Day 2 Rapid Fire Sessions: Health Promotion and Education

Carolyn Murray (on behalf of Gemma Hearnshaw) – NSW STI Programs Unit (STIPU):  "No Question Too Awkward: Nurse Nettie, the Online Sexual Health Nurse".

Nurse Nettie is a confidential, virtual online sexual health nurse created to allow young people to email questions they may have about their sexual health/sexuality and receive an answer from a sexual health professional within 24 hours (although Nurse Nettie does have weekends off!)  Nurse Nettie was created to address the concern that young people may be too embarrassed or afraid to ask a Doctor/Nurse or parent/caregiver questions about sexual health.

Nurse Netttie does not provide diagnosis online but instead refers on to the most appropriate service where indicated.

Nurse Nettie commenced in April 2014 and the data presented was up until March 2016. In this time Nurse Nettie had received 761 questions with 77.4% of these being from people aged <30yrs.  Approximately 52% were from NSW and 17% were from abroad. 

Common question categories are listed in order below:

STI/HIV risk – 14%

Anatomy – 12%

Symptoms – 11%

STI/HIV testing – 10%

Contraception – 8%

In conclusion, Nurse Nettie has been shown to allow large numbers of young people to receive information about their sexual health in a confidential, personal and specific manner.

Nurse Nettie can be accessed at: https://playsafe.health.nsw.gov.au/ask-nurse-nettie

In today's presentations a strong theme came across that we need more data for sexual health services & the effectiveness of STI's in teenage programmes.

HIV is increasing in some populations.

Professor Mark Hayter, UK, talked about the importance of integrating a multidisciplinary approach         in Sexual Health.

That substance use is often predictor in context of higher risk sexual activity/practices/behaviours. 

Alcohol remains to the most significant driver, which equates to more sexual partners.

Evidence has shown that Clinicians need to identify higher risk individuals and interactions around substance use need to be more substantial, such as motivational behaviours skills. We may also need to consider bring in a Specialist in Drug and Alcohol/addiction, or refer on to another service if the expertise is not available in the service delivery model. 

CHEMSEX - MSM sexually disinhibiting drugs use, often with Viagra. 

Potential sexual Partners meet on line, App's - meeting up sites. 

Increased numbers of partners. STI’s risks increased 

PrEP is available option, but also need to address chemsex behaviour. 

Behaviour modification interventions such as education and prevention can reduce changes in behaviour, in drug use and unprotected sex & which reduces the risks of considerable harm. 

Evaluating 1 stop shops for (sexual health clinics) and the effects on staff. Research has shown mixed results of this. 

Need to build research into service design and evaluation with partnerships with Universities. 

Reaching out to Schools - Sex Education & relationships:

Nursing is best suited to deliver this care in outreach setting such as schools.

Nurse lead sexual health, mental health and substance use & care delivery to schools children and adolescents, is better delivered and protective under a broader health objectives, as a sexual health clinic at schools will become political. 

Wednesday 16/11/2016

A/Prof James Ward spoke about the divergence of HIV rates within Aboriginal and Torres Strait Islander (ATSI) communities.

HIV/AIDS in Australia has been a contained epidemic until now.

In 2015 Australia has seen the highest number of notifications in ATSI patients on record since the numbers have been monitored.

This is almost double what the Non-Indigenous notification rates are.

The majority of notifications are in men who have sex with men (MSM) at 51%, then the Heterosexual population is 21% with IV Drug Users at 16% of the notifications. (this was previously 3% in the 'early days')

Reminder that these figures are already 11 months old. Timely surveillance data is crucial.

The rate of notifications in Indigenous females is three times the rate of that of Non-Indigenous females.

This has been high in all regions, not just the urban and inner regional areas but now in the remote areas.

A/Prof James Ward mentioned there are a number of reasons why divergence is occurring but highlighted a few of the main reasons to be:

- a young, mobile population in more regional and remote communities

- risky practices such as sharing injecting equipment and the high prevalence of sexually transmitted infections (STI's)

-there is a lack of needle syringe programmes in the remote areas.

