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.

Day 2: Afternoon Session Joint Symposium

Chaired by Teddy Cook and Ange Davidson.

So I'm going to be jotting ideas and themes as I go, paraphrasing.

Trans populations are and are becoming more so a at risk population in multiple areas, including violence, socioeconomic disadvantage, but also within HIV and sexual Health.

Teddy goes to say that despite your personal thoughts towards trans and gender diverse people, today is about your clinical practice, and this is what counts. "Lets consider this a call to action" "Because we need you. We have been erased over the last 30 years. We are not considered as a priority population in any state and except for the most recent statement".

The capture of data using sex, gender or identity is has been holding back ability to identify and treat. This has become so that people consider rates of trans and gender diverse people within risk populations to be low. This is false and unless people identify or area identified within data, we cannot make decisions on providing services to this population.

Furthermore, within the grouping MSM, trans men or trans masculine have been forgotten and erased.

Trans and gender diverse (GD) people area a VERY diverse group. Some define themselves within a multitude of different ways, a handful of examples being Trans, non--binary, brother-boys and sister-girls, queer... I could go on.

Trans men are men, and trans women are women. I would qualify this statement however trans and GD people do have some particular needs met (such as identifying that trans men may still need pap tests or trans women will need to consider prostate checks as they age).

Teddy asks, Will you stand with us to stand with us to move toward meaningful steps towards trans inclusion and recognition in this area of clinical care?

Panel Members (apologies if I don't go into everyone's CV's, believe me they've an interest and investment in this area).

Ange Davidson is a Sexual Health Nurse at Gateway in Wodonga, Victoria

Mish Pony, Gender Diverse and Trans sex worker representative for Scarlett Alliance, Australian Sex Worker Association

Dr Ayden Scheim, Global Public Health at University of California

Lisa O'Brien, Sistergirls and Brotherboys Australia, NSW

Jeremy Wiggins, Victorian Aids Council, EQUINOX Clinic, Vistoria

Dr Stuart Aitken, Sexual Health Physician, Gold Coast, Qld.

Dr Vincent Cornelisse Sexual Health Physician, HIV, PrEP and Transgender medicine, Melbourne SH Centre

Q: What does trans and GD inclusive clinical care look like to you?

The underlying theme here is that currently, in Australia, trans and GD people have fragmented care. Multiple panelists recognised this and that integration within primary care is needed to provide holistic care to this population.

Specific healthcare needs such as ARV treatments may be attended by GP's with experience and knowledge in this area, much in the same way as hormone therapy for trans people. The specific need to see an endocrinologist is not always necessary and some panelists make reference to "gatekeeping" within the medical profession, where patients require clinicians approval and guidance in this area, which may not always be the case.

Another theme that arose was the lack of experienced clinicians in rural or remote areas, even in cities outside the East Coast, meaning that people seeking medical transition (ie. hormone therapy) will need to travel for these healthcare needs, often away from their families and communities. In particular this is raised as a potential issue with Aboriginal or Torres Straight Islander people away from their mob, moving to larger centres or cities and the increased risk of socioeconomic disadvantage when moving to areas of higher cost, less support and increased isolation.

Another point made by the panelists is that there is significant difference from state to state (or territory) in regards to models of care, legality, requirements in particular to gender marker recognition. Informed consent is a healthcare model that removes particular onus from clinicians and allows trans and GD people to engage in their own healthcare and needs. It is not always necessary that someone be deemed "Trans" by a psychiatrist or psychologist before being allowed to commence on hormone therapy.

One great quote was "We don't send gay people off for sexuality assessments anymore, why should we do so for trans people?".

Q: Trans-specific healthcare is not specific healthcare, it is general, simple healthcare. How does this play out in your practice?

One panelist referred to their own practice and the normalisation of providing care to trans and GD people is paramount, that many of the clients they see have grown up in a society and culture hostile towards them and historically a medical model pathologising them. From a social justice point of view, one panelist made the statement that workings with trans and GD people was "very clinically satisfying" for these reasons, helping people through providing comprehensive general practice care.

One idea that was brought forward, that the concept of Evidence based practice is particularly binding to us as clinicians. Not all areas are so bound to the requirement that we must have hard available evidence in studies before we change practice. This in my opinion is an interesting concept, as on one hand I agree that we must be guided by scientific methodology that has been proven to be what makes "best practice" however the thought from the panelist(s) that we should strive to be more open to other forms of practice whilst evidence and studies are conducted in this area.

