Joint Symposium: Are we there yet? Reaching global goals for HIV in Asia and Pacific Regions

Health vulnerabilities, human rights and the war on drugs in the Philippines.

Jonas Bagas, Programme Officer, Asia Pacific Council of AIDS Service Organisations, Bangkok, Thailand

The focus of this session was to discuss how our neighbours are meeting global goals for HIV, in terms of leaving no one behind in the aids epidemic.

The ongoing fight to end the public health threat of AIDS concerns all of us. The epidemic does not respect borders, whether it be new migrants that have acquired AIDS overseas and settle in Australia or tourists visiting overseas and returning with an acquired infection.

The Philippines in particular has one of the most explosive HIV epidemics in the Asia and Pacific Region. High levels of discrimination and stigma towards key populations such as men who have sex with men (MSM) continue to exist.

Are the Philippines there yet, will they meet the Fast-track target of 90-90-90 by 2020? No, Jonas informs. In fact, targets are way off with 260 000 new HIV infections in 2016 alone.

141% increase in HIV infections was reported since 2010, particularly among key populations and young MSM. Gay men are suffering and dying in silence, fearful of accessing healthcare.

Barriers hindering progression towards targets include; poor knowledge, increase prevalence of STIs, chem sex and low-level condom use.

Prevention targets are also not being met. ½ of MSM, people who inject drugs and sex workers are not even aware of their HIV status. Treatment targets are also off track.

The Philippines are not there yet, Jonas states they will not get there by 2020 or by 2030.

Why? Political struggles, human rights violations and the war on drugs are all key contributors that need urgent attention. Politics are core of the response.

Take home message was we need to work towards zero discrimination, uphold human rights and continue the fight to ends aids for all.

One of the biggest challenges facing health now and into the future is that of antimicrobial resistance, and Monica Lahra from the WHO did a fantastic job at outlining the issue.

Almost 40 years ago the specialty of infectious diseases seemed almost dead as it looked as if mankind had won the battle against microbes. However this was short lived as natural selection ensured antibiotics were no longer our golden bullet. 

Though to some degree antimicrobial resistance is an inevitable consequence of antibiotic use, antibiotic abuse has certainly led the problem to explode throughout the world.  Inappropriate use in hospital, community health facilities, pharmacies and pharmaceutical companies (dumping in water ways) and agricultural practices (fish farms and livestock) have all been the major of drivers of this. Furthermore travel has ensured these organisms are spread throughout the world. For example Poor antibiotic practices have ensured the subcontinent is riddled with ESBL enterobacteriaceae. A survey of Swedish travelers stools before and after returning from the subcontinent showed extremely high carry rates of ESBL after returning to Sweden, often persisting for months. It's tragic to hear now Colistin resistance is being widely seen, particularly in livestock.

So how do we tackle this growing problem? Not easily. Improving awareness and education to healthcare providers so they rationalize and appropriately prescribe antibiotics is key. Restricting over the counter purchasing of antibiotics must accompany this. Increased surveillance and research is also a key to understanding the patterns, distribution and resistance profiles of such organisms. And finally better hygiene practices must continue to be promoted. 

This talk was presented by Udesha Chandrasena, Policy Officer, Scarlet Alliance, Australian Sex Workers Association, Australia

Udesha spoke about the results from a study conducted by the Scarlet Alliance, involving an online survey that was distributed to sex workers including members of the Scarlet Alliance. The survey looked at potential implications of HIVST 

Sex workers in Australia have low rates of HIV infection despite laws that stigmatise and discriminate against them. This is largely due to the success of peer eduction, outreach services, and safer sex information practices.

Benefits of HIVST may include providing testing options that are private and confidential and that take place outside of a clinical setting 

The risks of such testing , however, may include a higher rate of false reactive results due to sex workers being a low prevalence population 

In addition, there is no opportunity for pre and post test counselling 

In the event of a reactive result this may be considered evidence of HIV infection as per the National Policy on HIV testing, which could have consequences for the sex workers due to current laws and policies that are in place 

It is important to ensure that if HIVST was carried out, sex workers are supported and that information is available regarding what to do in the case of forced or coerced testing. Privacy rights also need to be protected

In addition, clear information regarding the risks of false reactive test results and the need for confirmatory testing needs to be in place

The sex workers who completed the survey generally welcomed HIVST, however they were concerned about the legal implications and other possible drawbacks as mentioned above

The symposiusm on Trans-inclusion in clinical care was stimulating discussion with a diverse and representative panel facilitating the talk. 

