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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GP chlamydia testing has doubled in the last few years, but remains low.

75% of chlamydia cases were in asymptomatic patients attending for non-sexual health reasons.

 

A trend worldwide of increasing syphilis notifications after 2000.

About half were in gay men who were HIV positive, and half who were HIV negative associated with increasing HIV testing and monitoring.

Syphilis monitoring was done routinely with HIV testing.

The proportion of patients who were asymptomatic increased at the same time to > 80% of cases being asymptomatic, from most cases being symptomatic.

Such opt-in health checks have had benefits elsewhere.

Opt-in STI testing in Aboriginals resulted in positive STI rates of 9.7%.

 

Contact tracing websites for anonymous notification of partners: inspot, sugestatest, thedramadownunder, letthemknow.

Of those intending to use these websites, 23% actually did.

Of all the partners notified, 20% actually got tested.

 

Retesting for those who test positive.

1 in 5 will get reinfected within 12 months, most likely from an infected partner.

Reinfection increases the likelihood of PID by 5-fold.

Reinfection increases the likelihood of transmission of HIV.

Of men not returning for a retest, some were sent an SMS reminder.

60% of those sent a reminder attended for retest, compared with 30% of those who did not receive a reminder.

Posted by on in Workforce Development

Testing for rectal chlamydia in women: is it worth it?

Heterosexuals are the ones doing most of the anal sex.

2-3 fold increase in the amount of anal sex in females since the mid-90s.

3-5% rectal chlamydia prevalence in heterosexual women and men.

Recommended rectal testing in those who report ever having anal sex or are symptomatic.

Rectal swabs taken in 18.7 % of women presenting.

Swabs are more likely in sex workers, bisexual women, older age group, and those recalled for testing.

Urogenital swab positivity rate is 7.5%.

Rectal swab positivity rate is 8.3%.

70% of infections were rectal and vaginal.

11% were vaginal only.

19% were rectal only - and all had no rectal symptoms, so would have been missed, meaning we would miss 1 in 5 chlamydia infections.

Anal intercourse is rarely asked during history taking.

It can include toys, fingers - “there are fingers, toes and tongues going everywhere...”

 

Gonorrhoea infections of the rectum, pharynx and urethra in same-sex male partnerships attending a sexual health service in Melbourne, Australia.

Gonorrhoea within individuals, with same day testing of partner revealed the following results:

34% rectal infection,

22% urogenital infection,

7% throat infection.

Of those with throat infection:

60% of partners had anal infection, but wearing condoms or not for insertive anal sex did not affect the likelihood that their partner would have anal gonorrhoea.

21% of partners had throat gonorrhoea.

23% of partners had urethral gonorrhoea.

80% of throat gonorrhoea is missed on culture compared to NAAT.

Throat gonorrhoea spontaneous clearance rates are high.

Urethral gonorrhoea incubation period is only day(s) before it becomes symptomatic, whereas pharyngeal infection often remains asymptomatic.

 

Front-to-back wiping and dabbing wiping post-toilet significantly associated with anal neoplasia & HR-HPV carriage in high-risk women.

Women comprise the largest number of anal cancer cases. Why?

Women with a previous HPV-mediated gynecological cancer were studied.

Risk factors identified were: older age, inflammatory bowel disease, active and passive smoking, autoinoculation by front to back wiping.

Highly robust association found with all.

Dabbing showed a protective effect.

 

The changing pattern in sexually transmissable infection and HIV diagnoses in New South Wales publically funded sexual health clinics, 2010-2014.

HIV/STI testing and treatment is mostly done in General Practice.

Which ones are managed in public clinics?

Looked at chlamydia, gonorrhoea, infectious syphilis, and HIV.

Infectious syphilis and gonorrhoea are increasingly diagnosed in public clinics.

Gay men contribute highly in the proportions of infections.

 

The molecular epidemiology of Neisseria Gonorrhoeae in New South Wales in 2012-2014.

Increasing notification rates of gonorrhoea in females.

Is there an association in infection with particular genotypes vs gender (heterosexual networks vs MSM transmission)?

This study did in fact suggest that there is increasing infection rates within heterosexual networks.

 

Injecting drug use is associated with high risk sexual practices and sexually transmitted infections in gay men.

STIs and injecting drug use.

Less attention paid to injecting specifically in published studies.

Injecting drug use noted in 3% of HIV negative persons and 14% of HIV positive persons.

