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

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

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

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

-       Testing

-       Access to care

-       Treatment, and

-       Prevention

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Day 2: Rapid Fire Session Sexuality and Reproductive Health:

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

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

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

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

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

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

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

Hilary Caldwell from UNSW presented qualitative research that utilised thematic analysis to interpret data from 17 semi-structured, in-depth interviews with sex workers who have female clientele. The participants were self-selecting volunteers who were sourced through their organisations and via Facebook. The participants were from varied backgrounds, genders and geographical locations. The data gathered demonstrated the demographic diversity of female clientele who utilised the services of the surveyed sex workers. According to the workers, female clientele had varied income levels, ethnicities and ages. The female clientele shared similar motivations for seeking these services as male clientele. Motivation was often focused on the women’s safety, the discretion of the professional and the desire to utilise the services of a “sexpert.” The surveyed sex workers made note of the ways in which women buy sex, noting the importance of mitigating risk. Most women counteract this risk by utilising agencies rather than brothels, seeing private sex workers, buying erotic massages and using referrals from other women who buy sex. Making note of the behaviour of their female clientele, the sex workers mentioned that the women were less likely to push the boundaries of the sex worker or haggle for discounts, but were more likely to bring up consent and “check in” with the sex worker during a session. Interestingly, this is the only empirical evidence of its kind in Australia. As the market increases for women buying sex in Australia, it will be interesting to see how the research keeps up with this burgeoning trend.

Professor Gracelyn Smallwood 'Aunty' delivered a highly emotional discussion about the realities faced by many Aboriginal People and Communities across Australia.

Most of the Closing the Gap money (75%) is not going to grassroots level of the people.

it is been swallowed up by university research, and provides jobs to non-aboriginal people.

Gracelyn said that poverty is widespread and needs to be cleaned up.

Many don't have running water and sanitation is poor. 

Food is marked up 200%

Most are unemployed and on Centrelink benefits.

ICE/ substance/drug use is high, including injection.

Concerns about HIV reaching remote and rural communities.

High rate of imprisonment  

Aboriginal Health & Community Services need culturally appropriate programs.

Non-Aboriginal people involved in programs deliver need to go into communities before and consult and talk with keys players/stakeholders and elders. 

Local grass root program delivery don't have to cost lots of money,                                                             such as the 'deadly program' and 'grog kills skills' delivered on a  shoe-string budget. 

Gracelyn talked about her us of the (world famous) Condom man.

This health promotion/prevention strategy was used successful and widely as a healthy alternative to the scary 'grim reaper' advertisements to assist combating HIV/AIDS. 

 Non-Aboriginal People need to speak out more and advocate for ABSTI People by keeping it on the agenda.

Australia needs to reconcile with the past and the ongoing injustices against Aboriginal and Torres Strait Islanders People's. 

Please read Gracelyn thesis which she addresses these multilevel issues in Australia's Indigenous People. http://www.atsiwlsnq.org.au/reports/Gracelyn_Smallwood_2011_thesis.pdf

Thankyou Aunty, your inspirational presentation. It was the highlight of the conference for me and together we can all individually and collectively help to improve the health and lives of Australians Aboriginal and Torres Strait Islanders People. 

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

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

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

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

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

Key messgaes

This model works and has increased testing among GBM.

Day 2 Rapid Fire Sessions: Health Promotion and Education

Carolyn Murray (on behalf of Gemma Hearnshaw) – NSW STI Programs Unit (STIPU):  "No Question Too Awkward: Nurse Nettie, the Online Sexual Health Nurse".

Nurse Nettie is a confidential, virtual online sexual health nurse created to allow young people to email questions they may have about their sexual health/sexuality and receive an answer from a sexual health professional within 24 hours (although Nurse Nettie does have weekends off!)  Nurse Nettie was created to address the concern that young people may be too embarrassed or afraid to ask a Doctor/Nurse or parent/caregiver questions about sexual health.

Nurse Netttie does not provide diagnosis online but instead refers on to the most appropriate service where indicated.

Nurse Nettie commenced in April 2014 and the data presented was up until March 2016. In this time Nurse Nettie had received 761 questions with 77.4% of these being from people aged <30yrs.  Approximately 52% were from NSW and 17% were from abroad. 

