NSW HIV diagnosis and care cascade 

Sweden and Denmark are the only countries so far that have met the UNSAIDS 90-90-90 targets. Yesterday, Phillip Keen from the Kirby Institute demonstrated that NSW has also reached this goal ahead of schedule with an estimated 91.3% of NSW residents living with HIV diagnosed, 92% receiving ART and 94.5% virally suppressed. Enhanced data collection and quality methods that have been introduced in NSW could be adopted elsewhere.

NSW now aims to have 90% of people diagnosed with HIV on treatment within 6 weeks.

Interventions internationally which have reduced access gaps 

In 2009, UNAIDS set an ambitious 90-90-90 treatment target to virtually eliminate HIV transmission. The goal was that 90% of people living with HIV would know their status, 90% would be on ART, and 90% would have viral suppression. Yesterday we heard about how these targets have been achieved in NSW and are on their way to being achieved in Australia, overall.

Hard work is left to be done in the remaining 10-10-10 who have not yet benefited from Australia’s improvements in early diagnosis, early treatment, treatment as prevention and PrEP.

Dr Jeffrey Klausner from the University of California, Los Angeles, is an expert and innovator in this area. He shared ideas that have worked internationally to close the gap in hard to reach groups and with limited resources including ART and HIV self-test vending machines. He has been involved in an online PrEP clinic that offers online eligibility screening and pathology ordering with a telehealth consultation and mail delivered PrEP. Given the inequitable access to and uptake of PrEP in Australia, the increasing demand for PrEP and the corresponding pressure on clinical services to deliver PrEP, this is a model well worth considering.

www.preptechyth.org

HIV & AIDS: Theme C Symposium – Addressing access and inequity in Australia’s HIV prevention response.

People from Sub-Saharan Africa and South East Asia have the highest rates of HIV diagnosis in Australia in relation to country of birth, and people are often diagnosed late. Victoria Sande and her colleague Corie Gray presented an engaging talk about a collaborative study which aimed to identify barriers and enablers for testing among these high risk groups.

The study involved focus groups across four states (Western Australia, South Australia, Victoria and New South Wales), and included 77 participants. Questions were centered around HIV knowledge, access and barriers to testing, and ways to increase testing.

Generally, results showed a lack of knowledge in relation to testing across the groups.

Identified barriers to testing included:

• ·         Ideas about why people attend health services. Health services were seen by some as only for those who are sick.
• ·         Some indicated they preferred not to know about an illness which was feared.
• ·         The cost of attending health services.
• ·         Fear of homophobia.
• ·         Participants identified gaps in knowledge about where to get tested.
• ·         HIV was not seen by some as an issue in Australia. They felt that they had been tested on arrival and were therefore in a ‘safe’ country. This was reinforced by the perceived invisibility of HIV in Australia. They did not see much information or concern about it in their surroundings.
• ·         Some older participants had negative experiences of HIV in their country of origin and this impacted on their engagement.
• ·         Fear of having to return to their country of origin if receiving a positive diagnosis.
• ·         HIV was seen by some as associated with people different to themselves, people who engaged in activities such as drug use or sex work.

Some of the motivators for testing were:

• ·         GP initiated testing
• ·         Influence of peers

The presenters suggested that alternative testing methods, including self testing and home testing could be attractive to people from these high risk countries.

HIV testing as part of a regular health check was considered a more acceptable approach, as this did not entail identification as someone at higher risk.

Health promotion targeting the broader community might also be more successful, as opposed to targeted campaigns that these groups do not identify with.

The presentation highlighted the importance of a culturally sensitive approach when encouraging testing for people from these high risk backgrounds.  

Epidemiologist Barbara Telfer presented the findings of a cross sectional study which used NSW HIV notification data to identify predictors of late diagnosis.  Of the potential risk factors examined, the study found the following four factors to be associated with late diagnosis:

• ·         being over 50 years of age
• ·         being  female
• ·         being born outside Australia
• ·         residing in regional /rural areas

Late diagnosis is an important problem because it delays treatment, enables ongoing transmission, and can lead to poorer health outcomes.  If we are to continue progression towards virtual elimination, we need to identify the more elusive gaps in detection.

The study included data from 1465 notifications between January 2013 and June 2017, of which 38% (550) were considered late notifications. Late notification was defined as a CD4 count of less than 350 or an AIDS defining illness or death within 3 months of diagnosis, in the absence of a negative HIV test in the preceding 12 months.