Discussion started with the gender experience rather than identity and the identification of the trans-gendered women, trans-gendered men and non binary people who seek health care.  Important points raised included highlighting the need for education and upskilling of health professionals, if you are unsure, ask...ask about pronouns; ask "are you enjoying the sex you are having?", ask about the body parts used.  There is decreased sexual health literacy in this group as they feel they "aren't part of the conversation".

In relation to HIV, the concern was that they are "not seen as a target group" by some, and yet trans women who have sex with men have higher rates than MSM groups.

Another important point around health for trans people raised was that there is not one group who takes the lead for Trans Health Care and this needs to happen - a Mandate for Trans Health!  Normalised Health Care with GPs who are comfortable rather than care by endocrinologists is the way forward.  

Presenter:  Professor Donna Mak

Given my own interest in gonorrhoea, it has been fascinating hearing what is happening in other parts of the country.

Here, Professor Mak presented the WA epidemiological data.

She noted that whilst rates remained highest in the historically high incidence ATSI group; these rates were relatively static.  The highest rate of rise of incidence was observed in heterosexual urban females.  The age group of highest incidence has shifted from the younger 15-24 age group to the 25-34yo age group.

They have an enviable program which allows them to assess the proportion of positive tests with the denominator of all requested pathology (apart from a single laboratory) and noted that the percent of positive tests are rising. 

From 1^st July 2017, enhanced surveillance for gonorrhoea has been implemented in WA; which involves a fax to the test provider with treatment recommendations and contact tracing recommendations plus some data collection.  If there’s no response, in certain groups follow up will be implemented: that is if the patient is under 16, tested by corrective services, ATSI, pregnant, a sex worker or client, outside Metro Perth, homeless or tested in hospital or by an after hours GP. 

Strains circulating in ATSI populations seem to remain sensitive to triple ‘zap packs’ of amoxicillin, azithromycin and probenecid; whilst urban populations are being treated in line with dual therapy recommendations.

Presenters:  Rekha Pai Mangalore; Shu Jin Tan; Prianka Puri; David Griffin.

The early bird not only got the worm, it got fungi, bacteria, a host of psychosocial and engagement challenges and Haemophagocytic lymphangiohistiocytosis.

The case presentation was a wealth of diagnostic and treatment dilemmas in late presenting, immunosuppressed patients.  All were from different parts of the world, and all proved Higgins Dictum will always hold true in immune suppression: Patients can have as many diagnoses as they damn well please.

Cases included disseminated histoplasmosis; HLH driven by HIV with concomitant nasal NK/T-cell lymphoma; a cryptococcal IRIS unmasked by ART initiation in an unscreened Australian gentleman; and a challenging tertiary syphilis involving gummatous and neurological disease. 

Dr Adam Bourne from La Trobe University in Melbourne spoke to four statements about safe sex drawn from his experience working in many countries.

1.  Sex is safe if it feels safe 

In some countries e.g. the Netherlands, HIV is being transmitted within regular sexual relationships rather than casual sex due to beliefs around the person being a risk rather than the type of sex being had. Familiarity, trust and a romantic halo effect led to more unsafe sex whereas perceptions about a person led to safe or no sex at all - e.g. in the U.K., 70% of men are not willing to have sex with a positive person.

2. Safe sex is what is possible

A world map of countries providing PrEP highlighted how PrEP is not an option in much of the world for safe sex. In some countries there is poor access to viral load testing making it not a tool for decision making. In some African countries water based lube is not available and it gets confiscated at customs due to association with gay sex.

3. Safe sex is about safe environments

Safe sex is non-threatening.  What does safe sex mean when there is lack of consent or threats to physical safety? Nearly one in 5 MSM in Southern Africa have experienced blackmail, entrapment or rape. What about safe sex when under the influence of drugs or alcohol?

4.  Safe sex is what I understand or appreciate 

For many condoms still equals safe sex.  For example in the UK only 30% of people have heard of PrEP and only 50% would use it if it was available. Other questions included can a pill really protect against HIV? Or what does undetectable mean? 

Dr Bourne commented that Australia is ahead of many countries in Europe and UK with MSM knowledge about PrEP and also knowledge about safe sex within relationships i.e. talk test trust together. 