Non-injectors’ rates of chlamydia, gonorrhoea and syphilis were stable from 2010 to 2015

Rates with injecting drug users were tripled in all three infections over the same period.

Sexual networks in these men are key.

Injecting drug users need screening for these infections as a priority.

 

Higher STI yield among asymptomatic gay men attending a community-based shop-front service compared with a fast-track sexual health clinic service.

Community-based vs clinic-based asymptomatic STI testing centres for GBMs.

The overall results were twice the STI yield in the community-based vs the traditional clinic-based testing centres.

Highlights the importance of introducing more community-based testing centres.

 

Is the increase in syphilis notifications in Victoria due to increased testing?

The rates have nearly doubled in the last 12 years.

Analysed around 30% of the reported syphilis cases from 2012 to 2015.

Around 40% of GBM are tested for syphilis.

80% of syphilis is in gay men.

40% is in HIV positive gay men.

The increase in the proportion positive was much greater than the increase in testing.

With the advent of PrEP, this can only get worse.

 

Gonorrhoea positivity and risk factors among Aboriginal and non-Aboriginal women attending sexual health clinics in Australia.

Gonorrhoea in Aboriginal and Australian-born non-Aboriginal women.

Publicly funded sexual health clinics.

33,000 women were tested, 1.8% tested positive.

Aboriginal women were 3.5 times more likely to test positive.

Multivariate analysis highlighted strong association with chlamydia coinfection, remote areas, and age 16-19.

There was a slight increase in rates over time in non-Aboriginal women.

 

Gonorrhoea among males in Victoria, informed by the Australian Collaboration for Coordinated Enhanced Sentinal Surveillance (ACCESS).

The power of ACCESS in giving important information with a wide range of surveillance data.

This study looks at gonorrhoea tests in men over time.

Testing has increased.

Rectal testing among men has increased.

Pharyngeal gonorrhoea is an important reservoir of infection, data is available, and will be presented shortly.

Although laboratory data looks crude, there are lots of things we can link in with it.

 

Pro-active follow-up of victims of sexual assault: an initiative to improve medical care in inner Sydney.

A novel approach to follow up of sexual assault victims.

Medical follow up following sexual assault is generally low.

Individually phoned by a counselor and history taken.

Mostly women.

60% suffered vaginal assault, 12% anal assault, 1% oral assault.

2/3rds attended for assessment.

At initial visit, STI detection rate > 10%.

At 2 week visit, 5.6% had STIs detected.

Pregnancy testing should be routine in women of childbearing age who test positive for syphilis.

Women with syphilis present late.

The earlier a pregnant woman is treated for syphilis the better the outcome.

Up to 20% of women with syphilis are pregnant.

Women with syphilis are more likely to have other STIs.

Pregnant women identified as having syphilis are regularly tested throughout their pregnancy for evidence of ongoing infection to reduce the likelihood of congenital syphilis.

One case of confirmed congenital syphilis and 2 suspected cases where the baby required 10 days of iv penicillin in Northern Territory in the year described.

These rates are typical per state per year in Australia.

Anal cancer is the most common non-AIDS cancer in HIV positive MSM.

Up to 100 times the risk compared with the general population.

90-92% show HPV types 16 (or 18), second only to cervical cancer in its association with this virus.

29% of positive MSM test positive for HPV type 16.

1 in 5 go on to Incident HPV16 (test positive at 12 months) - 4% in total.

Higher risk with anal STIs.

Clearance of most HPV types is common - 50% will clear per year.

HPV16 is twice as difficult to clear than the other HPV types (only happens in 20%).

Predictors of clearance - younger age, smaller lesions, low risk lesions.

 

30-50% of HIV positive men have HSIL (high-grade squamous intraepithelial lesions).

 

It is not standard of care to treat these (unproven effectiveness).

New Zealand surveillance data from 2006.

55% (1 in 2) report any drug use.

21% (i in 5) report harder drugs (excluding cannabis and poppers).

44% of those used stimulants.

Polydrug users much more commonly report condomless anal intercourse and have higher STI incidence.

Drug use universally associated with increased risk behaviors (consistent with disinhibition) and decreased adherence to ARVs.

HPV vaccination has been a major success in Australia.

“Cervical cancer vaccine”, not HPV vaccine - unsure how the public would respond to a vaccine against an STI.

Introduced in 2007 in females, and 2013 in males in schools.