Common question categories are listed in order below:

STI/HIV risk – 14%

Anatomy – 12%

Symptoms – 11%

STI/HIV testing – 10%

Contraception – 8%

In conclusion, Nurse Nettie has been shown to allow large numbers of young people to receive information about their sexual health in a confidential, personal and specific manner.

Nurse Nettie can be accessed at: https://playsafe.health.nsw.gov.au/ask-nurse-nettie

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

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

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

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

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

Similarities:

-       Both have transformational zones

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

-       Pre-cancerous lesions are histologically similar

Differences:

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

-       It is more difficult to visualise anal lesions

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

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

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

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

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

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

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

Wednesday 16/11/2016

A/Prof James Ward spoke about the divergence of HIV rates within Aboriginal and Torres Strait Islander (ATSI) communities.

HIV/AIDS in Australia has been a contained epidemic until now.

In 2015 Australia has seen the highest number of notifications in ATSI patients on record since the numbers have been monitored.

This is almost double what the Non-Indigenous notification rates are.

The majority of notifications are in men who have sex with men (MSM) at 51%, then the Heterosexual population is 21% with IV Drug Users at 16% of the notifications. (this was previously 3% in the 'early days')

Reminder that these figures are already 11 months old. Timely surveillance data is crucial.

The rate of notifications in Indigenous females is three times the rate of that of Non-Indigenous females.

This has been high in all regions, not just the urban and inner regional areas but now in the remote areas.

A/Prof James Ward mentioned there are a number of reasons why divergence is occurring but highlighted a few of the main reasons to be:

- a young, mobile population in more regional and remote communities

- risky practices such as sharing injecting equipment and the high prevalence of sexually transmitted infections (STI's)

-there is a lack of needle syringe programmes in the remote areas.

-failure to engage TasP (Treatment as Prevention) and PrEP (Pre-exposure prophylaxis) in the communities

-there is a high burden of disease and multiple co-morbid conditions in the Indigenous population and often these patients are on a number of other medications

He stressed the importance of being inclusive of all vulnerable populations when it comes to HIV.

The high prevalence of STI's in the 10-24 yr old age groups increases the risk of HIV transmission and poses an ongoing problem.

Previously there has been an increased focus on suicide prevention in this age group which is very important and needs to be ongoing , however, with the current Syphilis outbreak in Northern Australia and increase in HIV notifications more efforts need to be made to tackle this problem.

Unfortunately there is inequity in service delivery to these remote communities.

If we take a closer look at the Syphilis Outbreak in Northern Australia, the numbers of infectious syphilis diagnoses have risen exponentially. 

Could we be dealing with a similar chart for the HIV increases in the near future? Are we prepared for this?

Using some figures from Cairns;

-prior to 2014 there were approximately 15 diagnoses of HIV with 1-2 cases reported in ATSI patients.

-from 2014-2016 the diagnoses of new cases in the ATSI population increased to 50% of the total number of cases.

Most of the cases recently have been in young men who identify as bisexual or heterosexual.

The recent high level summit report in Brisbane has highlighted what is deemed important in terms of tackling this problem in communities.

Workforce development is crucial. Downsizing in certain areas is disastrous as currently the Indigenous population is in the most vulnerable position regarding the HIV increases.

HIV needs to be managed in the Primary Care setting using the support from central public agencies to assist with management.

There needs to be outbreak management and community involvement at every level.

Some suggestions have been to make HIV testing within 30 days after a STI has been diagnosed a nKPI. (National Key Performance Indicator)

To make STI and BBV (Blood Borne Virus) testing compulsory linked to the Aboriginal and Torres Strait Islander Health Check. (Medicare Item 715)

To have Medicare Item numbers for STI/BBV testing.

Education with regards to health literacy is important together with rehabilitation programmes and opioid substitution therapy for IV drug users.

Post Exposure Prophylaxis (PEP)is misunderstood and the community do not know how or when to access this.

James Ward stressed that the community needs to be involved at the forefront of the efforts ,the community needs to be engaged.

I would hope that after attending this conference that all of us walk away with at least a few strategies to take back to our practices or organisations to help prevent HIV becoming an epidemic in the ATSI communities.

