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. 

NSW HIV Diagnosis and Care Cascade: Meeting the UNAIDS 90-90-90 Target. Phillip Keen, Kirby Institute 

Phil discussed the HIV care cascade plan launched in 2014 by UNAIDS to have 90% of PLHIV diagnosed, 90% of people diagnosed with HIV to be on ART, and 90% of those on ART to achieve viral suppression by the year 2020. 

In relation to this, where are we now with these targets in various countries and in particular what has been achieved in NSW. Sweden was the 1st country to achieve these targets.

 Through increased testing and treating, treating sooner and more aggressively has resulted in NSW to achieve 90-90-90 in 2016. To help meet these targets the way ART was prescibed was changed to not be influenced by factors such CD4 count or symptomatic HIV. So more people commenced on ART that previously had not been, and commencing newly diagnosed HIV on ART within 6 weeks. Also the ways and means of people accessing HIV testing and treatment has increased.

 To increase the accuracy of data so as to be considered 'high quality' according to Granich criteria, data surveillance and collection was revised and improved. Now NSW Health has raised the bar in the NSW 2016-2020 HIV Strategy aiming for 95% of people diagnosed with HIV to be on ART and 90% of people newly diagnosed with HIV to be on ART within 6 weeks.

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.

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.