Vaccination in schools is much more effective than trying to get the same people into consulting rooms.

3-dose coverage in 70% of females, and 60% of males.

4v-HPV quadrivalent vaccine effective against types 6, 11, 16, and 18.

Moving to a 2 dose schedule as other countries have.

Easier to roll out.

2 doses spaced > 6 months apart just as immunogenic as 3 doses in adults.

Approved by WHO in 2014.

Increasing interest in the 9-valent vaccine which includes all the oncogenic types.

Implementation of a 2 dose schedule likely to occur at same time as a switch to 9-valent vaccine.

Incredibly safe, no evidence of autoimmune diseases.

Incredibly immunogenic, with high levels of antibodies sustained for over a decade.

Incredibly effective, dramatic drop in types 6, 11 incidence rates since vaccine introduced. Now we are seeing a decline in high grade abnormalities (CIN grade III, carcinoma in-situ).

 

National cervical screening program: 2-yearly PAP test for women aged 18-69 years.

Uptake: 2-yearly 58%, 5-yearly 83%.

Effect: 50% reduction in incidence and deaths from cervical cancer.

80% of cervical cancer in women in Australia occurs in women never screened or under-screened.

 

New cervical screening test will be implemented from May 2017.

Why? - newer technologies (HVP tests and liquid based cytology), allowing us to target more risky lesions and test low risk lesions less frequently reducing cost, while at the same time predicted to reduce cervical cancer cases by 30%.

Primary HPV test with partial genotyping (HPV 16/18 DNA/RNA PCR), alongside liquid based cytology (LBC), i.e. two screening tests in one.

Five-year screening interval because of lower risk of progression to significant disease within that period.

Starting at age 25 years, up to age 74 years, because of a very low risk of disease < 25 years and that surveillance in this group has had no impact on survival.

Self collection is an option (just tests for HPV PCR, need to recall patient if positive for physician to take a swab for LBC, may reach those never screened or under-screened).

Still need a speculum vaginal examination but 9 in a lifetime rather than 26.

 

New terminology - Lower Anogenital Squamous Terminology (LAST):

HSIL - high-grade squamous intraepithelial lesion (CIN II, CIN III).

LSIL - low-grade squamous intraepithelial lesion (consistent with HPV infection).

SISCCA - superficially invasive squamous cell carcinoma.

Squamous cell carcinoma.

 

The test is reported:

High risk - HPV types 16 or 18 are detected regardless of liquid based cytology.

High risk - HPV types other than 18 or 18 and HSIL.

High grade lesions are referred for colposcopy.

Intermediate risk if HPV types other than 16 or 18 and LSIL.

Intermediate risk is screened annually.

Low risk - HPV not detected.

Low risk is screened in 5 yearly intervals if immunocompetent. “Immunodeficient” (CD4 count < 400, unclear what this means for those on immunosuppressive therapy) - screened at 3-yearly intervals.

 

See the slides: https://www.eiseverywhere.com/file_uploads/89ee372457dbcb849d3cd1077dfc871e_1010MonMarionSaville.pdf

 

 

Posted by on in Public Health and Prevention

Day 2 had so many interesting topics. The use of Information Technology to improve sexual health care, by Dr Christopher Fairley was interesting. It is true that all people have access to internet and most of them use internet as their first source of information. Websites can be use to educate people, make online appointments and ask queries. It makes things so much quicker and easier.

Everybody is busy these days and do not like waiting for hrs. CASI is a very good system which is being used in some clinics to answer sexual history by the patient itself. this has proved to be quicker, avoids awkward questioning by the clinicians and more honest answers are given this way. It is also beneficial for the clinicians if they know some sexual behaviors and risks prior to seeing the patient.

SMS results and SMS reminders are being favoured by patients and clinics. SMS results within 90 minutes or even in 24 hrs makes it so easier and quicker. SMS are also used for vaccination reminders and TOC reminders and have proven to be very successful. It saves time and is quick for both parties. The number of patients have increased in the last 10 yrs from 15000  to 50000, due to using IT appropriately . Websites like "let them know" and "Dramadownunder" have been very successful in contact tracing.

Take home message of " Set up a good database and it will save you for life" was food for thought.

 

 

Associate Professor Rebecca Guy gave the Gallows Lecture.

The theme was new technologies for STI prevention and adult health checks with the target populations

- Aboriginal and Torres Straits Islanders People, 

- Gay men, 

- Mental health 

 

Resources and Notification of Partners. SMS technology is preferred. 

