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.

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Looking at inequity and qualitative care data measures in UK for People Living with HIV min 2015, in the UK.

HIV – 98% diagnosed retain in care.

5-6 thousand new diagnosis yearly. 3,000 are gay men. 3,000 heterosexuals (people that acquired HIV abroad or late diagnosis, mostly new arrivals/immigrants).  

Most linked to care in first year of diagnosis

An early diagnosis in a high resourced country, shows similar lengths of life expectancy as the general population.

Many people feel (or experience) stigma and discrimination around social gatherings and settings.

Dental and Healthcare/GP’s are 2 areas the people living with HIV avoided.

 

Dr Gail Matthews, Sydney. HEP C Updates –

200,000 to 300,000 people living with HEP C in Australia.

2-3 thousand people living in Australia co-infected with Hep C and HIV.

Since the new Hep C Treatment begun 12% of the Hep C population.                             40,000 (20% of this Hep C population) expected to be treated by the end of 2016. Predominately genotype 1. Genotype 3 (less).

Updates to Census Guidelines for Hep C – 2016.

Gastroenterologists (Specialist) treatment rates have fallen to 50% with other Dr’s/Prescribers accounting for an increasing amount in March to June, 2016.

Possible Risk of HBV reactivation on DAA therapy. The risk levels are unclear. Prescribers can discuss with Specialist about Serology or treatment concerns.

 

CLOSING PLENARY - looking towards 2020!

President Elect Donald Trump accession in US and Global politics was discussed, with unanimous concerns of the possible impacts on marginalised groups, such as people living with HIV.

PEPFAR – is a major global initiative, assisting those with HIV/AIDS. It was thought funding may be less sustainable and diminished under Trump Presidency.

PrEP – Pharmaceutical Benefit Scheme - (PBS) Australia, hopefully rolled out next year. Need to target Aboriginal people, CALD Communities.                                                         There is an over-representation of ABSTI with HIV.                                                                     STI rates are climbing.  Condom use needs to remain as valued!

Partner with Aboriginal lead services to effect better outcomes for ABSTI Communities. Need high level engagement to focus on ABSTI chronic health conditions, mental health, HIV, STI’s and long term future funding arrangements.

ABSTI community lead primary healthcare in partnerships/collaboration with agencies.

Need better national co-ordination. Invite all stake-holders to assist in managing – Treatment as Prevention (PrEP) collectively.

Equitable care

Develop greater sense and involvement with communities.

Challenge the ‘spitting law’ that is been brought up by 3 states. This is NOT Evidence based practice. A motion agreed by all was held at the end of the Conference today.

Focus now needs to be on other priority populations, such as Woman and heterosexual males to be seen as a priority populations.

Develop internationally agreed best policy – basic guidelines of care and treatment.

There is a lack of engagement with governments and communities. This needs to change NOW!

Speak up and challenge funding cuts. We need to INVEST MORE.

Non-Aboriginal people to ‘speak up and be a voice’ for ABSTI plight and their needs.  

Migrants Medication and medical needs to be covered.  

Collaborate with local communities. How do we reach out to others less engaged?

What resources do we have and how can we mobilize them better?

Look towards Aboriginal Medical Service (AMS) for leadership in Primary Care delivery.  

Globally, The United Nations (UN) is under threats by been constantly undermined by States with vested interests.  

Next step in HIV care and treatment is a vaccine. Injectable is expected 4 + years away.

 

See you all in Canberra, ACT in November 2017 J

 

 

 

 

 

      

 

 

 

                           

 

 

 

         

 

 Aboriginal & Torres Strait Islander Health (ABSTI) – HIV & STI’s in the Australian ABSTI health context.

 Presented by A.Prof. James WARD and Prof. Gracelyn Smallwood and other eminent panellist discussed these contemporary health issues with Australia’s ABSTI people.

 HIV – double the rate of Non- Aboriginal people

                   With 60 % - Men that have sex with Men (MSM)

                             20% - Injecting drug users

                             20% - Heterosexual     

                                                                                                                                                               Please note that  -  20 % of HIV Diagnosis are Women and 12% live in remote and rural & communities.                                                                                                                                                                                                                                                       33% late diagnosis with 21 % having advanced HIV. In the general Population – 90% are diagnosed.

MEDICATION and adherence and co-morbidities are a huge burden.                               Mental Health/ depression – 12% report feeling depressed, with 9.6% of the general population report this.

The social determinates of health – ABSTI have poorer general health with unique challenges in addressing ABSTI HIV care and treatment. Medication burden.             Complex health.

 the effects of ongoing racism and discrimination.

 Feel “SHAME” and their spirits is low.