Barbara noted that the study relied on data provided by the clinician giving the notification.  Some notifications could not be included due to missing information, which draws attention to the need for accurate data collection.

The study concluded that greater efforts needed to be made in the earlier detection of HIV amongst the groups found to be at high risk. The findings highlight the need for testing efforts to be inclusive of those who may not readily identify as needing a screen, to think both broadly about testing, and to be aware of those patients who we may have neglected to consider in terms of their risk. It is also a reminder for those clinicians working in rural and regional areas that they may be key players in earlier detection.

Hello from the Australian 2017 Sexual Health Conference

The session started after the afternoon tea when everyone was tired and looking forward to going home. The two MCs Heather Mugwagwa and Praveena Gunaratham steered the group to life.

 The presenter Ms Victoria Sande is a current Masters of Public Health student at Curtin University. She shared the stage with her counterpart Corie Gray. They discussed Barriers to HIV testing in the sub-Saharan Africa and South-East Asia immigrants to Australia.  

They discussed the following in a nutshell:

 Immigrants were diagnosed at a very late stage

Access to ART is limited compared to Australians.

They discussed reasons forHIV late diagnosis as based on their original background in Africa and Asia.  The need to go to the hospital was required only when one is critically ill. There was no need to visit the hospital when one is fit and strong. Their background discriminated against people with HIV. It associated HIV with bad behaviour were sufferers are labelled as prostitutes and unfaithful. Since HIV was incurable and the disease itself was referred to as a death penalty and this brought a lot of emotional issues and anxiety. It was best for one not to know his/her status because knowing was more killing than not.

Australia did not make it easier for them.They read in the media about their immigrant’s counter parts’ HIV positivity status being publicised in both electronic, digital and print media. They became worried about their privacy, stigmatisation and racism that comes with it. These factors further distanced them from testing, diagnosis and getting treatment early. They prefered to remain ignorant than to know their HIV status. They were also afraid that the Australian Government criminalises HIV infection, quarantines them, and denies them Permanent residence. They are also limited HIV treatment access as compared to their Australian counterparts.  It became more unattractive for them to know their status thereby delaying their early testing and treatment.

Their issues require immediate attention via accurate dissemination of information via their  Peers and immigrant educators. There is a need for other groups to understand their background and adjust so as to help them.

Early testing and diagnosis are important so as to reduce and limit the spread of HIV infection. There is need to broaden HIV testing e.g. by use of rapid testing, self-collection kits, and oral testing.

Day 1: Afternoon Session

Welcome back to the afternoon (evening really, my laptop ran out of juice). In case you were wondering, it did eventually stop raining. Also, apologies for the formatting error in my last post, I'm sorry you had to see that.

The afternoon session in the main theatre was PrEP and was fascinating. I chose share with you the EPIC-NSW analysis done by Associate Professor Rebecca Guy from the Kirby Institute at UNSW.

Quickly a bit of information for those not from NSW or familiar with this program. Expanded PrEP Implementation in Communities in New South Wales (EPIC-NSW) is a study commenced in March 2016 and was designed to provide free access to PrEP to people at high-risk of HIV infection for free. This is the result of an active partnership between NSW Health, the Kirby Institute, ACON and clinical services involved in the study. The study was planned to have a rapid rollout and high clinical coverage within target populations and now has enrolled over 7,500 participants.

Rebecca spoke to the study, highlighting the similarities and disparities in demographics of people enrolled in the study and with data for new HIV notifications in MSM. The data for HIV notifications was taken from 2015 and the EPIC-NSW data up to and including September 2017.

Rebecca told us how the data shows mostly similarity in the capture of population at risk within the age, locality (urban vs. regional and remote) and to a somewhat lesser degree people identifying as Aboriginal or Torres Straight Islander (ATSI). However the one area demonstrated to have a disparity between the data and HIV notifications is that of people born overseas. Rebecca’s analysis has shown that in particular, people born in South East Asia (SEA) and North East Asia (NEA) are not reflected within the EPIC-NSW enrolments. From the data above, the rate of HIV notifications for persons born in NEA or SEA are 2.5 and 2.4 times respectively compared to the numbers reflected within the EPIC-NSW data.

In 2017 ACON increased the number of culturally appropriate programs, advertisements and information was released, targeting these populations. Examples such as posters in other languages and programs and information targeted to particular language groups has coincided with a marked increase in the population reflected within the study.