23% notified partner/s

Only 1/5 followed up in a clinic 

www.letthemknow.org.au

www.thedramadownunder.info

HOW is this going to change and effect my PRACTICE?

I will incorporate more IT into my clinical practice, as the Research has shown that clients and patients prefer SMS technology.  I have found this to be more effective approach in contacting those less engaged and harder to reach Clients, as it appears to be less intrusive means of contact & provides people the choice of when they want to make contact.

 

Other presentations on sexual health - Chlamydia 

Discussed health seeking behaviour. 

Focus on Adolescents

Low testing rates, 20 % people became re-infected in 1 year.

Issues are PID, infertility.

Gay men, increase risk HIV 

www.access-study.org

 

 

 

In the Gollow lecture Rebecca Guy discussed the important role of new technology for STI prevention including interventions such as: -

-CASI an electronic self-registration tool has proven acceptable reduced waiting times and improved data collection.

- ACCEPT showed the need for opportunistic Sexual health screens in primary care for young people due to high prevalence of CT and presenting complaint often not being sexual health related simple computer prompts increased testing by 30%

- SMS and postal test kits have been used to improve re-testing rates

 

Mark Hayter called for collaborations within sexual health with other specialities such as family planning and drug and alcohol services. Incorporation of family increased consult time but decreased unintended pregnancy, without increasing STI rates.  In addition inks with family planning could even go someway to dispel contraception myths held by Australian men as highlighted in Mary Stewarts lecture ‘contraception and the Australian male’.

 

Craig Rigney, CEO Kornar Winmil Yunti spoke about the KWY community based response to high rates of Aboriginal family violence and a lack of accessible culturally appropriate services. The Aboriginal family violence program maintained client safety through ‘women’s business’ and ‘men’s business’. Men’s business included a perpetrator program, which was aimed to unpack perpetrators own held trauma so that they can be accountable for their own violence.  Although initially many attendees were mandated from court self-referrals are on the increase. Rigney discussed that undoubtedly valuable outcomes are hard to evaluate.

 

In ‘rethinking testing and management of sexually transmissible infections’ Catriona Bradshaw drew attention to the lack of guidelines internationally for rectal MG with treatment shifting towards doxycycline. She called for a reduction in macrolide use and improved contact tracing and TOC rates.

Jane Tomnay analysed PDPT in the Australian context drawing attention to challenges in primary care such as who will pay for PDPT? And how do you write a script for the partner if the partner has never attended the practise.

PDPT was criticised in NT in 2012 when it coincided with child abuse allegations as a way that abuse could remain hidden – something to think about especially in relation to pick up rates of family violence/ domestic violence. 

Daniel Richardson proposes HCV testing should be considered in relation to sex in certain groups even if heterosexual (namely women) and in HIV negative MSM on PrEP – when asked about increased cost due to Australian labs only performing HCV RNA, Richardson suggested lobbying for HCV antigen tests he denied value of LFT’s as a screen, referring to the MSM in PROUD and EPIGAY whom contracted HCV through sex having had no change in transaminases.

In the sexuality lectures Hilary Caldwell Challenged gender based narratives about the Australian sex industry stating that its no longer sustainable to claim only men command and objectify bodies when buying sex or that that power dependent activity is inherently oppressive. She described how women buying sex (WBS) In Australia are more likely to do so from women than men and that these women were diverse with any ethnicity and any income. WBS stay for longer and buy sex less often prioritising safety and a sexpert. Angela Davies looked at the impact of pornography on young peoples sexual lives. There are concerns that porn can normalise risk behaviour promote harmful attitude. An Online survey of 15-29y revealed both male and females used porn. Porn was considered a more detailed sex resource compared to formal sex education where pleasure is the goal instead of risk. There were positive and negative impacts. Positives impact included – positive body image, sex positive, normalising taboos, ‘a safe space to sexplore’, in some males prevented other risk behaviour. Negative impact included  - negative body image, unrealistic expectations, and limited representation of sexuality, harmful attitude and behaviour. A significant portion reported no impact of porn. Do this group have protective factors preventing impact or are these most at risk who lack insight?

 

A huge thank you to Gracelyn Smallwood who gave an inspirational talk around the importance of involving appropriate people in a community to deliver culturally appropriate health promotion that engages communities as a whole.