-failure to engage TasP (Treatment as Prevention) and PrEP (Pre-exposure prophylaxis) in the communities

-there is a high burden of disease and multiple co-morbid conditions in the Indigenous population and often these patients are on a number of other medications

He stressed the importance of being inclusive of all vulnerable populations when it comes to HIV.

The high prevalence of STI's in the 10-24 yr old age groups increases the risk of HIV transmission and poses an ongoing problem.

Previously there has been an increased focus on suicide prevention in this age group which is very important and needs to be ongoing , however, with the current Syphilis outbreak in Northern Australia and increase in HIV notifications more efforts need to be made to tackle this problem.

Unfortunately there is inequity in service delivery to these remote communities.

If we take a closer look at the Syphilis Outbreak in Northern Australia, the numbers of infectious syphilis diagnoses have risen exponentially. 

Could we be dealing with a similar chart for the HIV increases in the near future? Are we prepared for this?

Using some figures from Cairns;

-prior to 2014 there were approximately 15 diagnoses of HIV with 1-2 cases reported in ATSI patients.

-from 2014-2016 the diagnoses of new cases in the ATSI population increased to 50% of the total number of cases.

Most of the cases recently have been in young men who identify as bisexual or heterosexual.

The recent high level summit report in Brisbane has highlighted what is deemed important in terms of tackling this problem in communities.

Workforce development is crucial. Downsizing in certain areas is disastrous as currently the Indigenous population is in the most vulnerable position regarding the HIV increases.

HIV needs to be managed in the Primary Care setting using the support from central public agencies to assist with management.

There needs to be outbreak management and community involvement at every level.

Some suggestions have been to make HIV testing within 30 days after a STI has been diagnosed a nKPI. (National Key Performance Indicator)

To make STI and BBV (Blood Borne Virus) testing compulsory linked to the Aboriginal and Torres Strait Islander Health Check. (Medicare Item 715)

To have Medicare Item numbers for STI/BBV testing.

Education with regards to health literacy is important together with rehabilitation programmes and opioid substitution therapy for IV drug users.

Post Exposure Prophylaxis (PEP)is misunderstood and the community do not know how or when to access this.

James Ward stressed that the community needs to be involved at the forefront of the efforts ,the community needs to be engaged.

I would hope that after attending this conference that all of us walk away with at least a few strategies to take back to our practices or organisations to help prevent HIV becoming an epidemic in the ATSI communities.

I found the presentation by A/Prof James Ward eye-opening and motivating.

We all have a responsibility to play in changing the course of the diverging HIV rates within the Indigenous population.

"Holding Space for those who hold doubts" by Christy Newman, was very interesting. It described a view from a patient's perspective of what it means being on long term treatment possibly for rest of their lives and the implications.

There are several reason as to why patients may not choose to be on treatment. Some being just not ready for a life time commitment, some dealing with the new diagnosis, financial situations, co-morbidities that they already have which may affect or delay them from starting ARVs or simply being on long term medications.

It was clearly outlined with examples that patients need to have an option of being able to make choices in regards to when and whether they want to be on treatment. Are they on treatment as they need to be on it for their own benefit or is it to protect others from acquiring? Sometimes the side effects or the disruption caused by taking these medications would raise the question in their mind " protecting others from acquiring HIV? not a good enough reason to start meds"..... A point to be noted.

As clinicians it is our responsibility to explain the individual benefit of ARVs and the Public health benefit to the patients. However it is the individuals choice as to which direction they want to take. Hence holding space for those who hold doubts is an important step in HIV care.

Epidemiology of Anal HPV and Anal Cancer

Overview of the role of HPV in cancer.

Over 100 different types.

HPV 16 causes over half anal cancers. Other oncogenic types together cause about 80% of anal cancers.

Infection with many types is common.

Over 40% MSM have HPV infection at any one time. More common in HIV positive, and more common again if immunosuppressed which makes clearance less likely.

Anal cancer increases with age above 45 years.

The rates are much higher in HIV positive MSM compared with HIV positive men.

In the current HAART era 3% of HIV positive MSM develop anal cancer, rates that equal cancers like colorectal carcinoma.

Screening was offered and readily accepted.