 Stigma from HIV.                                                                                                                                                                             Need to trust clinicians and respect for clients confidentially is utmost important.  

  

Needle Syringe Program (NSP) – 

ICE/Crystal has become a big issue.  

We can’t wait for an outbreak to occur, so we need to increase access to NSP services, such as in outreach programs.  

 Health and Community Partners/organisation to work with the community needs, in culturally appropriate ways, including not driving it (program & service health delivery) with experts  without consulting, involvement & input from respected key community stakeholders.

Partner’s organisations needs to ask local people to teach cultural norms. 

PANEL DISCUSSION –

90 % of the general population know HIV Status

80% of the ABSTI know their status (20% don’t!).

Reduced life expectancy (estimates 20 years compared to non-aboriginal Australia people).

need a grass roots approach, need to empower the local people by using their knowledge and expertise about their own local communities and support solutions at local levels.

Funding been cut by Governments with 75 % of Funding is going to non-grass roots, such as University Research & government bureaucracy.  

3% population in jail, 

                                                                                                                                          

food prices are increasing in local and remote communities 

Poor sanitation

No jobs, lack of career pathways

 

Cairns Doctors advised that the syphilis epidemic came first, then linked with HIV.  

Recently 1 female and 4 males (MSM) aged from 18-25 years HIV +                                  young mobile, homelessness (is a major barrier), couch surfing, staying with Aunties, not taking medication as forgets due to constant moving. Finances - Centrelink – cut off.

 Aboriginal Medical Service (AMS) – Aboriginal controlled services across Australia -      there can be an issue of taking blood in ABSTI Peoples.                                                          Non-Aboriginal Health care workers need to provide better cultural translations -           explanations as to why blood is needed (MEDICALLY) to be taken.

With young people there is a better acceptance of outreach programs that deliver rapid testing for Syphilis.  

Issues in screening STI’s in prisons

Aboriginal Community Health Workers – not getting paid and recognised properly.

Some Clinicians can be uncomfortable offering a HIV Test.

Clinicians needs to be flexible in care delivery. Work to ‘hold confidence’ with Clients.

How can Services be friendlier to ABSTI Peoples?

Building good working and trusting relationships is everything. Keeping rapport and people engaged.

Service providers need to become more effective!

Burden of disease/s, reluctant in accessing care, complex family dynamics, isolation.

Family worries, social issues, turning up for appointments and reminders.

Shame aspect – needs to be taken out of HIV. Of not having housing, which prevents people from becoming stable and stay on treatment.

 

 

 

 

 

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A.Prof. James. WARD - Aboriginal Health Perspectives.

A Predicted divergence of what is happing in Aboriginal and Torres Straits Islanders community’s in relation to HIV and STI’s.

  

New diagnosis of HIV in remote communities due to young mobile population.

Risk Behaviours such as sharing NSP Equipment, with a background of increasing prevalence of STI’s.

 Failure to engage Treatment as Prevention (PrEP) as need to take other medication (pill burden) for multiple health conditions/comorbidity.

 10-24 years age group, increasing Chlamydia and Gonorrhoea -                                                                  This highlights the inequities and lack of access to care.

 

Hep C – mostly transmitted through injecting drug use (IDU).  

Hep C has increased 43 % in 2011 – 2015.  

It effects the youngest 15-24 years old.

Hep C has 8 times the incidence in Aboriginal people (than non-Aboriginal People).

 

Rural and Remote Communities – need more access to Aboriginal Primary healthcare for testing and treatment and treatment as prevention (PrEP).

HIV in Cairns, QLD – young Aboriginal & Torres Straits Islander men in 2014-2016 had 50 % increase in HIV. This also effects bi-sexual men and men that don't dentify as gay.

NO access to NSP. Difficulties in approach to NSP and harm minimisation.

(Treatment as Prevention) TASP.

Prof. Ward said that we could learn from Canada’s first nation’s people in Saskatchewan that have a background of unresolved grief & intergenerational trauma. 

Increased of IDU and STI’s = HIV !

We need to prevent an outbreak occurring in our rural and remote Aboriginal and Torres Strait Islander (ABSTI) Communities. Health services are already limited and they would also not be able to cope with a major outbreak occurs. This would devastating to these communities.

ABSTI – vulnerability of population.

Need to increase the workforce in meaning work and career options

Need timely surveillance data, to be able to respond quickly    

Medicare to cover costs

Need to advocate ‘outside and ‘raise our voices’ (to Governments and the Australian people to increase awareness and be able to act/prevent). Especially non-Aboriginal People need to stand up and raise their voices about concerns and issues of our ABSTI People.