Becoming Serodiscordant: The Seroconversion Study Interviews. Steven Philpot, Kirby Institute. 

In this study participants were interviewed between 2009-2014, and the aim was to gain knowledge of perspectives of those recently diagnosed with HIV. Topics discussed included: The seroconversion event, sexual practices prior to diagnosis, reactions to and management of diagnosis, post-seroconversion sexual practices, attitudes towards treament for HIV and viral load. Most participants in the study identified as gay, with some bisexual and queer also, with a mixture of ages, ethnicity and various relationship status.

Steven presented the analysis of response from 41 participants of which 25 were men in serodiscordant relationship, 6 single men who were previously in relationships but their relationship ended once HIV diagnosis made, and 10 were single who discussed previous serodiscordant relationships in which they were the HIV negative partner. 

In these relationships, renegotiating sex with regards to infectiousness, responsibility and intimacy were discussed. Also, reaffirming relationships with regard to love, support and strength. Various narratives were shown and were certainly wide and varied in their individual experiences. Some relationships suffered or ended as a result of thr new HIV diagnosis, some relationships became stronger and provided an opening of communication between partners, though couples within an established relationship when diagnosis made grappled with chages within their intimate relationships.

It will be interesting to see what lived experiences will now occur withinin serodiscordant relationships and a new HIV diagnosis in the day of UVL for prevention and the introduction of PrEP, as this study predates these changes.

In the plenary session on Wednesday morning, I was able to see Prof. Andrew Grulich from the Kirby Institute present information about maximising the population-level impact of PrEP.  Initially he spoke about where we have come with PrEP from 2010 with the results from iPrEx study released through to 2012 US FDA approval, 2015 results from Ipergay and Proud studies and 2016 TGA approval in Australia.  The PROUD and Ipergay studies show 86% efficacy in adherent individuals, research shows that adherence issues when measured in rectums is more forgiving than in vaginal mucosa where daily adherence to PrEP is more important - but notes no studies have been done in women.  

PrEP Activism has highlighted what an important individual and population based intervention PrEP is, and education, demand building and advocacy for widespread availability has lead to @70% uptake in eligible high risk men in NSW and similarly in San Francisco.  San Francisco has reported a 50% decrease in new diagnoses (not incidence).

Challenges continue to be in equitable access to PrEP, and identified young people and ethic minority groups being not well represented in PrEP uptake cohorts.  

Increases in STIs are counterbalanced by increased testing and shorter duration of infection.

This talk inspires me to get back to work and recruit more clients to the QPrEP trial in Brisbane.

Trans gender and diverse (TGD) population are of high priority for STI/HIV according to (WHO) last year.

TGD are of greater risk for discrimination, stigma and neglect.

Currently TGD are not mentioned in the National or State and Territory STI/HIV strategies. They need to be included for the collection of data and future research

*What should inclusive Clinical care look like for TGD population?

Many have to access multiple services to have healthcare needs met. There is no particular one-stop-shop.

Shared care is needed with client involvement in all aspects of their care, keeping it open and empowering.

TGD people need sexual health care amalgamated with their hormone therapy reviews. It brings them to test more regularly if needed.

Not all TGD medically transition.

National standards of care differ around the world.

EQUONOX Victoria supplies a one-stop-shop and uses the Informed Consent model. It has Psychological practitioners through to a GP Prescriber which improves access to care with less waiting time.

Good access to care improves health quality

TGD have a higher risk of suicidality, as much as 50%

Research is needed to help provide best practice.

GP'S need to be up-skilled in the area instead of passing people on by referral due to ignorance.

How can this be done? Certainly through Med School training, but also practicing GPs

We need to change registration forms and Notification forms to start collecting data and build better relationships with workforce development

A good resource video "PrEP 4 Trans"

There were several great talks given on the final day of the ASHM conference. The morning HIV&AIDS symposium s100 prescriber session, entitled ‘changing landscapes in therapy’, discussed current and future issues pertaining to antiretroviral therapy, their interactions with other medications and their role in co-morbidities. Professor Mark Boyd from the University of Adelaide gave an interesting talk on ‘When is 2 drugs better than 3’. Antiretroviral therapy (ART) has often been referred to as ‘triple therapy’, reflecting the current guidelines and current practice of prescribing 3-drug combinations to achieve full virologic suppression.

