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.

Globally we are at a crossroads, with significant progress made towards the virtual elimination of new HIV transmissions in Australia by 2020. Success is characterised by collaboration and strong partnerships between community-based organisations, research, policy and (some) affected communities. Combination prevention strategies have been enhanced through peer-education and harm reduction programs, condom usage, PrEP, PEP and TasP. Also, there has been a focus on increasing the quality of life for PLHIV. 

In Australia, the sector is well positioned to achieve the UNAIDS global targets of 90-90-90.

But is this enough?

There are persistent issues for people of culturally and linguistically diverse communities. Late diagnoses are an ongoing issue, in particular with Aboriginal and Torres Strait Island communities, as well as South East Asian populations. For Aboriginal and Torres Strait Islander people, the rate of HIV is more than double that for non-Indigenous Australians, exacerbated by a completely unique set of transmission drivers. Criminalisation is still impacting negatively on sex-workers and their access to services. Data on key populations, such transgender and culturally and linguistically diverse populations is incomplete. Stigma and discrimination, barriers to health literacy, shame and machismo are having a continued impact on progress.

From a moral and human rights perspective it is imperative that on one is left behind!

Over the period of  the epidemic we have amassed a great deal of evidence and a good blueprint of what works well to enable the sector to move forward, but action needs to be taken now to:

  • Enable equitable access to new HIV testing technologies and harm reduction strategies
  • Reduce barriers to accessing treatment and care
  • Increase health literacy among the sector workforce and throughout communites
  • Enhance the meaningful opportunities to involve affected communities
  • Improve the framing and reach of health promotion efforts
  • Advance shared care models and dedicated services for key populations
  • improve date and surveillance, research and evaluation strategies
  • Continue to invest in partnerships

What is our response?

Are grass-roots efforts like we saw in the 80s and 90s needed or even achievable? We need to assess what things are different now and ask what support is needed by affected communities today to give them a voice. As well, we need to better understand what role other key stakeholders (policy-makers, funders, practitioners and researchers) collectively play - we need better funding models and more visibility of the issues.

How do we coordinate our efforts for efficiencies and synergy ti ensure no one is left behind?

"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

TGD are being recognised as a high risk population (WHO 2015)

Nineteen percent of Trans women world wide are HIV (+ve). Limited evidence about HIV among trans males is available due to the lack of data/evidence.

ACCESS (Kirby Institute 2017) Data shows out of 696 people 5.2% were HIV (+ve); 8.9% were trans women and 4.5% trans men. Trans women were more likely to report sex work

Barriers to Prevention: Methodological, cultural, social and system, geographical and under representation

Legal Barriers: Pathologisation and legal sex recognition

Trans and Gender Diverse people are a community of interest in UNAIDS/HIV elimination program.

They are not included in the National HIV strategy or included in STI/HIV reporting. This misses the opportunity to collect data of behaviors and STI/HIV testing among the TGD population

In a STI/HIV testing service a research project was produced to collect Sentinel Surveillance data via surveys that demonstrated the importance of the data collected

Three surveys were set up to collect the data between 2013-2017

The 3rd (2017) survey asking gender identity and sex assigned at birth: Of 1220 surveyed, 88 (7.2%) reported to be TGD, of which 61 of those reported to have a gender identity that was different to the one designed at birth 

Thirty nine has tested more than once at the service

* Take home: Simple changes to data collection based on community consultation had a considerable impact on the utility of surveillance to help guide STI/HIV prevention and care for TGD people

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 Public Health and Prevention

One of the biggest challenges facing health now and into the future is that of antimicrobial resistance, and Monica Lahra from the WHO did a fantastic job at outlining the issue.

Almost 40 years ago the specialty of infectious diseases seemed almost dead as it looked as if mankind had won the battle against microbes. However this was short lived as natural selection ensured antibiotics were no longer our golden bullet. 

Though to some degree antimicrobial resistance is an inevitable consequence of antibiotic use, antibiotic abuse has certainly led the problem to explode throughout the world.  Inappropriate use in hospital, community health facilities, pharmacies and pharmaceutical companies (dumping in water ways) and agricultural practices (fish farms and livestock) have all been the major of drivers of this. Furthermore travel has ensured these organisms are spread throughout the world. For example Poor antibiotic practices have ensured the subcontinent is riddled with ESBL enterobacteriaceae. A survey of Swedish travelers stools before and after returning from the subcontinent showed extremely high carry rates of ESBL after returning to Sweden, often persisting for months. It's tragic to hear now Colistin resistance is being widely seen, particularly in livestock.

So how do we tackle this growing problem? Not easily. Improving awareness and education to healthcare providers so they rationalize and appropriately prescribe antibiotics is key. Restricting over the counter purchasing of antibiotics must accompany this. Increased surveillance and research is also a key to understanding the patterns, distribution and resistance profiles of such organisms. And finally better hygiene practices must continue to be promoted.