Rebecca concluded that although we mostly have participation that reflects the population targeted, we still have work to be done in order to reach the goals of the EPIC-NSW study.

Through my position in a sexual health clinic, I have been involved with this study, although I am well and truly at the lower end of the food chain than Rebecca. It is worth recognising the impacts on changing information available and making culturally appropriate services available to engage an under represented population. This is a great example of how changes in strategy can have a significant effect, although as Rebecca said, there is more work to be done.

I will be back tomorrow and hopefully won't be writing so late, I am now more prepared for batteries running out mid session. See you tomorrow!

The Talk was presented by Mr Joel Murray, Senior Officer Policy and Research from Living Positive Victoria 

Reference from Reform of the Sex Work Act 1994 ( VIC ); Policy Statement

Introduction 

Living Positive Victoria, The Victorian AIDS Council, Scarlet Alliance: Australian Sex Workers Association and Vixen Collective: Victoria's Peer - only Sex Worker organisation, are supportive of the full decriminalisation of sex work in Victoria.

The Position statement deals with the narrower issue of sex workers living with HIV, but it should be seen as part of a broader call for full decriminalisation of sex work. Law regarding commercialised Sex should mirror those of other consensual sexual activity. This statement summarises the case for reform of the Sex Work Act 1994 ( VIC )

Background

Sex work in Victoria has been regulated via a licensing system since 1986. A licensed system allows for the establishment of Brothels and escort agencies. Similarly sex workers are required to be registered in order to work legally in brothels and escort agencies. It is currently illegal for as person living with HIV ( PLHIV )to undertake sex work. 

The knowledge of HIV in 1986 was limited - WHO advised governments around the world that Sex workers were an at- risk population. Therefore, to not allow PLHIV to engage in sex work was seen at time to be in the interest of Public health. 

However, in 1994 when the current statute was enacted, increased knowledge of HIV and treatment, the advancement of human rights of PLHIV and the sex industry's considerable efforts in health promotion, demonstrated that provisions within the statute that disallowed PLHIV from undertaking sex work were not justified on Public health grounds.

Issues

Public Health and Human Rights 

The prohibition on HIV positive sex workers does nothing to protect public health, but rather forces HIV positive sex workers to work illegally, potentially harming HIV response by driving HIV underground. 

The Equal Opportunity Act 2010 sets out attributes on the basics of which discrimination is unlawful according to Victorian law.

Barriers to accessing health and HIV specific services

Criminalisaiton of sex workers living with HIV establishes a barrier to access services, treatment, care and support. ALL PLHIV should be able to access education and effective antiretroviral treatment to further reduce risk of HIV transmission. 

Stigma and discrimination 

Sex workers living with HIV face the potential for multiple levels of stigma and discrimination depending on their personal circumstances and how they wish to identify. To identify as both living with HIV and being a sex worker is to face at least twice the level of discrimination. 

Sex work and HIV in Australia 

In Australia, significant efforts have been undertaken to ensure the widespread adoption of safer sex practices in the sex industry. This has resulted in lower rates of STIs among sex workers compared to general population. In addition, there have been no documented cases of HIV transmission from a sex worker to a client in Australia. 

Inconsistent laws between Australian jurisdictions relating to sex work by PLHIV, may cause a person to unintentionally break the law simply by going about their work in a state or territory has different laws to their place of residence.

Policy Context

This position is supported by a number of Australian and international policy contexts, including but not limited to

• Victorian HIV Strategy 2017 - 2020
• Seventh National HIV Strategy 2014 - 2017
• AIDS 2014 Melbourne Declaration; nobody left behind
• UNAIDS Guidance Note on HIV and Sex Work
• UNAIDS 2016 - 2021 Strategy 
• UN General Assembly Political Declaration on HIV and AIDS 2001,2006,2011 and
• The Ottawa Charter for Health Promotion

Started in Cairns in 2014-

Prominently young indigenous males, facing social challenges consistng of poor housing situations, employment issues, drug and alcohol use, high mobility and low health literacy.  MSM and sporadic IDU use.  Coinfection with STI's especially syphilis.

Challenges -

Low levels of testing occurring in this group, with individuals not identifying as being at risk, low health literacy and lack of knowledge of HIV.  Knowledge of TasP poor and known sporadic engagement with health services and treatment compliance issues.  Stigma, shame, cultural factors and lack of trust are contributing to challenges in culturally appropriate contact tracing.