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Khadija was born in Sierra Leone and arrived in Australia in 2001. There is an impressive list of projects and organisations in which she is heavily involved including her long-standing involvement with ShineSA and No FGM Australia - a not-for-profit Australian organisation where she is currently the Executive Director.

She gave the opening address at the 2016 Australasian Sexual Health Conference in Adelaide and also provided a second presentation titled 'Sexuality and Female Genital Mutilation - The Psycho-Social Impact of Sexual Dysfunction due to Female Genital Mutilation'.  

Today she kindly spoke with me about FGM in the context of health settings with a particular focus on sexual health clinics.  It is with her generous permission, and that of ShineSA, that this audio interview is able to be shared.

Due to the size of this 12 minute audio file, it is hosted on the external link below:

https://soundcloud.com/user329177428/khadija-gbla

For more information on FGM and FGM in the Australian context see the following link: http://www.nofgmoz.com 

 

Gonorrhoea in MSM: Is kissing a major means of transmission?

Main Points:

  • Significantly higher rates of gonorrhoea in MSM compared to heterosexual men => Why?
  • Much higher incidence of of pharyngeal gonorrhoea in MSM compared to rectal infections & urethral (urethral = lowest)
  • Prevalence of pharyngeal gonorrhoea in MSM is ~ 11% => ??why so high compared to other sites, especially when anal sex &/or oral-penile, oral-anal sex is reported to be LOW
  • Working hypothesis: pharyngeal gonorrhoea is most likely transmitted through kissing, ?related to high rates of MSM kissing multiple partners in e.g. clubs & pubs

Personal reflection on personal practice => I remember a patient who was married (to a woman) who frequently engaged in MSM sex. This patient was Dx'd with pharyngeal gonorrhoea & stringently denied any sex with his wife for a very long time but had kissed her. His wife was admitted to hospital with Reactive Arthritis related to gonorrhoea infection. Based on patient report: the only possible means of gonorrhoea transmission to his wife could be through kissing

Posted by on in Uncategorised Posts

Pharyngeal infection with Neisseria gonorrhoea represents a large, asymptomatic reservoir of infection, and is thought to be an important driver of transmission among men who have sex with men (MSM). Which sexual activities drive the transmission of gonorrhoea between the pharynx and other sites? Could it be oral sex? Rimming? Chemsex?

Kit Fairley, Professor of Public Health at University of Melbourne and Director of Melbourne Sexual Health, wonders if it might be all even more surprising - kissing. But not just any kissing - 'proper kissing with a tongue and all the rest of it.'

In  a thought-provoking presentation, Fairley points out that gonorrhoea rates are highest among young MSM, and fall with age. While this might suggest a degree of acquired immunity to gonorrhoea, it might simply reflect changes in kissing throughout the age spectrum. Rates of oral sex, the traditionally accepted route of transmission to the pharynx, do not fall with age. Furthermore, penile-oral sex relies on urethral gonorrhoea as the vehicle for transmission between pharynges of different partners. Urethral gonorrhoea, however, is almost always symptomatic, and urban MSM are quick to access health services early in the course of gonococcal urethritis. 'The penis' says Fairley 'is an innocent bystander in this whole affair.'

How plausible is this? Neisseria meningitidis, the organism from which N. gonnorhoeae evolved aeons ago, is readily transmitted through saliva, and kissing is a well-recognised and important route of transmission for the meningococcus. N. gonorrhoeae, or at least it's DNA, can be readily detected in saliva of those with pharyngeal infection. 

If this hypothesis is correct, something as simple as antibacterial mouthwash might crack the transmission dynamics of gonorrhoea and spare the need for cephalosporins. And besides, who wouldn't prefer to kiss a man with fresh, minty breath?

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Professor Rebecca Guy from the Kirby Institute delivered a talk on how new technologies are important for STI prevention. Media technologies allow young people to 24-hour access to information on sexual health. Computer assisted survey instrument (CASI) is an efficient way for clinics to collect information and triage clients. It is acceptable to both patients and clinicians. Studies have found women are more likely to report higher numbers of male partners via CASI than during a face to face consult with a clinician.

ACCEPt is a prevalence study, which aims to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing among 16–29 year olds in the general practice setting. Findings from the study include: 73% of chlamydia cases in the study were asymptomatic patients attending for non-sexual health reasons. This highlights the importance of offering all young people chlamydia treatment at GP visits. 

Point of care testing (POCT) in rural areas has been successful. POCT can significantly reduce the time from diagnosis to treatment in many clients-especially marginalised populations who are often transient.