Q: In regards to HIV and Sexual Health care, where does this place trans and GD people?

Not all panelists agree that TGD people should be a priority population for HIV! Controversy!

One panel member refers to data showing that approximately half tans women in the last 12 months were not sexually active. Although limited accurate data exists, there is evidence that trans and GD people are both at higher risk and not at higher risk of HIV.

The panel then discussed how appropriate training for care of trans or GD people can and should be implemented. A general concensus that training should commence early in the career, preferably at university, to explain the basics of transgender and GD persons and their healthcare needs. There is experience within the trans and GD community that when meeting a practitioner who has a gap in experience or knowledge that they then need to themselves educate the practitioner in "trans 101" type information and this is not seen as ideal, particularly when a client themselves is not in a position to do so.

Final Thoughts, in no particular order.

- Training to include trans and GD issues, particularly for specialists

- Changes to data collection to include trans and GD persons

- Trans healthcare is simply healthcare. It should not be only for Psychiatrists or Sexual Health practitioners.\

- Increase in culturally appropriate healthcare for trans and GD persons

- Opportunity for trans and GD inclusive programs for Sexual Health and HIV medicine.

- That systems can and should change to adapt to new models of care (for screening, SH and HIV care and general healthcare for trans and GD persons).

Self-Perceived Problematic Relationship with Drugs and the Use of Alcohol and Other Drug (AOD) Services among Gay and Bisexual Men

Professor Adam Bourne

Statistics show drug use, including cannabis, cocaine, ecstasy and methamphetamine for example, is up to three times higher among the Gay and Bisexual male population, nationally and globally.

Drug related harms occur from risky drug use, increasing the risk of disease transmission. For example, methamphetamine use and erectile dysfunction has been reported to increase the odds of HIV infection among this population.

Other drug related harms among Gay and Bisexual males have been observed from the use of GHB and crystal meth. Of concern is the increased mortality rates attributed to GHB overdoses in London, with one death reported every 12 days between 2014 and 2015 in addition to poor ART adherence secondary to crystal meth use.

The Flux study aimed to understand how drug use is situated among gay and bisexual men. How comfortable are they engaging with alcohol and other drug (AOD) services? What are the barriers? One point of note was that there was a fear of judgement and the perceived lack of understanding from AOD services in terms of the synthetic types of drugs being used and the different ways Gay and Bisexual men use the drugs compared to other populations.

A comment from the audience triggered the response that a move forward may be to try to meet the needs of people who are sexually active and who chose to use crystal meth, exploring ways of how to use it safely.

The overall aim is to reduce disease transmission and improve engagement with AOD services for all, but in particular for those who believe their drug use is problematic.

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Dr. Alena Simonis presented an interesting presentation on Labiaplasty which is a surgical procedure which aims to change the appearance of the labia majora and or labia minora and surrounding skin.

I was surprised to hear that Female Genital Cosmetic Surgery (FGCS) can be performed by anyone with a medical degree, as it stands there is no formal training. In the US, Labioplasty is the 4^th most requested cosmetic procedure with similar trends in most of the developing world.

Dr. Simonis talked through a GP based survey she was involved in which included 443 GPs. The two figures that stuck out for me were as follows;

- 50% of the GPs had been asked about FGCS

- 35% of which were under 18 years of age

The survey highlighted that most women asking about FGCS were also in an emotional and vulnerable state. In response to the increasing FGCS demand, the RACGP has developed the useful guidelines  which also identifies the various reasons women of many ages are requesting FGCS;

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https://www.racgp.org.au/download/Documents/Guidelines/Female-genital-cosmetic-surgery-toolkit.pdf

Dr Klausner discussed  using various innovative ways to increase HIV and STI testing, treatment, adherence, and prevention via the use of technology-based and online methods. The aim was to reach the hard to reach, in a way that was accessible and individuals not feel judged.

Testing occurred in various ways including in community based settings at places accessible to our frequented by hard to engage individuals such as sex workers, injecting drug users, homeless. A walk-in self testing service was set up where12,500 people per month accessed this service. The self- testing facility would allow people to go in and fill in an electronic risk assessment, print identification labels, then dispense the appropriate swabs for the self collected samples. A result would then be given in 2 hours.