The way forward-

Urgent culturally appropriate health promotion activities, increasing point of care testing, access to condoms,TasP, PrEP, NSP's.  Treatment and support needs to be individualised using a multidisciplinary outreach approach.

Jennifer Hoy: Director HIV Medicine, Alfred Hospital and Monash University

Most cities and countries have now achieved the 90-90-90 HIV target: 90% of people living with HIV (PLHIV) are diagnosed, 90% of HIV-positive people receiving antiretroviral (ARV) treatment and 90% of PLHIV have viral load suppression. Now a push for a 4th 90 is on the table – 90% receiving Quality HIV care.  

Jennifer discussed two perspectives on this approach to quality care: the patient’s and the healthcare provider’s perspective.

From a patient’s perspective, approaches to quality care can be measured through patient satisfaction surveys and reported patient outcome measures. Such reportable measures includes individualised patient-centred care encounters, experiences of HIV related discrimination and stigma and ease of access to care.

From the healthcare providers perspective, quality care means establishing appropriate management, monitoring and screening of HIV related co-morbidities, ensuring efficient care in a patient-centred manner delivery.

Adapting a new culture of quality of care improvement in HIV treatment would be crucial. This new culture is the key to future sustainability of this 4th 90% target, with clinical audit being its main driver. Clinical audit scrutinises care delivery at different care provision levels. Starting at individual healthcare level providers, to health care settings, the state level and to the highest national level. Vital shortfalls in care delivery could then be identified, feedback these outcomes, for crucial brainstorming of targeted intervention strategies. 

Therefore, to achieve this 4th 90% of HIV care which is ‘Quality of Care’, audits are important! The “measurement-intervention-measurement-intervention” approach to care, because viral suppression is not the end goal of HIV treatment. It is health-related ‘quality of life’.

The Talk was by Rimke Bijker who is a PhD Student from The Kirby Institute. 

As aging population with HIV positive in Asian countries, risk of increasing trend of Cardiovascular Disease is unavoidable. Overtime, about 60 % of patients (HIV Positive) will be aged over 40 years in 2025.

Risk of  Cardiovascular Disease (CVD)comprises traditional risk factors as well as specific factors

- Traditional risk factors comprises dyslipidaemia, diabetes status, hypertension and also smoking

- Specific factor such as high Viral Load count, Low CD 4 count 

There is an ongoing research Over 10 - year period at Asian region, which included 20 clinical sites, 12 countries and some part of South East Asia 

The cohort data base was used from TAHOD ( Treat Asia HIV Observational Database ) was established in September 2003

This based on Gender, Age, ART regimen, status of Diabetes Mellitus 

Assumptions

- Patient remains on current anti retro viral therapy 

- Stopped Abacavir ( ABC ) < 6 months ago 

- No Family history of  CVD data, based on prevelance of the same population

Clinical Data

Total number of study - 3406, comprises ;Male 69 % and Female 32 %, > 50 age  29 %

Hetero 68 % Homo 29 %

Projections

– increasing trend doubled of risk of Diabetes in 2026 compared with 2017, ( almost 1500 events in 2026 )

- Global data for burden – 900 events, although throughtout the period the same for 2026

Subgroups of outcome 

-          Male > female

-          Age > 50 higher than younger

-          Income does not change the outcome 

-          DM > than no DM

-          Protease Inhibitors  > no Protease Inhibitor Regime 

Limitations of Study

-Critique on risk scores

-Generalisablity

-Risk score Based on mostly European population 

Take Home Message 

There will be doubling of CVD events in a decade time. Therefore, Primary physicians / health care professionals need screening for those population

 Age as Older patients, having Diabetes and also taking PI Regimen are high risk of having CVD events 

There is no conflict of interest for this study 

HIV infection in young people in Australia has thus far not been well characterized. In the  ‘Trials, Treatment and Toxicity’ session, Dr Carly Hughes from Monash Medical Centre in Melbourne used the Australian HIV observational database (AHOD) to compare demographics between adolescents/young adults (13-24yo) to those over 25years. She described the need to further characterize the population of young adults who are newly diagnosed, given the complexity adolescence and young adulthood places on management of chronic diseases. This has been experienced in other sectors such as patients with type 1 diabetes. Main points from the presentation:

-       223 new diagnoses of HIV were made in those <25 years of age since 1997

-       A significantly higher proportion if females are represented in new diagnoses made in young adults (<25years) compared to over 25

-       The <25yo group had higher CD4 counts and lower VL at diagnosis, but this difference was lost at time of treatment initiation

-       There was significantly higher loss-to-follow up in the <25yo group  compared to >25yo (incidence rate of 8.8 vs 4.68 per 100 person years)

-       There were significantly higher rates of treatment interruption in the <25yo group

Normal 0 false false false EN-US JA X-NONE

Data from this study highlights the challenges of managing adolescents and young adults with newly diagnosed HIV and the need for additional methods to engage younger adults in medical care. Social support networks could play a role here - the opening plenary talk by Nic Holas on ‘Living with HIV online’ discussed the growing role of online support networks for people living with HIV. He described the role his online support network , 'The Institute of Many' (TIM), has played over the last few years in providing another avenue for people living with HIV to obtain information and find additional support. Clinicians could play an increasing role in this space to help engage younger individuals.

There has been a large shift in the practice of HIV medicine towards that of chronic disease management and management of co-morbidities. One such co-morbidity is osteoporosis/osteopenia – the incidence of which is increasing, driven in part by the ageing HIV population, as well as ART-related effects such as tenofovir disoproxil fumurate (TDF) use. In the session on ‘Trials, Treatment and Toxicity’, Prof Jenny Hoy from the Alfred Hospital and Monash University discussed her findings on a recently completed randomized trial looking at the bisphosphonate zoledronic acid versus TDF-switching on bone mineral density (BMD). Main points from the talk:

-       TDF has previously been shown to cause lower BMD and increases fracture risk (TAF has been shown to have less of an effect on BMD than TDF)

-       Switching from TDF to another agent shows improvement in BMD

-       Zoledronic acid has also previously been shown to increase BMD vs placebo in HIV-positive individuals

-       The trial was a randomized, open-label 2-year trial testing zoledronic acid (5mg) vs switch of TDF to alternate ARV (in most cases to abacavir or an integrase inhibitor) on BMD at time 12 months and 24 months

-       43 patients were analysed for the zoledronic acid group and 42 for TDF-switching

-       There was significantly higher increase in BMD in the zoledronic acid group compared to the TDF-switching group (6.1% vs 2.9%) at 12 months, which continued to increase in the zoledronic acid group at 24 months (7.4% vs 2.9%)

-       The study was not powered to comment on changes in fracture rates

Overall the study demonstrated significant increases in BMD in patients treated with zoledronic acid compared to TDF-switching, however it remains to be seen whether this translates clinically to reduced rates of fractures. Given the ageing cohort of the HIV population and predicted increase in osteopenia/osteoporosis, coupled with previous data demonstrating increasing frailty – risk of fractures remains an important clinical concern. Clinicians should aim to screen for and manage risk factors for co-morbidities early. This was summed up in Prof Georg Behrens opening plenary talk– to consider a ‘hit hard and early’ approach to HIV co-morbidities.

Normal 0 false false false EN-US JA X-NONE

Sara Bell from the University of Queensland discusses on-line HIV self-testing kits.

As a means of encouraging more Australians to get tested for HIV and increase testing frequency, providing access to self-testing kits is a convenient step in the right direction. However, self-testing in not currently available in Australia. It has been proven that the demand is there, with data showing Australians are already conducting internet searches seeking self-test kits from overseas. While this shows a willingness to self-test, caution must be taken as seeking kits from unknown sources presents a certain level of risk, with the possibility of overseas test kits being substandard.

Sara and her team conducted a pilot in Queensland, with the aim of assessing whether an integrated HIV self-testing service delivery model would be accepted and how feasible the service would be in a peer-led Queensland community setting. A particular target population included men who have sex with men (MSM) living in regional, remote or rural areas.

630 test kits were ordered, including 87 from non-Queensland locations. Although eligibility was such that the participant was required to live in Queensland, data showed that there is a demand nationally.

An important finding showed 32% of MSM and bisexual males in Queensland reported never being tested for HIV. While we know there are many reasons why people choose not to engage with health care providers, what we do know is that while HIV related stigma and discrimination continues to exist, the chance of a person stepping forward for testing is decreased. Therefore, self-testing kits may break this barrier due to convenience self-test kits provide.