This has come to question recently with a few trials completed or ongoing that assess dual therapy vs standard triple therapy. There are obvious benefits to dual therapy – reduced pill burden in the ageing cohort would have the effect of reduced drug interactions, as well as possibly improved adherence and drug tolerability. In the same session we heard from Ms Krista Siefred from St Vincent’s about polympharmacy and its associated adverse effects, as well as from pharmacist Ms Alison Duncan on the complexities of drug interactions between ART and other medications. Simplification of ART regimens would greatly assist in these matters

Mark presented several studies comparing dual therapy vs triple therapy. A meta-analysis was performed comparing this, looking at effect on dual vs triple therapy on virologic suppression. Overall, pooled results did not demonstrate a superior result for triple therapy over dual therapy for both viraemic patients and patients switching ART. In more recent studies using integrase inhibitors, again dual therapy (including a dlutegravir + lamivudine regimen, or an intramuscular cobotegravir + rilpivirine regimen) was shown to be non-inferior to standard triple therapy for virologic suppression.

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Although interim data looks promising, long-term safety and efficacy of dual therapy is still yet to be fully examined. As such, it is not yet recommended for clinicians to routinely change patients to dual therapy regimens, although this switch may be a feasible option in the future.

Nurse Practitioners began evolving in Australia in 2000 with Health Practitioners continuing to prescribe treatments for clients.

With advanced nursing roles, the NP needed to evolve and develop novel innovative care.

In Primary Care, NP model  to be successful needed: Organisational support, Funding, develop a plan for the model in collaboration and present a business plan.

A supportive navigator needed to drive the plan, was key to success

MBS item numbers then developed (82200,82205, 82210 and 82215 which made the model financially sustainable.

Nurse Practitioner's Scope of Practice needed to be updated and approved through APRAH. It looked at inclusion/exclusion criteria, autonomous and collaborative practices, updating the scope of practice.

IVDU is the most frequent mode of HIV transmission globally

In Australia, Clean Needle Exchange Programs have reduced the risk

Comparison of IVDU V's no IVDU in the Australian Observational Database showed

IVDU  had 40 new diagnosis

IVDU with MSM had 56 new diagnosis

IVDU population had a higher risk of loss to follow up and mortality and viral suppression took longer than those whose risk was MSM only.

The IVDU with MSM group had the highest risk of virological failure and the highest risk of being lost to follow up

HIV quality of life with stigma and treatment adherence has been well established

Quite often we see poor mental health, isolation and co-morbidities associated with stigma and discrimination.

(WHO) declared 90% diagnosed, 90% on treatment and 90% with viral suppression by 2020. We should look at adding another 90% Good health and quality of health.

Overall health testing should be offered at regular intervals in HIV care with the individual referred onto other services as needed, to improve the quality of health

A PoZ QoL survey was developed with 4 domains that included 13 questions about health*

*Psychological, Social, Functional and Health Concerns. with the survey results/outcomes being higher than expected. 

Looking at PrEP and HIV/ART treatments as prevention in the 6 months prior to the 2016-17 Gay and Periodic Survey, showed an increase of casual sex being reported by those using medical prevention.

There was a decline in the use and frequency of condom use 39% (2016) - 32% (2017) and a reported increase in casual anal intercourse (CAIC) 22% (2016) - 27% (2017) as more MSM joined in the uptake of PrEP.

Socioeconomic demographics showed PrEP users were more likely to be Uni educated, in full- time employment and engaged with Gay men networks

PrEP users reported to be more sexually active than when they were not taking it and more likely to engage in condomless sex due to reduced anxiety of HIV risk.

The Periodic Survey in Melbourne ans Sydney reported PrEP users had 11% more partners and 11% less condom use.

* PrEP users becoming more sexually active reflects the successful targeting of PrEP

Dr Eric Chow. Senior Research Fellow, Melbourne Sexual Health Centre.

Risk factors for gonorrhoea in heterosexuals.

Eric looked looked at various factors as to providing reasons for the increased incidences of gonorrhoea infections in heterosexuals in Australia. The risk factors explored were: 

Change in partners/ condom use

Dating Apps

Travel

Drug and or Alcohol use

Bisexual men

In Eric's research the biggest risk factor was travellers, bisexual men and also people using Dating Apps such as Tinder. 

It seems that there are much larger numbers of people travelling overseas, particularly to high prevalence countries and having unsafe sex. There was a higher proportion of travellers from Western Australia, which may explain partly the very high increase in gono notifications in heterosexuals there in recent years.