Increase the current low testing rates for HIV.                                                                                                                                                             Use a diversity/combination of strategies include - strengthen Aboriginal and cultural appropriate Primary care.

 Currently on 32% of people with STI’s are offered HIV Test. This needs to be offered 100%.

 Community itself needs to be interested and engaged.

 

 

 

Elimination of Hepatitis C and HIV coinfection in Australia

 As Australian clinicians, policy makers and communities affected by hepatitis C march into a new era of widespread, accessible Direct Acting Antivirals (DAAs), Dr Joseph Doyle from Melbourne’s Royal Alfred Hospital gave a timely presentation about the feasibility of eliminating HIV/Hepatitis C Virus co-infection.

The global burden of Hepatitis C Virus (HCV) infection is massive at 115-130 million people. Australia shares a relatively small burden of these infections, with an estimated 230 000 people living with HCV.  Globally, 2.2 million people are co-infected with both HCV and HIV. Between 7 and 10% of people living with HIV have HCV, with their odds of acquiring HCV six times that of the HIV-uninfected population.

As with HIV infection and the familiar 90-90-90 goal-posts, the WHO has set ambitious targets for viral hepatitis. By 2030, WHO aims to eliminate hepatitis C transmission, with 90% reductions in incidence, and 90% of those infected treated effectively. This is expected to prevent 7.1 million deaths between 2015 and 2030.

To achieve this, health policy makers must address specific gaps in:

-       Testing

-       Access to care

-       Treatment, and

-       Prevention

To be maximally effective, testing must be sufficiently frequent among populations at risk. Early diagnosis and treatment scale up to the point where 80% of all new cases of HCV were treated has been modelled to drastically reduce HCV incidence. Testing must be available at little or no cost to consumers, and provide reliable results. In Australia, antibody screening assays are widely available in organized laboratories with excellent quality assurance. Gaps persist in the diagnosis and assessment of hepatitis C: the current requirement for Nucleic Acid Amplification Testing (NAAT), genotyping, and assessment for fibrosis each presents a barrier to treatment. Multiple visits are often required to plan effective antiviral therapy, and each step represents a risk for disengagement. Algorithms for laboratories to deploy reflex HCV Ag/RNA testing in the event of reactive antibody screens would be useful. When these factors are combined models suggest improvements in treatment uptake and reductions in HCV incidence.

For hepatitis C and HIV coinfection, injecting drug use plays a role in up to half of cases. In contrast to HCV mono-infection, sexual transmission is also important, particularly among HIV+ men who have sex with men (MSM). Modelling suggests that sexual behavioural change could dramatically reduce sexual transmission of HCV, but the challenges to implementing this in an era of reducing condom use are considerable. Linking testing and early diagnosis with harm minimisation is important, and in some cohorts results in reduction of IDU risk behaviour.

Rates of testing for HCV are currently good among people living with HIV. Victorian data suggest that PLWHIV are tested an average of 1.4 times each year. Consideration should be given to increasing the frequency of testing, but restriction of this to higher risk individuals seems prudent.

Access to care has significantly improved in Australia in 2016. PBS-subsidised DAA therapy became available in March 2016, and unnecessary restrictions on prescribing for able prescribers were lifted in November of the same year. Australia wisely and bravely avoided the temptation to impose restrictions to access DAAs based on fibrosis, alcohol consumption and ongoing drug use. These aspects have seen the proliferation of interferon-free treatment in Australia. Interdisciplinary collaborations that have embraced participation by hepatologists, infectious disease physicians, sexual health physicians, public health professionals, virologists, general practitioners, and community members have liberated hepatitis C treatments from hospital environments to the community where much wider, more acceptable, sustainable implementation can develop. The multidisciplinary Consensus Statement on hepatitis C treatment has been instrumental in facilitating community provision of hepatitis C treatment.

Effective antiviral treatment of hepatitis C is the cornerstone of hepatitis C elimination. Although the safety and efficacy of the current generations of DAAs have provided extraordinary advances in the treatment of HCV infection, further advances are needed. The development of well-tolerated, safe, efficacious, pangenotypic regimens that require increasingly less reliance on fibrosis status and previous treatment history would be beneficial.

Communities at risk of coinfection include people who inject drugs and men who have sex with men predominantly, but those born overseas in countries with hig prevalence of both infections should not be neglected. 

Cost effectiveness of interferon-free DAAs is well-established for those with advanced liver disease, but the cost of treating those with early infection without fibrosis is well within Australia’s resources. 

Harm reduction strategies around injecting and sexual behaviour are an important part of primary prevention, but also crucial in preventing reinfection after successful therapy. Treatment offers opportunities to collaborate with harm reduction agencies, and reinforce messages of risk minimisation.