Online ordering of in-home HIV and STI testing kits, and Outreach voucher programs were other ways to make testing more accessible.

To increase adherance to PrEP or ART individuals can go to online program and customise how and when they get reminders to take there medication and reminders for testing through patient engagement software. Also was noted that PLWHIV could check their CD4 counts and VL and found that there was increased medication compliance in this experience.

With regards to prevention of HIV and STI's condom vending machines were widely distributed to areas to increased accessibility to condoms. Online ordering and initiation of PrEP is an option too where individuals can go online and answer questions regarding their history and risk factors. Appropriate pathology testing would be ordersd including HIV and Hepatitis B serology. Once results are available if person is eligible to commence PrEP they are prescibed medication and it is sent to them. All done without having a face to face consult with a doctor.

In this presentation by UNSW post-doc fellow Dr Anupriya Aggarwal investigated the role of actin in HIV cell to cell spread. They looked at the structure of actin and the location of HIV in the actin during viral assembly and then budding. HIV was found more often on the curved actin surface versus the shaft area, and intersects with the ARP 2/3 pathway. The presentation was full of amazing 3-D representations of their findings - with the localisation of HIV eGFP shown in relation to the cell surface.

This presentation was a summary of the results of a survey undertaken by a group of GP's , following an increase in requests for labioplasty.

The procedure of labioplasty can vary but in general, involves trimming of the labia minora and possibly trimming of the clitoral hood.

Long term research has not yet been achieved in terms of the long terms effects of this procedure, particularly in relation to post menopausal women. 

The presenter indicated that in many women, the labia minora extended beyond the labia majora and was therefore normal but women who sought this surgery believed that they were abnormal. What was often unknown by the women seeking the surgery is that 'more tissue=more sensory availability' . 

Psychological drivers for seeking the surgery have often been overlooked, hence the GP survey that was undertaken, with 443 GP completing the survey. Alarmingly 35% of the GP's had experience of this request from women/ girls  less than 18 years of age. 

Factors that were useful to consider in talking to patients about their concerns were various and included perception of normal versus desirable /influence of  pornography/ choice of underwear I.e. G strings and their comfort level and so on. 

The take home message is that this surgery appears to be unnecessary for physical reasons in many cases and that the long term effects are unknown. 

A/Prof Darren Russell: Complexities of providing prevention tools to a vulnerable population; Lessons from an outbreak in young Indigenous people in FNQ

A look at the rise in HIV cases in Indigenous Australians in Far North QLD with more than 30 cases since 2014.  This has come hot on the heels of the local syphilis outbreak in 2011, where over 1000 cases and 5 congenital syphilis cases were reported.

Darren talked about the public health and clinical response, which had to overcome barriers to treatment and engagement.  The community and individual cultural and social responsibilities can mean avoidance of care that might cause shame.  This is compounded by remoteness, low levels of health literacy, employment, housing, financial and substance issues.  Despite being a significant at-risk group, PrEP knowledge and use is scarce.

What stood out is the importance, and the difficulty given history, of building healthy, trusting community relationships.  The gap is not yet closed, but in some areas widening.

This whirlwind run with two enthusiastic and knowledgeable presenters reinforced that implementation of Evidence Based Medicine means clinicians need a basic understanding of how the data is being collected, sifted and analysed to provide treatment recommendations.  I’ve just completed (with some difficulty!) an introductory biostatistics university course and was looking forward to consolidating the knowledge.

First, Professor Matthew Law gave a rundown of the basics of statistical inference.  His Key Points:

•      5% of all studies with a significant finding have occurred by chance – thinking of all the studies in all the journals in all the world, this is a sobering perspective!

•      Look at confidence intervals to get an idea of how precise this estimate is – narrower is better, but crossing the ‘no difference’ value negates significant p-values.

•      Failure to reject a null hypothesis doesn’t mean the null hypothesis is true.

•      One tailed tests suggest mathematical jiggery-pokery and should be approached with caution!

Next, an explanation of what the different types of models and tests all mean, by A/Prof Kathy Petoumenos.   She ran through the differences in variable types, model types, and how to interpret reported calculations such as relative risk, odds ratios and hazard ratios.

Her (very reassuring) Key Point: Ask a friendly statistician!

In this era of information galore, KPIs and rapidly evolving evidence base, we as clinicians should consider basic statistics knowledge for ourselves mandatory, and biostatisticians part of our multidisciplinary team.