 Professor Mark Hayter from the University of Hull spoke about integrated sexual health services and highlighted the need for school based sexual health clinics. There is some evidence to show a reduction in births to teenage mothers and a reduction in chlamydia rates among young men in young people who have access to school based sexual health clinics.

More focus is needed on alcohol misuse interventions and services. Alcohol consumption can reduce inhibitions and can lead to unsafe sexual practices. Clinicians should include alcohol and drug history as well as the patients sexual health history and provide brief interventions and referrals to appropriate services as needed.

It was also highlighted that whilst PrEP is very important for HIV prevention we also need to counsel men around safe drug use when they engage in “chemsex” as this can pose further r

 Christopher Fairley postulated that pharyngeal gonorrhoea could be transmitted by saliva-via deep kissing and by using saliva as lubricant; which stirred great interest among the attendees in this morning’s session.  Anti-bacterial mouthwashes may be the way forward in substantially reducing gonorrhoea prevalence. Watch this space!

 Catriona Bradshaw discussed Mycoplasma genitalium (MG) and Chlamydia trachomatis (CT) infections in the rectum. There is no standardised treatment for rectal chlamydia. The Centre for Disease Control guidelines does not distinguish between urogenital and rectal chlamydia.

Doxycycline appears to be the best treatment for rectal chlamydia. A randomised control trial is underway and this will inform treatment guidelines for rectal chlamydia.

MG has been less studied that CT and the data available on rectal MG is limited. MG testing is unavailable in many settings and may take 2 or more weeks to get a result.

There have cases of macrolide resistance, which have meant that this clever bacterium may need dual antibiotic therapy to treat and there is a great need for more antibiotics to be developed.

Key messages

-Doxycycline should be used over azithromycin for rectal chlamydia while awaiting RCT evidence

-Rectal MG is commonly asymptomatic and more common in HIV positive males

-MG is predominantly macrolide resistant

-Better treatment guidelines and treatments are needed

 Jane Tomnay- Patient-delivered partner therapy for STIs: the current state of play in Australia

Patient delivered partner therapy (PDPT) describes the practice in which treatment is prescribed for the sexual partner/s of an index patient diagnosed with a sexually transmissible infection, as well as the index patient. The patient then delivers a prescription, or the treatment, to their partner/s. PDPT aims to target those partners who are unwilling, unlikely or unable to consult a health professional in a timely manner.

Jane presented about the difference between a ‘provider referral’ versus ‘patient referral’ for the treatment of STIs. PDPT can be less resource intensive and was found to be acceptable to many. PDPT is already happening in Australia and the NT has taken the lead with this initiative.

Key messages

-PDPT works

-PDPT for chlamydia using azithromycin is safe

-Pharmacist’s knowledge regarding PDPT was low therefore education is needed

-In trials there has been no difference in partners followed up between medication PDPT and prescription PDPT

 

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The afternoon symposium dedicated to Indigenous Health started with Associate Professor James Ward's summary of the STRIVE study.

 

The STRIVE study commenced in 2009 and was a randomised community trial with an intervention of a sexual health quality improvement program in 65 remote communities in northern and central Australia.

 

The primary aims of the STRIVE study were:

1. To determine whether targeted clinical review and support provided to health services can achieve substantive and sustained improvements in the provision of sexual health clinical services in remote Aboriginal communities

2. To determine whether the attainment of best practice levels in clinical activity can reduce the prevalence of STIs in these communities.

 

The results of the primary aims were discussed in today's presentation. The specifics of the quality improvement program were not discussed.

 

Results of aim 1: Improvements in the provision of sexual health clinical services

The study showed an improvement of testing rates and retesting after a positive result. The increased uptake of testing in men was more significant than testing in women. Some clinics were "high performer clinics" with 2.5x testing rates in men compared to the control group. The study took place over 3 years. Unfortunately, the increased testing rates were not sustained after the 1st year. The results also showed that only 30% of people with a positive STI result where offered/had a HIV test. Given the recent increase in HIV notifications in the Aboriginal and Torres Strait Islanders in the far north, this is alarming.