Although no highly efficacious vaccine for hepatitis C has been developed, the public health role of partially effective vaccines should be considered. The role for such vaccines will depend on the degree to which prevalence is reduced. If treatment uptake is high enough to reduce the prevalence of HCV to very low levels, a partially effective vaccine is unlikely to be of benefit. In the setting of ongoing high prevalence, or of high reinfection rated, a partially effective vaccine may be of considerable benefit.

Just as the HIV Cascade from the Kirby Institute’s Annual Surveillance Report informs HIV public health practice, so does the HCV care cascade. Priot to the introduction od DAAs in the community, only 2000 people accessed treatment for HCV. The introduction of HCV DAAs saw 27 000 HCV-infected people being treated by the end of July 2016, representing 13% of all people with HCV infection in Australia. We are on track to providing treatment to 40 000 people by the end of 2016. This enormous scale up of treatment for hepatitis C is unprecedented, and is a globally important public health intervention.

Networking models for HCV acquisition among PWID are well-described. Higher connectedness to communities with high HCV prevalence of confirms intuition. The high level of connectedness to others with HCV suggests strategies for increasing effective uptake among  networks. Similar strategies might be effective among sexual networks of MSM in whom HCV is prevalent. ‘Bringing your friends in’ is potentially effective for both PWID and MSM networks, suggesting a singular effective strategy for co-infected networks.

To meet the WHO targets regarding reduced transmission, modelling suggests Australia must treat 4 700 HCV-infected PWID annually. To meet WHO mortality targets, 5 600 HOV infected PWID must be treated annually according to modeling. Given the uptake of DAA treatment in its first year, Australia is on track for reducing both mortality and transmission targets. Costs for achieving this are estimated to be around $7 billion, but prudent deal-making on behalf of the federal government is likely to achieve thi results for substantially less cost.

Reducing HCV acquisition among PLWHIV requires an understanding of the complex environment in which HCV transmissions occur. Factors include rates of partner change, condom utilization, injecting behaviour, sexual dynamics that include group sex an use of sex toys, and concomitant partnerships. Agency-based modelling, which accounts for such complexity, suggests a greater efficacy in HCV incidence reduction than compartment based modelling, and supports the efficacy of providing treatment to those with high risk sexual or injecting networks.

How can this be implemented? The Co-EC Study examines the utility of nurse-facilitated hepatitis C treatment in community settings. This study demonstrated that most people aith coinfection can be treated safely and effectively in community settings, providing that collaborative care is available when needed.

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In summary, there are many parallels between HIV and Hepatitis C treatment. Treatment cascades are informative for both conditions, and there are many primary and secondary prevention messages that can be shared with benfit between sexual and injecting risk networks. Australia is on track to eliminate hepatitis C and HIV coinfection with its insightful, innovative adoption of community-based direct acting antiviral treatments for hepatitis C.

'I speak more truth than the Pope'

Professor Gracelyn Smallwood is Professor of Nursing at Central Queensland University and Adjunct Professor at the Division of Tropical Health and Medicine at James Cook University (JCU), Townsville, Queensland (QLD). She is also a Birrigubba, Kalkadoon and South-Sea Islander woman who participated in a panel on Thursday 17th November at the Symposium on Aboriginal and Torres Strait Islander peoples - 90/90/90 - but who are the 10/10/10?

After Dr James Ward re-presented data on the more than doubling of HIV diagnoses amongst indigenous people in Australia in 2015, he said 'we are a critical point in the epidemic' and clearly need to act urgently.  The panel discussed proposals and strategies to respond to this dire situation, such as ways to get more people tested, diagnosed and into care.  Here I try to capture some of what Professor Smallwood said, as without such insights from aboriginal people and without action on these at a much higher political level, the medical, scientific and health professions cannot solve this.

Professor Smallwood, with decades of nursing and midwifery experience in rural and remote communities as well as in the city, and over 50 years of advocacy for her people, gave a clear and compelling response.   'We need to implement the National Aboriginal Health Strategy, Bringing them Home report and all other reports that have been written and not followed through'.  'HIV will be the last nail in the coffin' she said, and she has said this before.   'Locals are key.  We need blackfellas as chief investigators and aboriginal health workers are the key players, start empowering them, ask *them* to be keynote speakers . Get deadly health workers into clinics to undertake testing'.  Hardly any money gets down to the local level.  There's is a 200% markup on food (in remote areas), jobs have been phased out, it is no wonder people are using drugs'... 'Give me any disease', she said and 'I will give you the answer'.  