Presented by Darren Russell: Associate Professor, Cairns Sexual Health Service

Darren mentioned in his report that of the 450 PLHIV attending Cairns Sexual Health service, 13% were Aboriginal and/or TSI. This number though not out of control, presented an issue for concern. In 2014, there was an outbreak in FNQ aka “the Cairns Cluster”. This outbreak was more predominant in the younger male population (18-30) and because these individuals are young and highly mobile, the threat of infection spreading was notable.  Other reasons elevating the risks are social disadvantage propagating poorer health outcomes, increased drug and alcohol use and low health literacy.

The HIV care continuum was used to guide treatment from detection to viral suppression. This care model enabled the team to observe how their Indigenous clients moved in and out of the treatment cascade influenced by personal life circumstances at a given time. This constant shift though multi-factorial, revolves around the social determinants of health such as income, housing, education and family situation. 

With gaps identified, the team came up with means on how to keep clients engaged in their treatment. An invidualised response is essential; support the client with their needs; have the consultation where the clients want it done (even under the tree!); utilise Aboriginal health workers to build trust and provide culturally appropriate care. The team also identified areas for improvement like expanding the multidisciplinary team to involve more members; Increasing contact tracing and linkage and finding novel approaches to make the service more available and appealing to the Indigenous members of the community.

Sexual Health from an Indigenous Perspective

Professor Gracelyn Smallwood

Prof. Smallwood, a Professor of Nursing and Midwifery at Central Queensland University lead an inspiring session, capturing the audience’s attention not only with her outstanding achievements on a global level but her strong presence, proud ties to her Indigenous heritage and great sense of humour.

Coming from a family of 19 children, Prof. Smallwood’s rise to success has been remarkable. As a young Indigenous female, stating “I want to be a doctor and I want to buy a pair of shoes” her parents ensured she strived towards what they called “a white education” to achieve her goals. Progressing through the world of academia from Midwifery to Masters and later PhD and even meeting Nelson Mandela, Prof. Smallwood has excelled as a global leader in sexual health.

“Name a disease, you name it, they’ve got it”, referring to her people, seemed to be an inspiration for her efforts to achieve greater health outcomes for Indigenous communities.

While Prof. Smallwood has worked on many International projects, what stood out the most was her success in designing and implementing a culturally appropriate program “Condoman”, as an alternative to the famous 1997 Grim Reaper HIV campaign. Pushing barriers, Prof. Smallwood recruited a young, fit Indigenous footy player to dress up as Condoman in a tight lycra outfit to roll out their campaign and it was an absolute hit! Their aim was to promote the use of condoms to minimise disease transmission in Indigenous communities. The impact of the campaign was recognised on a global scale, attracting International attention and support from the World Health Organization.

A take home message was that her people are not after ‘Equality’, they are after ‘Equity’. We need to empower Indigenous communities, increase their access to health care, educate and uphold their human rights.

Julie began her presentation with a slide that outlined food security measures as quantifying the availability of food; the ability to access available food; the ability to utilise available food, and; the stability of accessible and available food sources.

In Australia, 1 in 6 people report having experienced food insecurity at least once in the last 12 months (Food Bank, 2016), which aligns with other data pertaining to food insecurity. Thus far, the prevalence of food insecurity amongst people living with HIV is unknown.

The rationale for the study is underpinned by literature that links food insecurity to adherence issues. Also, the HIV Futures 6 study showed that 42% of people living with HIV received financial support through government means and that 31% lived below the poverty line.

Julie’s study utilised data from participants who utilised service across 6 sites in Sydney. The goal was to have 200 participants of varying age and ethnic backgrounds and with varying CD4 counts and viral loads. Administered through a phone survey, the study involved asking participants questions that were rated using the USDA six item subset tool. 162 participants were surveyed (92% male and 8% female) which ultimately matched the gender balance of the HIV Futures study. Of those surveyed, it was found that 47% were food insecure.

All Indigenous respondents surveyed were found to be food insecure. Key factors for food insecurity included being unemployed or living on a pension; inner-city living; a low CD4 count, and; a lower self-perception of health. Employment and education beyond high-school level led to better food security for those surveyed.

Julie emphasised that an awareness of food insecurity for people living with HIV may be lacking in the sector and that this is an issue that needs further investigation.

Dr Power began her presentation with a brief outline of Stigma, stating that “stigma is a social product”, rather than something that is an innate part of who we are as people.