 

Results of aim 2: Prevalence of STIs in the community

The STRIVE study did complete prevalence data of chlamydia, gonorrhoea and trichomonas in the remote communities involved in the study. Unfortunately, I do not have that data to present here. Associate Professor Ward was obviously disappointed with the results that showed no change in prevalence over the length of the study. The next step in data analysis of the study is to see if the high performer clinics had a change in prevalence and try to determine factors which made these clinics high performing. Factors which seem to be associated with better results include: community-controlled clinics, availability of gender-based staff and more stable staffing.

 

The relative rolling door of staff in remote communities is one possible reason why the increased testing rates were not sustained over time. In fact, the lack of sustained results over the term of an intervention was mentioned in the next presentation by Barbara Nattabi.

 

Summary of the Indigenous Session

The session started with Assoc Prof James Ward presenting the notification rates of STIs in Aboriginal and Torres Strait Islanders in comparison to non-Indigenous people in Australia, rightly describing the difference in notifications as a human rights disaster. Unfortunately, there was no magic answer given for how to improve this during the afternoon. The afternoon finished with Professor Gracelyn Smallwood giving the history of her journey in sexual health and the growth and fame of Condoman. It was nice to end with a positive story and a reminder that a "bottom up approach" can be both cost effective and productive.

Gollow Lecture by Rebecca Guy:

  • Focus on the ever-increasing utility of the various (existing, new & emerging) IT platforms & applications for:
  1. improving client & patient care experience
  2. increased efficiencies / time savings for clinical staff and thus also for the service as a whole
  3. the potential and actual role(s) for technology to be utilised in both primary & secondary prevention

Examples of efficacious technology utilisation:

  • Sydney Sexual Health:
  1. electronic patient self-registration + appointment self-arrival system reduces the amount of time spent in reception by (a significant) 4 minutes
  2. Benefits of CASI (computer assisted self interviewing): "most people don't want to discuss their sex lives in detail with doctors and nurses" => much easier to respond honestly to questions on a screen than go through the 'gruelling agony' of a face to face interview with a clinician
  • Computer prompts for GP's shown in one study to increase opportunistic testing of e.g. chlamydia by a significant 30%
  • Significant improvement in partner notification via websites such as 'Drama Down Under' & 'Let Them Know'
  • Significant increase in re-testing rates utilising an SMS reminder system (NB: ~20% of people have a reinfection within 12 months of a +ve result) => in 2009 SSHC instituted an SMS reminder service. Result: 64% return rate for re-testing; a significant increase in re-testing rates vs a verbal recommendation after Rx. of the first infection
  • * Very interesting 'side discussion' re: the use of online dating & hook-up apps => not only the domain of the young; rather, people of ALL ages are using these platforms. Also of note => people who use these online / dating apps are more likely to have had an STI in the past & more likely to have a higher number of casual partners
  • ?? The Future:
  1. Online Clinics?
  2. Home STI testing?
  • Finally: Rebecca promoted clinicians to access the freely available Kirby Institute Data sets: http://www.data.kirby.unsw.edu.au/

Day 2 - I found Christopher Fairley, Melbourne Sexual Health Centre, Alfred Health, VIC, Australia witty and captivating!

He gave a quick talk on Pharyngeal Gonorrhoea questioning WHY is it SO common in MSM - why not Chlamydia or HPV??

Are they kissing more partners? 

As there's no difference in rates of oral sex between MSM and MSW or the rate of transmission if they only kiss or kiss plus have sex.....it doesn't make sense!!

He suggests that gonorrhoea is transmitted in saliva and saliva is used as a lube when rimming and that the penis is irrelavant to transmission of gonorhoea in MSM.

He also spoke about using an antibacterial mouthwash such as Listerine to substantially reduce transmission of gonorrhoea 

HPV

  • SPANC: http://kirby.unsw.edu.au/projects/study-prevention-anal-cancer-spanc
  1. Prospective 3 year study on anal HPV in older gay/MSM i.e. 35 years & older; important because this will be a mostly unvaccinated cohort
  2. HPV 16: ~ 50% of all HPV related cancers plus it is the type least likely to be cleared
  3. HSIL (high grade intra-epithelial lesion): found in 30-50% of HIV +ve men
  4. Cochrane review: there is no current evidence that treatment of high grade lesions prevents progression to cancer
  5. Research being done into the potential for anal cancer biomarkers to predict disease persistence

Syphilis

  • Australian surveillance data 2006 - 2015: 14,200 notifications for syphilis
  • Indigenous Australians are 6 times more likely to be infected with syphilis
  • Significant increase in syphilis in MSM during the 10 years to 2015
  • Rates of syphilis in MSM in Victoria => approx. the same rates in both HIV +ve & HIV -ve men (differs from epidemiology data in other jurisdictions where the rates of syphilis in HIV +ve men tend to be far higher than in HIV -ve men)