 

Quote shared by on in Legal and human rights, stigma and discrimination

I'll admit it now, I haven't been very up-to-date on the global approach to Hep C treatment, but this talk really brought me up to speed on several aspects.  Thanks to Dr Joseph Doyle for the great talk.

 

Global elimination targets

  • worldwide there are 2.2 million people living with HCV/HIV
    • compares to 37 million with HIV
    • odds of HCV infection were 6 times higher in people living with HIV
    • most HepC infections related to IVDU but some sexual exposure
  • target: 30% reduction in infections and 10% reduction in deaths (2020)

 

Elements needed for elimination

  • testing
    • early reliable diagnosis, frequent, regular testing
    • diagnosis allows connection with care and treatment, education, harm minimisation services, may influence at risk behaviour
    • Aust: recommends annual testing
      • but may need to recommend more frequent testing if we are serious about eradication
  • access to care
    • recent PBS listing to many new drugs
    • all are now interferon free
    • community prescribing is encouraged (after discussion with ID/hepatology)
    • no disease stage or drug/alcohol restrictions
      • in contrast to other countries where drugs are restricted to those with cirrhosis
      • this restriction would reduce costs but won't make much headway into eradication
  • effective treatment
    • sofosbuvir and velpatasvir (single pill regimen for all genotypes)
    • others are also coming soon
  • treating people at risk
    • target IVDU, MSM, born overseas in HPC
  • cost effective allocation
    • $20k for 4 years of extra life (if severe disease)
    • $60k for 6 years of extra life (if mild disease)
    • therefore even cost-effective to treat mild disease
      • many other options cost >$20k per year of life
  • harm reduction strategies
  • HCV vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The medications are effective, the funding is there to support the clinicians, patients are enthusiastic and actively seeking treatment - I think this is an exciting time for Hep C management and I am optimistic to see the future.

The single-most incredible presentation at the conference.  Dr Kedar Narayan presented on some amazing new technology which is allowing us to view HIV in a completely different light.  He somehow managed to explain what is clearly a very complex principle in simple terms, and with plenty of humour sprinkled in.

 

  • traditional electron microscopy only provides a 2D image of the cell
  • focuses ion beam scanning electron microscopy (FIB-SEM) allows a 3D image
    • the tissue is embedded in a block, with the side face open to the EM scanning
    • the FIB laser is used to slice the tissue (like a deli slicer/cutting a loaf of bread) to reveal the next layer of the tissue
    • the EM can then image the 2nd layer
    • this is repeated 1000s of times to obtain a stack of images (like a CT scan)
    • computer software can generate a 3D image of the tissue, including all the internal structures
  • FIB-SEM can be applied to HIV
    • HIV virons actually use small tunnels from intracellular vesicles to the extracellular surface to escape the cell
      • this explains why other studies have found that the pH of vesicles were less acidic than expected (i.e. because they were actually connected to the extracellular membrane)
    • virological synapse
      • the dendritic cell actually “hugs” the T cell
        • rather than individual projections from the cell, the DC actually has lasagne like sheets (veils) to connect with the T cell
        • this excludes all drugs since the synapse is covered by the “hug”
      • often thought that the T cell is passive in receiving antigen presentation
        • not so - they can reach into the DC to sample for virus

 

What an exciting start to the day (following on from the excellent trainee sessions this morning), and the rest of the session proved equally as informative...stay tuned

Day 2: A Changing Sexual Landscape of Gay Asian Men in Sydney: Implications for HIV/STI Prevention

 Day 2: Rapid Fire Session Sexuality and Reproductive Health:

Tim Chen – Asian Gay Men’s Project Officer ACON NSW ‘A Changing Sexual Landscape of Gay Asian Men in Sydney: Implications for HIV/STI Prevention’.

Tim discussed the results from a survey conducted between September 2015 and June 2016 for Asian gay and bisexual men.  The survey was printed in English and Thai languages and conducted at sexual health services (including a[test]), sex-on-premises venues, forums, workshops and through partnership networks.  Some similar research had been conducted in 1999 and 2002 and it was decided there was a need to repeat this survey due to the rising incidence of HIV and STIs among Asian MSM. 

The survey this time round was more ethnically diverse than previous years .  Although the overall number of Chinese respondents did increase compared to previous years, the proportion of Chinese respondents decreased and a greater proportion of Thai, Indian and Filipino guys completed the survey.  

HIV and STI testing rates had increased but less guys were testing at GPs with increased rates of testing observed at community-based testing sites (eg a[test]) and hospitals.

In regards to condoms use, guys reported less anal sex with their regular partners but similar levels of condoms use with these regular partners.  More anal sex with casual partners was reported than in previous years with more condomless anal sex.