The interest shown in this pilot demonstrates that this form of on-line technology is indeed effective in increasing HIV testing among key populations such as MSM and bisexual males. It also shows that advertising on social media, dating apps and other websites is an effective platform to engage hard to reach populations.

This project aligns well with the UNAIDS 90-90-90 target and will be one to follow in the future.

Philip Keen, the co-ordinator of the NHPPP from the Kirby Institute gave a fairly uplifting presentation on the diagnosis and care cascade in NSW in relation to meeting the 90:90:90 targets.

90:90:90 refers to the WHOs aim of having 90% of PLHIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment with a suppressed viral load. The result would be 73% of PLHIV having a suppressed viral load. 

No surprise Sweden were the first to reach this goal, with 78.8% of PLHIV with a suppressed viral load. Numerous other countries have subsequently demonstrated >73% of the PLHIV with suppressed viral loads.

In Australia we fall short of this mark. However in 2016 health surveillance of the data from NSW had some interesting results. 91.3% of PLHIV were Diagnosed, 92% of these were receiving treatment and 94.5% of those on treatment had a suppressed VL. This equated to 79.3 % of PLHIV in NSW having a suppressed Viral load. Better than Sweden.

So this proves what I have always said, that NSW should form its own country as the rest of the country is holding us back... In all honesty it demonstrates there is probably a significant amount of inequality between various parts of Australia in accessing appropriate care. 

A very interesting talk today by Assoc Prof Adam Bourne today addressing many of the benefits and obstacles to reducing harm in sexual practices.

I thought the most fascinating part of the talk centered around the use of Pre-Exposure Prophylaxis (PrEP). Recently I heard there were almost as many people on PrEP in Sydney as there are on ARV's. 

The talk was largely a positive spin on PrEP, highlighting how it has improved sexual experiences, and undoubtedly the mental well being of the MSM community as well as PLHIV. However many of the issues associated with its use stem from peoples reluctance to use PrEP due to the stigma associated with taking HIV medication. I felt however the issues of condoms no longer being used by many using PrEP in casual relationships was understated. PrEP no doubt has a crucial role in prevention of transmission of HIV in serodiscordant couples, however if our message is its safe to have sex with multiple casual partners if we have an undetectable viral load or PrEP in the absence of other safe sex practices (such as condoms), the rates of other STIs will skyrocket. I know many of these STI's are treatable, though with resistance patterns seen in gonorrhea and the latency often seen in syphilis we could have serious problems on our hands. Not to mention the fact there is resistant HIV virus in the community, to which the PrEP may be ineffective. The message we should put out is yes PrEP can protect you from HIV (in most instances), however it doesn't mean that if you shouldn't use a condom if you're going to have sex with multiple casual partners. 

PrEP is still a long way off in East Timor (my current place of work), though as health resources improve could be a great aid to reduce HIV transmission.

Integrated service provision is essential in the delivery of consumer-centred care that is accessible, acceptable and affordable.  Through ongoing engagement with the key populations in the community, services can be mapped to ensure that there is ongoing assessment of marginalised communities in particular those living with HIV, multiple co-morbidities and poor social situations.  Access doesn't always equate to acceptable services it therefore is essential to consider what the community identifies they need and considers safe.  Signalling safety is best achieved with a broad approach through the multiple social layers.  Partner organisations play a pivotal role in extending access to prevention strategies aimed at improved consumer outcomes.  This holistic address of multiple needs can only be achieved through enabling service principles that are integrated and promote, equitable, affordable, acceptable services to exist within the communities most in need.

Professor Michael Levy, Australian National University, ACT, Australia

Within this session, Professor Michael Levy discussed harm minimisation strategies within the prison environment, including the controversial provision of a needle exchange program in Alexander Maconochie Centre (Prison), Australian Capital Territory (ACT), Australia and achievements in reaching global targets for hepatitis C treatment.

Prof. Levy, a tireless advocate for prison needle and syringe programs, led us through the session by providing a background on the situation and the barriers encountered.

His passion was clear as he spoke about the frustrations of being so close yet so far from achieving the ultimate goal of implementing a needle exchange program in the ACT. Prof. Levy expressed the challenges faced in getting Corrective Services to share the same enthusiasm.

The event that occurred in 1990 in New South Wales, Australia where a detainee living with HIV used a blood-filled syringe to stab an Officer who subsequently died still remains a major barrier to moving forward in the harm reduction response. This case, he states, is nested within Professor Kate Dolan’s PhD thesis on HIV transmission in Australia. Since this time, agitation among Corrective Services has remained.

