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.

HIV notifications in Aboriginal and Torres Strait Islander people are increasing, mainly in men, mainly in Qld, particularly in regional settings. Transmission risks are different - higher IDU and heterosexual transmission than amongst non-Indigenous individuals.

Prof Russell spoke specifically about the FNQ outbreak that commenced in Cairns in 2014, and now included about 30 new diagnoses. Coinfections with syphilis is common (known concurrent / preceding syphilis outbreak in the area), and there have been 5 deaths due to congenital syphilis. This in itself is staggering. Mainly young men (2 women). Mainly MSM though not gay-identifying. Only sporadic IDU use has been reported. New cases include Cape York, Torres Strait and NT. 

Various measures that could be considered with regard to prevention were considered -systemically in this talk by this experienced HIV clinician who has been based in Cairns now for many years.

  • Condom use (Fagan et al 2010, self reported behaviours suggest similar rates of condom use amongst this group to others, but younger sexual debut, more sexual partners. Unlikely to be able to significantly increase.
  • Test and Treat - low level of HIV testing overall in this group.'Nth QLD STI Action Plan' covers syphilis but not really HIV; Good testing of male prisoners in Cairns, reasonable antenatally for women. Adult and young peoples health checks now include HIV testing. Consider - point of care testing (ALere Determine accessibility)
  • TasP - the presenter considers this is the most likely strategy to reduce onward transmission but costly, logistics etc.

A Recent audit found significant numbers at high risk of onward HIV transmission in need of case mx and extra support. Significant need for individualised management. Leaks from the Treatment cascade are myriad/multiple - shame/stigma, as well as more mundane issues like money/transport availability, poor hosing, low health literacy, alcohol and drug use. Furthermore this is generally a highly mobile population.

  • PrEP - Pessimism was expressed for this as a strategy in this group, despite 3% prevalence amongst the 2000 on PrEP in QLD. (4% population indigenous). However most in SE Qld.Pessimism because of low health literacy, most don't identify as gay; more engagement and culturally appropriate PrEP promotion is needed. On-demand PrEP or long-actin PrEP may be more appropriate in this target group.
  • Health promotion is urgently required-  but some ideas are circulating/in development.

The importance of knowing your epidemic is illustrated dramatically here.

Dr Anastasia Pharris from ECDC in Stockholm gave a detailed and insightful presentation on the state of HIV in Europe.

 

Current situation 

  • Globally HIV incidence is decreasing due to ART and viral suppression, but Europe is still increasing, mainly in the east
  • 80% of new HIV infections in Europe in 2015 were in Eastern Europe and mostly attributable to IDU but this is declining over time
  • MSM may be under-reported in the East
  • Mother to child transmission is very low in virtually all countries

Is Europe's response to HIV sufficient?

  • Probably not as many people are diagnosed too late
  • There is a big move now to test and treat regardless of CD4 but in undocumented migrants this falls short
  • Viral suppression is achieved in many countries, but Russia and the East are well below targets

Challenges and opportunities moving forwards

  • Europe needs to implement what they already know works
  • Harm reduction coverage remains low in parts of Europe and should be improved
  • Changing the culture of testing to community based, home sampling and non-medical staff will expand in the next 10 years
  • Many countries are still on the fence about PrEP, particularly in the East
  • 2/3 countries in Europe report that funds for HIV prevention are insufficient to implement the necessary prevention strategies
  • Low cost interventions should be utilised to target populations at risk e.g. Health promotion through apps (I will discuss an interesting poster about this in a later post)

Stigma remains an issue and Europe is not addressing this adequately

This was a very interesting discussion and there are points to consider in the Australian context – the use of mobile technologies and partnering with the private sector in this space; maximising access to harm reduction strategies as we know this works; and looking at expanded opportunities for testing outside the medical model to engage high risk populations.

 

 

 

 

 

Tagged in: EACS 2017

The Australasian Viral Hepatitis Elimination Conference 2017 held in Cairns was a an eye opener for me. I was intrigued by the international efforts to try and meet the WHO target to eliminate Hepatitis B and C by 2030. The revolution of treatment of Hepatitis C with DAAs which have high cure rates with fewer side effects should make this possible. However, the message was clear, to meet this target globally, efforts should not be at the local national level only, the international scene needs to be the focus.

Professor Samuel So, director of the Asian Liver Centre presented a great example of one of the ways this could be done in the Keynote 3 session, JoinJade: A Culturally and Linguistically Tailored Campaign to Help End Hepatitis B. His centre is targeting the Asian community with higher prevalence of Hepatitis B both in the US and in Asia.
View his presentation
here.

 

In plenary 4, Dr Homie Razavi, managing director CDA, also demonstrated international efforts with provision of epidemiology data and the Global Procurement Fund. He highlighted the challenges faced in trying to make this possible globally with no country signing up to the procurement fund which should make the DAAs more affordable, especially for poorer countries with higher rates of Hepatitis C infection.
View his presentation here.

 

Locally, here in Australia, the gap between the indigenous community and the rest of the community in Australia is just as wide for hepatitis infection. The rates of Hepatitis B and C are significantly higher among the indigenous population. There was discussion of formulating policies and programs targeting the indigenous community, including formal and non-formal or "cowboy" methods to improve access and treatment for this community.

Working for the Aboriginal and Torres Straight Islander community health service in Brisbane, this is important for me as a take home message. I can't wait to get back to work and start implementing the knowledge I acquired! I also hope to take this information back to my country of origin Zambia, my bit of effort in trying to eliminate Hepatitis globally.