In conclusion, sexual practices and health-seeking behaviours have changed among Asian MSM in recent years with an increasing rate of condomless anal sex with casual partners (it is worth noting that this study took place before the commencement of the EPIC PrEP trial in NSW).

Community-based testing sites were also shown to be of great importance in ensuring high rates of HIV/STI testing in this population.

 

HIV and the law – a consensus statement

Paul Kidd from the HIV Legal Working Group (VAC and Positive Life VIC) launched a recently published consensus statement about HIV and the law at the ASHM hub during the afternoon break on Wednesday. The consensus statement was written by leading HIV clinicians and scientists and was published in MJA on the 7 November. 


Paul Kidd provided context around the development of the statement and an overview of the key points covered in the statement.

Context
There have been at least 38
Criminal cases related to HIV transmission or exposure in Australia and the rate of prosecutions hasn’t decreased with advancements in treatment and prevention options. HIV-related criminal prosecutions require that legal professionals interpret scientific evidence on HIV transmission risk and the harms associated with an HIV diagnosis. History indicates that scientific concepts may have been inconsistently applied in Australian trials and some people have received very harsh sentences (arguably too harsh).

 

Recommendations
The statement outlines the latest evidence on HIV transmission risk, prevention and treatment. The main points covered in the statement:

       The risk of HIV transmission during sex is very low (and may have been overstated in HIV-related legal cases in the past).

       In addition to condom use, the following should be considered as taking reasonable precautions to prevent transmission:

o   If an HIV-positive partner has an undetectable viral load OR

o   if the HIV-negative partner is taking PrEP

       Phylogenetic analysis cannot prove causation in HIV-related cases.

       Most people living with HIV are able to take simple and effective treatment and will have a normal life expectancy.

 

The statement recommends:

       Legal cases relating to HIV transmission should consider the best scientific evidence on HIV risk and harms

       Alternatives to prosecution, such as the public health management approach, are often appropriate

 

Paul thanked the impressive contributors for their authorship and the wider working group for their commitment to the statement. I was lucky enough to be involved in the development of the statement and it was great to be present for the launch.

 

The statement is available on the MJA website at: https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement

 

A PDF is available on the ASHM website:

http://www.ashm.org.au/hiv/resources 

Day 4- Increasing the demand for HIV testing

Mark Stoove discussed innovative ways to improve HIV testing.  50-70% of HIV transmission among GBM are attributed to undiagnosed infection. There were policy and regulatory changes in 2012, which revolutionised HIV testing in Australia. Rapid HIV testing was introduced and there was an increase in HIV testing in community settings. The uptake of rapid HIV testing has been modest. Barriers may include funding, lack of government subsidy and some services feel testing can be time and resources heavy. The majority of HIV testing continues to occur in primary health care settings using serological laboratory testing

Community based HIV testing services such as ACON provide a comfortable, peer based service which clients find very acceptable.  ACON in Sydney provides a peer based testing model, which is supported by nursing staff. Peer based clinics have successfully attracted first time testers that were classified as ‘high risk’. Rapid HIV testing has increased testing in urban areas but more needs to be done for those living in rural areas. We need to expand the geographical reach of HIV testing. The Terence Higgins Trust provided funding to increase testing in the UK. In a 14-month pilot study over 17,500 testing kits were posted and 10,410 specimens were returned. There was a positivity rate of 1.4% and this testing was welcomed by participants with 97% reporting that they would test this way again. Self-testing kits are available in the UK and the uptake has been excellent with over 27,000 units sold between April 2015 –Feb 2016. Half of the test kit users have never had a HIV test before.

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

-Funding may be a barrier for services offering HIV testing. Government subsidies could improve rates of HIV testing

 Vickie Knight spoke about the effect a[TEST] clinics has had on HIV testing among gay and bisexual men. It was found that the clinic on Oxford Street in Sydney has increase testing and also increased the frequency of testing. Factors that make this clinic user friendly include short wait times, the service is free, CASI is used which means intrusive sexual health histories are not taken by health professionals.

 

Key messgaes

This model works and has increased testing among GBM.

 

Quick update on a presentation by John McAllister

 

  • if source VL is undetectable, then PEP is no longer recommended
    • however, do need to discuss the reliability of the history of undetectable VL
  • Truvada should be used for PEP
    • avoid tenofovir and lamivudine (although cheaper)
  • 3-drug PEP
    • if 3 drugs are needed, then stick with dolutegravir (ALT increases by 22%), raltegravir or rilpiravine

 

Jason Asselin gave us a comprehensive overview of ACCESS, a national registry designed to pull HIV data from primary health care, sexual health clinic and the laboratory.