While Switzerland is recognised as the leader, commencing the first needle exchange program in prison in the world, various other countries have progressed, implementing programs since. However, this progression is yet to follow in Australia, where we sadly lag behind other countries in the global response.

The ACT had an aspirational plan to comply with the human rights of prisoners, advocating for the equivalence of healthcare by recommending a needle exchange pilot to minimise the transmission of disease, however their efforts were to no avail.   

While there is Government commitment from the Greens, the ACT Human Rights Commission, the Australian Medical Association and Public Health Association, the battle continues. While harm minimisation programs such as needle exchange services are yet to be implemented, other strategies such as therapeutic prevention, such as hepatitis C treatment, have been adopted as an alternative to managing the within prison risk behaviours of the sharing of syringes.

Prof. Levy discusses the remarkable achievements in reaching global targets of a reduction in hepatitis C prevalence. From a HCV Ab prevalence of 48% in 2010, to 20% in October 2016, an impressive reduction was achieved in just 18 months.

What we can be assured of is that while passionate leaders in global health such as Prof. Levy continue to be at the forefront, striving for improved public health outcomes, there is still hope. The dream may one day become a reality, where we see prison needle exchange programs, achieving universal health for all as we know ‘good prison health is good public health’.

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

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

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

• Condom use (Fagan et al 2010, self reported behaviours suggest similar rates of condom use amongst this group to others, but younger sexual debut, more sexual partners. Unlikely to be able to significantly increase.

• Test and Treat - low level of HIV testing overall in this group.'Nth QLD STI Action Plan' covers syphilis but not really HIV; Good testing of male prisoners in Cairns, reasonable antenatally for women. Adult and young peoples health checks now include HIV testing. Consider - point of care testing (ALere Determine accessibility)

• TasP - the presenter considers this is the most likely strategy to reduce onward transmission but costly, logistics etc.

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

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

• Health promotion is urgently required-  but some ideas are circulating/in development.

The importance of knowing your epidemic is illustrated dramatically here.

Presentation from Jenny Hoy (Alfred Hospital) regarding enmeshing quality improvement in routine HIV care.

One example covered was syphilis testing - recommendation that syphilis serology done with all HIV VL tests. Initial audit suggested only 25% or less of cases of HIV VL testing at Alfred were accompanied by syphilis serology. Response with clinician education was effective in improving testing to around 50%, but not durably so (decreased again after 1year). An individual clinician audit approach was more effective, and changing the system to 'opt out' (syphilis testing needed to be crossed off for it not to be done), proved successful. Food for thought regarding clinician behaviour and testing algorithms. When is an 'opt out' approach appropriate? And how does it impact on clinician responsibilities, patient rights, and health outcomes?

The next example presented by Prof Hoy concerned screening and management of HT by clinicians. Re-education was required for doctors to check BP, however surprise to realise that re-education was subsequently required to get them to do anything about the results! An important lesson, particularly given the aging HIV infected population - as presented in the last session I attended (Theme B this morning at 11:15am) and the new comorbidity focus on illnesses associated with aging including cardiovascular disease, bone mineral density changes and cognitive impairment. HIV clinician-gerontologists are uncommon, but at the very least HIV clinicians need to expand their skill sets to optimise their abilities to manage the new comorbidities seen in their patient populations. 

One of the important messages presented in this talk was that audit is required to improve quality of care - shortfalls may thereby be identified at individual provider, setting and state and national levels. Quality improvement needs to be integrated into care. To make changes durable however is the next challenge.

Finally, she discussed the barriers to Quality of care, for example-the importance of setting standards for quality, as is seen in the European Guidelines , for care of PLHIV. We do not have these in Australian guidelines at the moment. 

"Quality of life is inextricably linked to the quality of care that we deliver".

Minding the Gap - Daryl O'Donnell, CEO AFAO Australia

Spoke of the exciting possibility of ending HIV transmission in Australia. The laying down of a blueprint of this and the potential savings in new infections and healthcare costs in Australia. The challenge of what is needed to achieve this is sobering and important - commitment, money, vision and importantly more research into knowing our epidemic and the strategies that will work in our setting to achieve this. A great step by the government to consider this and be involved. An inspiring vision to work towards.