 

A/Prof Rebecca Guy, Head of Surveillance, Education and Research Program, Kirby Institute UNSW, Australia, discussed the importance of Epidemiology and measuring our response at an Australian national level as we strive towards the WHO Hepatitis B and Hepatitis C targets.

She highlighted parts of the tracking process using examples of data from various specific population groups. The HCV prevalence of participants from NSP is around 55%, the highest incident in any group, with only 50% reporting a HCV test in the previous 12 month period. Of particular concern is the number of <25 year olds with HCV notifications that had not declined but remained at 15%. A measure of risk behaviour showed the incidence of needle/syringe sharing in the past month amongst people who inject drugs is around 15%.

We were reminded of the importance of our task as the number of people suffering from severe complications of HCV infection (cirrhosis/ hematoma/ death) continues to increase gradually.

Australia has made a dramatic response to the availability of DAAs by treating over 30,000 HCV in 2016, though our response needs to be sustained at more moderate levels in order to achieve Elimination of HCV in our nation by 2030.

With regards to HBV the incidence of notifications in young people < 24 continues to decline, likely to be a result of our Hep B childhood vaccination program. However, the HBV Diagnosis and care cascade continues to lag behind that of HCV.

In the Epidemiology sense, WHO targets currently set are defined as "elimination as a public health problem" rather than eradication (reduction of the world wide incidence to zero) or elimination in its stricter sense (cessation of transmission of a disease in a single country).

There are a number of ways of tracking progress towards elimination of HCV as a PHP.

 

 

  1. Modelling showed that while the number of new patients initiated on DAA will decline after the warehouse effect has passed, the WHO targets can be achieved before 2030 by intermediate estimates.
  2. Data at a finer geographical level showed widely differing treatment levels of both Hep B and Hep C across geographic regions of Australia and the need for targeted action in geographic locations.
  3. Collection and feedback of health service delivery data to individual sites or groups of services provides valuable insight and highlight specific needs and facilitate tailored management.
  4. Identify and overcome various barriers to accessing prevention services
  5. Importance of measuring new cases of HCV infection using HCV RNA testing as well as HCV antibody testing.
  6. Improve the completeness of Indigenous data.

 

 

 

 

 

 

A key part of this is the use of "data linkage" where information from all sources of hepatitis C related data are fed back to a central HCV notification centre to facilitate research analysis.

 

It is vital that we collect and feedback this data to the various local, state and National organisations for future Hepatitis Elimination management in Australia.

 

See also selected speaker presentations from this session, including:

Plenary session #5 was an inspiring reminder not to forget the people who are at the centre of why we do what we do. 

Rhondda Lewis, viral hepatitis health practitioner with Cairns Sexual Health Service and Yvonne Drazic started the session, speaking about their involvement with the Cairns Hepatitis Action Team (CHAT).   CHAT was established in 2013 by peers to empower patients to be the lobbyists and agents of change in the area of viral hepatitis. 

Through Asset Based Community Development, focusing on peers’ strengths and abilities to explore the community’s needs and visions for the future, the group has been very successful in organising many large events and contributing to the goal of having Cairns “Hep C free by 2020”. 

They have tried to avoid using the word “problem” when referring to viral hepatitis to reduce further potential for stigma and discrimination.  Instead, they focus on resilience, peer support, learning from others and increasing confidence to empower and promote real engagement to improve health efficacy.   They are rightly proud of CHAT reflecting Ottawa Charter principles in a real world setting. (1)

See Rhondda and Yvonne's presentation here. 

A/Prof Phillip J Mills, Kulkulgal Tribal Elder of Zenadth Kes and Associate professor with the Australia Institute of Tropical Health and Medicine (JCU) followed with a talk rallying us to press for policy change when it comes to how we manage the Aboriginal and Torres Strait Islander population who are affected by viral hepatitis.  He made excellent points that we should ensure that our services are culturally appropriate and consider the whole journey for the patient and the impact of various social determinants of health, rather than managing the disease in isolation.  He challenged us to consider that the language we use can come across as demeaning and damage the therapeutic relationship, thus affecting engagement in care.

Lastly, Melanie Walker, the CEO of the Australian Injecting and Illicit Drug Users League (AIVL) presented 3 case studies demonstrating the impact Hepatitis C can have on families.   She also pointed out to us that while 29,160 people with hepatitis C were cured in 2016, 5,900 new infections occurred over the same time period. 

If we want to reach the target of elimination of Hepatitis C by 2030, prevention and harm reduction need to be our focus, as well as considering how to assist those who are less well connected to the health care system to access treatment.  

Melanie discussed some of the barriers being no Needle and Syringe programs (NSP) in prisons, no formal recognition or funding of peer workers, punitive measures targeting people who inject drugs (PWID), stigma and reduced access to health services in regional Australia.   

In addressing these issues, AIVL’s work over 2017-2018 will focus on enhancing NSP service outcomes, building capacity amongst peer educators and other health professionals, improving Hep C outcomes for people exiting custodial care to improve transition to primary care, developing resources directed at harm reduction in the ATSI and CALD communities, creating a new website and continuing to write national policy papers to improve health outcomes in PWID.

These impressive goals have the potential to make real improvements to the health and well-being of the lives of PWID, as well as contributing substantially towards Australia’s elimination target.

See Melanie's presentation here

 

1. Lewis, RM, Drazic Y, Engaging community: The Cairns Hepatitis Action Team – paths to patient involvement, Journal of Virus Eradication Vol3, sup 2, August 2017

 

 

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