I found the presentation by A/Prof James Ward eye-opening and motivating.

We all have a responsibility to play in changing the course of the diverging HIV rates within the Indigenous population.

Encouraging people to test for STI, is an ongoing issue for all health services. These three posters trialled different ways to increase testing, with varying results. SMS, parlor and ads via websites proved the least effective, while pop-up at community events was effective and highly acceptable.

Evaluating the impact of Grindr advertising on website traffic and HIV testing at a regional sexual health clinic Lead author: O'Reilly,M. et. al.

This poster looked at the effectiveness of advertising on Grindr. It was found that a large number of people viewing the website clicked on the ad, however it didn't translate to visitors to the clinic.

The conclusion was that they redesigned their website to make online bookings easier and are exploring other ways to increase visitors to the clinic.

Pop-up Rapid HIV Testing at Community Events: expanding the PRONTO! Testing Model! Lead author: Ryan, K.E. et. al.

They explored the uptake, acceptability & development of pop-up HIV testing via field notes and client surveys. 

After 78 tests, 98% of respondents reported being likely to test again at community pop-up events. 22% had no previous HIV test. 

Pop-up testing at community events was successful and highly acceptable amongst those surveyed and will be used at future events.

Intiatives to Improve Sex Worker access to STI screening in Sydney Local Health District: Lead author: Hatten, B. et. al.

Two methods were used. The first was SMS messaging to send reminders to sex workers to encourage them to have their scheduled 6 monthly testing. The second was offering testing in a parlour setting.

Both methods were found to not significant impact the rates of testing. 

Dr Cindy Liu from George  Washington University presented interesting findings on the vaginal microbiome today. 

 The term ‘dysbiosis’ refers to an ecological imbalance in the microbiome that impairs health. It moves away from the classic concept of infectious disease as being caused by a single pathogen, and moves toward the appreciation of disease as disruption to a complex, dynamic ecosystem. Disruptions might be the loss of ‘good’ bacteria, dominance of ‘bad bacteria’, but the imbalance leads to events that impair function, or induce inflammation. 

Earlier today, Liu described anaerobic penile dysbiosis: the polymicrobial colonisation of the subpreputial space with anaerobic flora, and its role in HIV acquisition. In her afternoon session, she built on this to describe one of the classic vaginal dysbioses: bacterial vaginosis (BV). BV is characterised by the overgrowth of anaerobic microflora, and reduction of Lactobacilli, and is therefore a vaginal anaerobic dysbiosis. BV is a common condition, and its management is characterised by persistence, recurrence. It is also associated with an increased risk of HIV acquisition, as well as a range of adverse pregnancy outcomes and pelvic inflammatory disease.

What is the relationship between these penile and vaginal anaerobic dysbioses? Are these phenomena sexually transmissible? The anaerobic organisms implicated in both processes certainly have considerable overlap, and evidence from several quarters supports the sexual transmission of BV.

 Liu and her colleagues enrolled 165 uncircumcised HIV-negative Ugandan men and their female partners into the Rakai Health Sciences Cohort. Self-obtained vaginal swabs from female partners were assessed for BV using the Nugent score, while swabs from the coronal sulcus were collected from men for assessment of their microbiome using 16S rRNA amplification.

Penile microbiomes were found to fit into four distinct patterns, termed Community State Types, which ranged from microbiomes with low diversity and few anaerobes (CST 1-3) to communities with very high diversity and a rich population anaerobic flora (CST 4-7): so called anaerobic dysbiosis.  

 Bacterial vaginosis was found more frequently among female partners of men with anaerobic dysbiosis than in men with lower levels of diversity and less anaerobic flora. This supports the hypothesis that anaerobic penile and vaginal dysbiosis are sexually transmissible and results from sharing of anaerobes within heterosexual settings.

 Longitudinal studies are needed to prospectively observe transmission events between couples, as well as account for potential confounders such as hormonal factors, hygiene practices and so on. Higher resolution molecular identification tools to better describe phylogenetic relationships between organisms shared by the partners are needed to confirm transmissibility.  

This was a sponsored satellite symposium, held at the ASHM/Sexual Health conference. It consisted of a panel discussion which was chaired by Dr Norman Swan.