 

  • his study included patients who had viral load testing within the last 12 months
    • the last VL for the year was used to allow more patients to be included
    • VL testiong as part of diagnosis was excluded
  • demographics: males were older, females were younger
  • results
    • citeria for undetectable VL was met for 71% (2009) => 87% (2014)
    • porportion of patients with a high viral load decreased
    • similar outcomes for M vs F
    • patients <40 years old were less like to achieve VL suppression compared to older patients
  • weaknesses
    • does not capture patients who did not engage in health service
  • ACCESS will be rolled out nationally from Jul ’16 – Jun’19
    • we can look forward to more comprehensive data

The opening plenary talk was given by Dr Valarie Delpech, who outlined the progress towards attaining treatment for all.

 

  • the UNAIDS target for 2020 is 90-90-90
    • 90% of patients diagnosed
    • 90% of patients on ART
    • 90% with viral suppression
  • data from Levi et al (2016) showed
    • 54% diagnosed, 41% on ART and 32% virally suppressed (2015 data)
  • there appears to be a great disparity in the countries able to achieve this with many having poor rates of diagnosis and hence low rates of treatment/viral suppression
  • Dublin declaration data: EU/EEA countries are performing better than the non-EU/EEA
  • to date, no country has met the 90-90-90 goal (except claimed by Sweden)
  • a major issue
    • most countries have very little data about actual rates (even 4 decades into the epidemic)
    • there is variation with data sources and quality of definitions/standard methodology

Has Australia met the W.H.O. guidelines on preventing HIV Mother to Child Transmission (MTCT)? This session looked at the current guidelines for antenatal care, management and rates of transmission.

As I work with antenatal and postnatal mums, I was interested in seeing if the current practices have had a positive effect on transmission rates. The answer...yes we have met the guidelines and reduced the rate of transmission.

Australian guidelines

1) HIV testing is conducted at the first antenatal appointment.

2) Clinical care of the mother include; CD4, VL, STI screening, starting ART and resistance testing

3) Strategies at birth; ART for the baby immediately, mode of birth decided by maternal VL, formula feeding exclusively. Baby to have HIV testing at 6 weeks and 3 months.

Surveillance of perinatal exposure

Data reviewed for the 30 years 1986-2016. 714 babies born to mothers who were HIV positive.

The rates of perinatal exposures are increasing, however the rates of babies with HIV have dropped significantly.

Rates of HIV testing has increased dramatically, and the exclusive use of formula feeding has also increased.

Conclusion

There has been an increase in the number of HIV positive mothers, but a reduction in the MTCT. Australia meets the W.H.O. targets. Which is fantastic news!

Day 2: No Question Too Awkward for  Nurse Nettie

 

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

 

Notes from talk:

The most recent syphiils outbreak in northern Australia highlights the vulnerability of this community due to isolation, reduced access to services and poor engagement with the health communities. 

Advances in HIV treatment in Australia has created an obvious divide with increased HIV diagnosis in ATSI communities. While non ATSI HIV diagnosis are mainly in men who have sex with men, this only accounts for 50% of the case load in ATSI communities.

Increased IV drug use appears to be fueling this with reduced access to programs such as needle exchange.

Canadian modeling is sobering if we continue on this same path.

 

Day 3 – Joint Symposium Session: Prevention of Anal Cancer in gay and Bisexual Men: The Current State-of-Play and Future Directions.

“What should we be doing for our patients now?”  Dr Jason Ong, Monash University, The Alfred – Melbourne Sexual Health Centre, VIC, Australia

Dr Ong acknowledged the HPV vaccine as a game-changer in the prevention of HPV-associated anal cancer however there is still a cohort of males who remain unvaccinated and therefore will continue to be at risk of anal cancer for many years to come.

Many ask the question: if screening for cervical cancer using the PAP smear works so well in early detection of cervical pre-cancerous lesions, then why can’t we take this methodology and apply it to anal screening of MSM for pre-cancerous lesions (aka ‘CHAP smears’)?

Some similarities and differences between anal and cervical anatomy and lesions were described:

Similarities:

-       Both have transformational zones

-       HPV responsible for a significant proportion of pre-cancerous changes

-       Pre-cancerous lesions are histologically similar

Differences:

-       The anal canal is a much larger area to swab (approx. 5cm tube)

-       It is more difficult to visualise anal lesions

-       Natural history of lesions between each site is different (up to 30% of anal smears are positive for abnormal changes)

-       Progression of changes is different as many more anal intraepithelial neoplasia (AIN) resolve over time compared to cervical intraepithelial neoplasia (CIN)

-       Different referral rates (only approx. 3% of cervical PAP smear result in onward referral for colposcopy but up to 60% of men undergoing anal screening would need referral due to the increased rate of high grade anal lesions.  This has implications for the workforce as it does not have the capacity to deal with such a large volume of referral for anoscopy or further investigation). 