With the revolution of Dating Apps, the incidence of gono notifications in heterosexuals has also increased and linked to this is bisexual men who may be having the best of both worlds in dating apps such as Tinder and Grindr and passing infection to hetero females.

It's an interesting and changing world we live in both in the digital world and the real world and sexual partners are more accessible in a variety of settings which is resulting in changes in notifications and the demographics of notifications are changing.

The injecting drug population in Australia contribute to 90% of newly diagnosed HepC, making health professionals working in the Drug and Alcohol sector pivotal to the health care outcomes of this community.  From a public health perspective better healthcare post diagnosis would reduce the the advanced progress of the disease by encouraging early thus reducing commodities.

We now have effective treatments that cure.

A discussion on what it is like to live with HepC and the past experiences with older injectable treatment V's new oral treatments, with highly successful cure rates was most insightful into the progression of the treatment journey for individuals diagnosed. Those individuals diagnosed who had experienced the older treatments with severe side effects and no success of clearing the virus, moved to using the new treatments with next to no side effects and had clearance of the infection within 12 weeks.

In 2016 reported cases of of HepC in Australia was 230,000. High risks groups need a holistic approach to care taking into account behavioral and social aspects. However recommendations are to treat first and deal with other lifestyle and behavioral issues later. This way we keep the client engaged in services

A great resource for health practitioners www.gesa.org.au (HepC treatments and Genotypes)

Interactive polling was used during this presentation to determine the group knowledge of testing and treatments for HepC.

This series of talks about the rise in gonorrhea in young people across Australian capital cities was fascinating and resulted in ample discussion and questions.

As Christopher  Fairley said, before we can control the increase in gonorrhea, we must first understand why it has occurred.

Risk factors are thought to be overseas travel from Australian cities to countries of high prevelance I.e. Indonesia, Vietnam and Thailand, bisexual men engaging in sex while OS and also perhaps the continual imported cases of gonorrhea from people of various countries of origin.

Another interesting suggestion was the type of sex education that is received  from people who reside in Australia as students and the gap in their education around condom use.

a discussion also occurred about the possibility of a strain of gonorrhea being more likely to cause infection in women than men, which may account for the high infection rate Moungst women now.

A very diverse group of talks which provided much food for thought. 

Challenges in the care of Refugee women living with HIV in a  regional town

This talk was presented as part of the HIV&AIDS symposium "Who is left behind in a virtual elimination of HIV" 

I found this talk, presented by Lauren Coelli , (Sexual Health Coordinator at the Gateway Health clinic , Wodonga) very inspiring , providing a great example of how to provide care for refugee women living with HIV in regional Australia which could be translated/adopted to similar clinics and settings

The Gateway Health clinic in Wodonga was established  in 2014

The clinic is a general practice clinic set in a community health service, 

one of it's focus areas includes meeting needs of refugees 

largely from the Democratic Republic of Congo (DRC), Bhutan and Nepal

The clinic currently looks after 12 women and one child living with HIV

all the 12 women acquired HIV as a result of rape

According to the DRC family code (444) " a wife owes her obedience to her husband"

marital rape is not criminal act

The women attending the service described high levels of anxiety about their HIV diagnosis, including fear of death and worry about children's future 

Bottle feeding their babies may identify the mother as being HIV positive, and feeding therefore often takes place in private

In addition, they reported fear of transmission, disclosure to community and ostrerisation by their community if their HIV status was disclosed

These concerns and fears have contributed to reluctance to join support organisations, fear of meeting other African people working at the clinic and distrust of phone interpreters

Some of the strategies employed by Gateway Health to overcome these barrier and improve patient care and outcomes have included gaining trust and building rapport with the women, providing a flexible, walk-in model, close collaboration with other local health care providers and up-skilling clinic staff (eg undertaking s100 prescriber training) to provide care within the service for the women rather than having to refer the women to multiple external service providers.

This iseries of interviews was captured across 2 groups of people who grew up queer in the context of a Catholic education. Group one attended school in the 1970's and group 2 in the 1990's.

Overall, in both groups, sex education was very brief and functional and included straight sex only. The only exception to this was when disease was discussed. 

Both groups sought their information from other sources such as porn, cleo magazine, dolly magazine and then the Internet, once available. 

A common theme in both decades was  that people growing up queer,  felt there was no place for them.