The question posted was- Can Australia be Hep C free by 2026? The short answer is....possibly.

Back ground

Hep C eradication treatment started this year. 20,000 people have been treated and by the end of this year 45,000. The bulk are patients were keen for treatment. Currently 82% of people with Chronic Hep C in Australia, have been diagnosed. This leaves 22% diagnosed. There is a dis-proportionally higher prevalence in the indigenous and incarcerated populations.

Resistance to treatment

Concerns remain in co-infected patients, that eradication treatment is difficult or may impact their HIV.These concerns linger from previous Hep C eradication treatments. They don't translate to the new treatment.

There are some drug interactions between ART and Hep C eradication treatment, however these can be managed.

Attitude change

An attitude change in government, patients and health care providers is required, to identify the remaining 22% of undiagnosed patients. This is needed, as without a significant reduction in Hep C in the general population, reinfection may occur. Re-treatment will then be required, and should be offered.

Hep C resistance

This has already occurred and needs to be avoided. Ways to prevent resistance is discussing with the patient to determine if they can access and afford the medication, for the entire treatment course. A wavering of the cost of opioid replacement therapy, needle exchange in prisons, nurse practitioner to subscribe treatment and patient education on preventing reinfection, will also contribute to preventing resistance.

Take home message

The uptake of Hep C treatment has been fantastic. Limit the opportunity for resistance by reducing the opportunity for partial treatment. Educating patients on preventing re-infection. Identifying patients who may have Hep C but never tested.

If this treatment to work, then we (and the government) needs to approach this treatment, like the Small Pox Eradication Program.

 Cindy Liu from the Milken Institute School of Public Health, George Washington University presented her findings on the relationship between the penile microbiome and HIV susceptibility. Liu hypothesized that the penile microbiome drives pro-inflammatory responses and in turn increases HIV acquisition.

 The space underneath the foreskin is a unique environment with a characteristic microbiome. Analysing subpreputial swabs from men in Uganda, Liu and her colleagues used molecular techniques to investigate bacterial populations prior to and after male circumcision. 16S rRNA sequencing was employed to characterise bacteria to genus level, and a pan-bacterial DNA RT-PCR was used to quantify total bacterial load. Together, these were used to estimate the absolute abundance of specific bacterial taxa in the subpreputial space.

Prior to circumcision, the subpreputial space was characterised by a diverse bacterial community that varied between individuals and over timel. A wide variety of anaerobes, including Prevotella, Finegoldia, Peptoniphilius, and Aerococcus, were isolated in high numbers. Post-circumcision, the populations of these anaerobes reduced, and resembled flora from other skin. Anaerobes decreased, populations became less variable, and Lactobacilli increased.

 Expanding on this, the investigators examined the immunological responses to these changes in the microbiome. Langerhan cells, the antigen-presenting cells par excellence of mucosal surfaces, are thought to be integral to HIV acquisition. In the inactivated resting state, Langerhan cells ingest HIV virions, and lyse them prior to presenting the lysed products to lymphocytes at the lymph node. In activated Langerhan cells however, degradation of HIV virions is bypassed, resulting in presentation of intact virus to nodal lymphocytes and the commencement of viral replication. Anaerobic flora were postulated to be triggers for Langerhan cell activation.

  Liu found that IL-8, one of the key cytokines implicated in immune activation, was significantly higher among men colonised by Prevotella, and other key anaerobic organisms.  IL-8 is known to attract neutrophils along a chemotactic gradient, and induce them to release MIP 3a alpha and MCP-1, which in turn lead to recruitment and activation of CD4+ T lymphocytes, drawing them closer to the epithelial surface.

 This work supports the hypothesis that an anaerobic subpreputial microbiome induces pro-inflammatory local immune responses, and that these changes are negated by male circumcision.

 Further work on the correlation between the penile microbiome and HIV acquisition is keenly awaited. Liu’s current collaboration with the Kirby Institute will examine the role of the ‘dorsal slit’ modified circumcision commonly practiced in parts of PNG, and will hopefully give insight into this cultural practice’s potential role in HIV prevention.

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

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 

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?

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

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.

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.