High-grade anal intraepithelial neoplasia (HGAIN) regress at a rate of 36/100 person years so if left alone, many would disappear.

In answering the question of whether we should screen for early anal cancer, Dr Ong explained that the best annual screening tool for MSM would be the digital anorectal examination (DARE).  As approx. 50% of anal cancers are externally visible and approx. 2.9cm in size, and due to the fact that many HGAIN resolve spontaneously over time without intervention, DARE is a most cost-effective and simple early detection technique.

In another study, Dr Ong also explored the acceptability of a DARE for men with favourable findings.  82% of men felt relaxed during the procedure and 99% were willing to have another DARE in a years time.

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As a side note, Dr Ong will be conducting a teaching session on Friday 16th Nov from 10:30am-11:00am using his plastic bum segment for this wishing to perfect their DARE technique …sadly I will miss out!

Dr Jason Ong:Monash Uni,The Alfred,MSHC

On Prevention of Anal  Cancer in Gay and Bisexual men:the current state of play and future directions

Excellent series of sessions

This session highlighted that we must reflect on some of the changing practices of rapid testing ,increase testing ,self  testing and remember the need for clinical examination also: LOOK

HPV VACCINE :THE GAME CHANGER

But a cohort has missed out

Do we adopt cervical screening protocol and do "chap smears"

Highlighted the key difference with anal Ca and cervical Ca although both SCC

Anal pap larger area,harder to identify lesioms in a collapsing environment,

Differing natural history

Differing referral rates,massive need for HRA/not feasible

No one agees best approach

Still no proof treatment assists outcome

.?trace the 30% males with HGAIN

Need better ways to treat,more RCT havent the specialists

Greater than 50% Anal Ca externally visible average lesion 2.9cm HUGE

BUTLess than 10% HIV  MSM  have annual anal exam

Need early Ca detection model:less than 2cm lesion possibly just excision with no spread or sphincter involvement,no chemo or radiation

Implement anal digital

Based on Wilson and Jungner screening critera 

;"GIVING THE FINGER TO ANAL CANCER"his PhD title

Key findings ;all specialists think it is important to screen for anal Ca but arent doing it

www.anal.org.au/clinician MSHC;:

Annual DARE study and recommendations

Acceptable,minimal s/e

99% clients willing to have annual dare

Dare is cost effective,safe,acceptable

TIME TO Do DARE translating evidence into action

Summarised;

Screen for precursor lesions

Triage

RCT FOR DARE unlikely

Jason is running an educational session at the ASHM hub Friday

DO YOU DARE?

Timely as Tasmania Sexual Health are  fortunate to have Prof Richard Turner:Colorectal surgeon Royal Hobat Hospital/UTAS

Continuing his research with monitoring HSIL anal paps :HRA ,histology ?treatment for HIV clients and Women with HSIL paps

He has spent time to demostrate DARE  to all clinicians and advises annual DARE

The final session by Brad Atkins of his horror story of his  diagnoses and treatment of anal cancer and being totally uninformed and underprepared and to be reminded of the STIGMA,embarrasment people feel

Makes it urgent to "AT LEAST LOOK AND PUT YOUR FINGER IN OR YOU WILL MISS IT"

BACK TO THE BASICS.....

Notes from talk stream:

Men who have sex with men are at significant risk of HPV related anal cancers. HIV negative MSM are at an estimated 20-40x risk and HIV positive MSM are at 100x risk!

HPV Vaccination is going to be one of the keys to help reduce this risk.

Many gay men have not been vaccinated for HPV and this is a key move that can help reduce incidence.

Many doctors are not doing DRE to examine for any anal lumps.

It's a simple, cheap and easy exam and can detect early anal cancers from 0.5cm diameter.

Early detection <1cm results in simple surgical treatment that may not require chemo/radiation therapy.

HIV positive men should be offered annual DRE and HIV neg MSM every 1-3 years.

Anal Paps are difficult to fully roll out at the moment as many early anal changes will self regress. Sadly anal colposcopy services are very limited currently making this one area of bottle neck in evaluation of early anal lesions.

This session has absolutely changed the way I will be practicing and caring for my MSM patients from today!

Good resource for futher information for both doctors and clients is this site created by AFAO.

http://www.thebottomline.org.au

Divergence in HIV rates within Aboriginal and Torres Strait Islander communities in Australia

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.