Her research focussed on findings that have emerged from the HIV futures study, which began in 1997 and is repeated and added to every two years. In this aspect of the study, Dr Power measured the social impact of enacted stigma that people living with HIV encountered, assessing levels of internalised stigma and also anticipated stigma. Ultimately, the study is intended to show the relationship between stigma and health outcomes; seeking to find ways to use the data toward strategies to combat stigma.

Participants in the research were surveyed through the most recent HIV futures 8 study. Questions repeated those of previous studies, but also new questions were developed using language that participants of previous studies had used to describe the impact of stigma.

Findings highlighted a significant increase in disclosure related fears, with isolation and social withdrawal being a dominant theme. People living with HIV who reported lower perceived stigma reported higher levels of social support, higher levels of disclosure and good relationships with the healthcare professionals they engaged with.

Stigma encountered within the workplace and anxiety about unintended disclosure at work featured highly in participant responses. Dr Power explained that these findings enables strategising toward combatting stigma through workplace focused initiatives. Even though the workplace often dominates people’s ability to move through life and is entrenched with hierarchies, workplaces are also structures through which to communicate. The findings of Dr Power’s research provides good evidence for resilience through workplace social support programs.

Leah Williams walked us through the ways in which her service created small changes to their service that resulted in greater outcomes for vulnerable groups.

The most vulnerable people living with HIV:- those 10% not on treatment or linked into services were identified and then the barriers to them accessing health care were identified , such as the need for a GP referral and the restrictions surrounding Activity Based Funding which means they can be discharged from a service if they do not attend 2 successive appointments. 

Flexible service provision is the key to accessing these hard to reach groups: - drop in clinics and small but important changes such as assistance from administrative assistants/ reception staff when vulnerable changes to attend.

The  take home message was : Tweak your service to meet the needs of vulnerable groups rather than asking those patients to access care that seems inflexible to them. 

Trans Rights, Sexual Health, and HIV: The View from Canada. Dr Ayden Scheim whom currently works in San Diego, USA delivered an interesting presentation on the global trans gender community.

The trans gender community is diverse and have low rates of access to health and HIV services. Dr. Scheim contributed this to a number of issues including violence, legal barriers, stigma and discrimination.

As a global health agenda and key population group, the overwhelming message Dr. Scheim highlighted was the lack of inclusive research/ data in this field which mainly comes from the US.

At a clinical service level Dr. Scheim recommended that we need to firstly understand the basic epidemiology of the trans community and we should be asking the following questions;

-       What sex where you assigned at birth?

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-       Which best describes your current identity? (which can included up to 33 possible answers)

Day 2 Morning Session.

Good morning folks, welcome back. The sun is shining, its still a bit cold in Canberra but you wouldn't recognise the place. I started the morning with the Opening plenary for the Sexual Health Conference, some fantastic speakers with valuable insights. Prof. Kit Fairley from Melbourne Sexual Health Centre was a highlight (fantastic speaker) as was Prof. Gracelyn Smallwood speaking on Indigenous HIV and sexual health with her career highlights numerous. Not just an informative session but also very entertaining. Wonderful speakers.

Our last speaker for the morning was Dr Ayden Scheim from the University of California speaking on Trans Rights, sexual health and HIV, referring to the studies, or lack thereof, in regards to Trans people in HIV and Sexual Health research. This as another area where work needs to be done and the way in which we as clinicians or researchers attend this will greatly impact on our ability to be proactive and effective. If I say something from personal and professional experience, work with us, not on us.

I will get off my high horse now and am currently sitting in the next session with Leah Williams, a Nurse Practioner from Perth Hospital speaking on the REACH Programme where maintaining clinical contact with at risk patients more likely to not be presenting.

Normally where referred patients would be discharged from care after two missed appointments, the Immunology clinic sought a change in the structure of clinic visits which is REACH. Candidates were identified as living in metropolitan area, with a detectable viral load and who would avoid or miss clinical appointments.

A cohort of 108 patients was found for the programme, consisting of 65% men, 32% women and 3% people identifying as trans. The research found that the most hard to reach people were Australian and not  born overseas. Interestingly a number of these people were identified as attending the clinic weekly despite no appointments, an indicator that people felt safe to be within this clinical area and with staff. Collaborating with other services, such as Emergency Department presentations by REACH clients being notified to the clinic and staff being able to take the opportunity to engage with the client.

