90% of people diagnosed with HIV on treatment within 6 weeks.

Interventions internationally which have reduced access gaps 

In 2009, UNAIDS set an ambitious 90-90-90 treatment target to virtually eliminate HIV transmission. The goal was that 90% of people living with HIV would know their status, 90% would be on ART, and 90% would have viral suppression. Yesterday we heard about how these targets have been achieved in NSW and are on their way to being achieved in Australia, overall.

Hard work is left to be done in the remaining 10-10-10 who have not yet benefited from Australia’s improvements in early diagnosis, early treatment, treatment as prevention and PrEP.

Dr Jeffrey Klausner from the University of California, Los Angeles, is an expert and innovator in this area. He shared ideas that have worked internationally to close the gap in hard to reach groups and with limited resources including ART and HIV self-test vending machines. He has been involved in an online PrEP clinic that offers online eligibility screening and pathology ordering with a telehealth consultation and mail delivered PrEP. Given the inequitable access to and uptake of PrEP in Australia, the increasing demand for PrEP and the corresponding pressure on clinical services to deliver PrEP, this is a model well worth considering.

www.preptechyth.org

HIV & AIDS: Theme C Symposium – Addressing access and inequity in Australia’s HIV prevention response.