Gonorrhoea

  • Studies into gonorrhoea site-specific infections in MSM couples => the number of gonorrhoea infections in certain sites did not correlate with the expected # of infections (in certain sites) when considering reported sexual behaviours e.g. far more throat infections than expected => leading to the hypothesis that kissing may be a significant factor in gonorrhoea transmission
  • Condom use: even when condom use is reported to be high (for anal intercourse) there was no significant difference in the rates of gonorrhoea transmissions overall

IDU

  • significantly higher numbers of all STI's in IDU vs non-IDU
  • far more HIV +ve MSM inject drugs vs HIV -ve MSM

Testing for MSM

  • Community based testing services are far more likely to attract gay/MSM plus have a significantly higher STI yield when compared to non-community based services. Conclusion: very important to maintain community based testing services

FAMSACA - is Forensic & Medical Sexual Assault Clinicians Australia. 

www.famsaca.org.au

Today commenced with FAMSACA breakfast which was very well attended.

The organisation is small group nationally and meets up every 2 years. It welcomes new members and provides clinical educational updates. 

The Australian media has increased its reporting on Domestic Violence (DV) in Australia.

DV has become a major topic and focus nationally, especially since Rosie Batty education campaigns and advocacy.

FAMSACA presenters discussed 4 different and highly complex Client cases.

Physical Assessment of Woman and Girls after an assault can be re-traumatising.

There is clear Pathways to E.D and Medically investigation. 

FAMILY PLANNING - Copper IUD is 1 of the most effective form of contraception. 

New Emergency Contraception Pill, Ulipristal acetate is 99% effective. Ideally to be administered ASAP and within 4 days of an event. After this time it's efficiently declines rapidly. Cost is approximately $50.00 AUD and will become available over the counter in 2017. Please refer to  www.ellaone.com 

Reporting Violence to Police and relevant Authorities in relation to Children.

We spoke about the potential difficulties of reporting if the victim refuses to consent in providing this information and requests confidentiality. 

Woman may often feel unsafe reporting to Police due to fears of retribution from men/boys. This can include threats to their children. Victims dislike reporting directly to the Police, an option would be to report this on-line, but the Police require the victim (witness) to provide details, otherwise they lack powers to investigate. 

Other challenges to services and clinicians are re-current presenters. This often presents in context of people with an Intellectual Disability or mental health, with a history of childhood sexual abuse. It is hard to establish safety with ongoing abuse. 

Under age children/young people with abuse, even under Guardianship present particularly difficult challenges. When they become of legal age of sexual consent the police are not so interested. 

Drugs and Alcohol are frequently seen but it’s also can be common not remember things/details. 

Clinicians need to celebrate small changes to cope and manage working in this area of trauma. 

It is important for Clinicians and Community Workers to know where to refer Clients and Patients to these Specialised Services. 

 

 

 

 

 

 

 

 

 

Day 1/ Monday 14/11/2016 - Highlights from day 1:

Today was full of diversity in Sexual Health Field.

It was amazing to see so many people come together to listen to each of the incredible presenters and discuss, debate and learn.

My main contributions today where through regular 'tweets' on my Twitter account.

Please check them out at Twitter @paulafe2

 

 

 

Sexual Health Day 2 Mycoplasma Genitalium

Mycoplasma Genitalium has a high prevalence within the community, is difficult to test for as well as being tricky to treat.

Mycoplasma his the cause of significant pathology including intrauterine death, PID, proctitis, cervicitis and urethritis.

Traditional treatment has always been 1g Azithromycin however there is significant emerging macrolide resistance. This leaves only Moxyfloxacin which is hard enough for me to get as a GP and Pristinamycin currently needing to be imported from France...

As reported we clearly need better testing that includes resistance screening as well as new antibiotics to target this insidious infection.

Mycoplasma Genitalium has certainly been a "theme" at this event and will be a a big part of future work. I have to wonder if MG infection may have been responsible for the many cases of "sterile prostatitis" I have treated over the years...

Watch this space.

 

With just over two weeks until the virtual 2020 Joint Australasian HIV&AIDS and Sexual Health Conferences, now is a… https://t.co/qdLZhBZgQ7

ASHM ASHM