Once i the programme, REACH patients could turn up whenever they like, which was no different to many of their previous attendance. No appointments were made on the books and so no data on "Did Not Attend" was recorded, a huge plus to the clinics KPI's. Focus was on the presenting issues of the patient rather than making visits specifically HIV focused. Another important change was having clinic Administration staff aware of the clients being part of the REACH programme and no reason for a visit was necessary, another way of making clients feel welcome and the clinic appear more accessible.

The "Virtual Clinic" was one innovation of REACH where patient case files were reviewed weekly by a multidisciplinary team and any changes in care or needs were identified in order to facilitate the above changes and give appropriate patient care.Ensuring more support was avaialble to patients commencing new treatments early on and after diagnosis was identified as an effective strategy and client medications were also made available to be picked up from the clinic daily or weekly and use of webster packs to keep things simple and accessible again were effective changes.

In total, DNA rates were halved, patients were happy and were no longer discharged by the service and quality care was given to the patients. The take home message was that we make small tweaks ourselves to make things work becuase patients less likely to do so. Hahaha, so true.

Thanks for following me and looking forward to the second part of the day.

Like the Partners study, Opposites Attract has demonstrated that undetectable equals untransmittable. There were no linked HIV transmissions after 591.2 couple years and 12000 acts of condomless sex protected only by viral suppression. Three incident HIV infections during the study were not linked to the positive partner on phylogenetic analysis highlighting the importance of PrEP for those having sex with other partners.

The true role of STI’s in HIV transmission requires further investigation says Dr Ben Bavinton of the Kirby Institute, noting that there were very high rates of STIs detected during the study despite no linked HIV incident infections.

The question of how soon is ‘safe’ to have condomless sex after ART initiation also requires further study.

The take away messages from Ben’s talk are the importance of regular STI screening in this group, PrEP for those having sex with other partners, and condoms or PrEP after starting ART.

Opposites Attract was a prospective longitudinal study of serodiscordant homosexual couples in Australia, Brazil and Thailand. Couples had testing and completed behavioural surveys at least twice per year during the study.

A point that struck me as important and should be given great consideration when managing patient’s HIV treatment is that they be given all available treatment options and that their choice should come first before a practitioner’s favourable choice of treatment. This given enhances treatment compliance which could spell success or failure of therapy. The patients are the masters of their bodies and therefore the best source of information as to effectivity of treatment for medications affect everyone differently. Medication’s efficacy is not measured by the number of pills taken.

When a patient contemplates and opens about wanting to change their medication, these should be given appropriate consideration; alternative medications be discussed freely and effects both positive and negative be laid out. Viral load testing is not necessary in all cases unless the medication change is due to drug resistance.

Patient-centred care should be the gold standard for practice.

Damian Purcell from the Doherty presented the story of discovery of a new latency reversing agent, currently in the process of in vitro experimentation using ex-vivo patient cells.

Background : agents trialled to reverse latency - PKC activators, HDAC inhibitors, Bromodomain inhibitors 

So why is a novel agent needed? Lack of specificity and potency have been a significant problem in agents to date, many of which have come from the cancer field.

For example - Work from the Purcell/Lewin labs at the Doherty has shown that HDACi inhibit expression of key HIV splicing proteins; HDAC inhibitors in vitro are unable to elucidate expression of spliced RNA, Bromodomain inhibitors on the other hand are able to lead to spliced RNA; this is rescued by the addition of tat protein.

Considering Tat ; 'the master regulator of HIV-1' - (its own latency reversing agent?) by recruiting kinases which help in regulating HIV transcription and RNA processing; Tat itself is also acetylated (thereby activated), which could also be inhibited by HDACi.

So what about new drugs? What do we want?

Tat can be produced without production of virus - and is a neuropathic protein...

Tat induces LTR specific response specifically. This is important, considering that what we are interested in is finding HIV-specific activation pathway 

A drug library was screened to look for agents activating tat in particular - (WEHI) - resulting in an amidothiazole being identified. Medicinal chemistry was used to increase the potency of the compound, which was then trailed on patient derived cells (obtained via leukapheresis); this demonstrated reactivation.

These agents appear to synergise strongly with bromodomain inhibitors (currently trailed agents) and appear to be specific for HIV reactivation, and selective for HIV containing cells that contain tat. 

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.