In HIV positive individuals there was almost twice the number of abnormal PAPs compared to HIV negative.

Abnormal cytology had high sensitivity but low specificity.

Adding HPV 16 + increases specificity.

What should we be doing for our patients now?

The HPV vaccines are a game changer.

Should we screen for early HGAIN (high-grade anal intraepithelial neoplasia)?

Similarities with cervical carcinoma, and that has a screening program.

There are key differences - larger area to swab, harder to identify lesions, different natural history (more high grade lesions less likely to progress to cancer), 40-60% would need to go on to high-resolution anoscopies, we need better treatments for high grade lesions.

Currently, more than 50% of anal cancers are visible externally, with an average size of 2.9cm, making them at least stage II disease.

Are we ready to screen for early cancers?

Can we implement early detection with an annual digital rectal exam?

Most HIV physicians think it is very important to screen for anal cancer, yet hardly any do.

Annual DARE (digital anal rectal examination) is well tolerated and an acceptable screening test for patients.

An update of the Study for the Prevention of Anal Cancer (SPANC)

High grade lesions are 5 times less likely to progress to cancer than cervical cancer in HIV positive men and 50 times less likely to progress to cancer in HIV negative men.

Mean age was 50 years.

Mean duration of HIV infection 15 years.

90% on treatment.

Almost all had CD4 nadir < 200.

Almost all were virologically suppressed.

After 1 year of SPANC the following findings:

The rates of HPV 16 were very high.

Clearance of this type is less than half of the other types.

Lesions were not associated with age or length of time infected with HIV.

High grade lesions were related to immunosuppression and lifetime anal experience.

New infection is common.

There is a high rate of 9-valent types in infections.

Over 50% of lesions persisted for 12 months.

Anal cancer is a huge and increasing problem.

Educating the community about HPV and anal cancer

AFAO (Australian Federation of AIDS Organisations).

The Bottom Line - campaign developed by AFAO to increase awareness of HPV and anal cancer.

Increasing awareness of HPV infection, DARE, anoscopy and biopsy, and information for those diagnosed with anal cancer.

Campaign materials included a web-site (www.thebottomline.org.au), 2 printed booklets for clinicians to give to their patients, poster.

A community perspective on anal cancer and anal HPV

Postal survey of how much respondents knew about anal cancer.

People thought their risk of anal cancer was the same as the general population.

People did understand what the symptoms would be.

Most had never discussed HPV or anal cancer with their doctor.

Of those that did discuss this with their doctor, it was the patient that brought it up.

One third of people would be really uncomfortable discussing this with their doctor.

76% had never been screened for anal cancer.

Most common examination was DARE, followed by high-resolution anoscopy.

84% hadn’t been vaccinated.

Living through the diagnosis and treatment of anal cancer

I was diagnosed with anal cancer in 2014, aged 52.

Diagnosed with HIV 1999, started ARVs 2005.

Having annual DARE because of family history of prostatic carcinoma.

Had surgery, then went back to work the following week.

Started chemoradiotherapy.

Looked after himself mainly, despite not coping well.

I needed to return early for a chemotherapy session, my liver was not functioning properly.

My skin was prickly, I was feeling nauseous, and it was recommended I admit myself to hospital.

Was told liver wasn’t working and I had to stop my HIV medication and pain relief.

I was released from hospital after 8 days, and prescribed bactrim, and had lost 20kg.

My CD4 count had dropped to 70.

I began my HIV medications again, and regained weight, but my kidneys shut down.

I had a problem with an overactive bladder throughout this (it was unclear what the cause was, my prostate or post-radiotherapy change). I was catheterised with a long-term catheter a few times, and developed a UTI.

My cancer has been cured.

My bladder has improved.

Questions

Is there a benefit vaccinating older people with early anal lesions?

There is evidence that early cervical lesions do have reduced recurrence following vaccination but no evidence yet for anal.

It is only funded for under 25 year olds, but if you can afford it, it is unlikely to do you any harm.

Should we be doing a DARE on HIV negative patients?

No, it is not cost effective, because it is not common enough.

If you’re going to do it, do it on a regular basis.