Dr Roanna Lobo

There has been significant progress towards the virtual elimination of new HIV transmissions in Australia by 2020.  This is evident by collaboration and community partnerships, combination of prevention strategies such as PrEP, PeP and TasP and the quality of life focus for PLHIV.  

Despite this there are still many challenges with late diagnoses and undiagnosed rates higher in Aboriginal peoples, heterosexuals, SE Asian populations, CaLD communities and other regional communities.  There is both a moral and human rights approach to leave no-one behind.

How can this be achieved -

• Equitable access to new HIV testing, harm reduction services and biomedical intervention for groups at highest risk
• Reduce barriers to accessing treatment and care
• Increase health literacy
• Meaningful involvement with affected communities
• Shared care models
• Improved data and surveillance, research and evaluation
• Continued investment and partnerships

Rates of Transmitted Drug Resistant Mutations in Newly Diagnoses HIV in NSW 2004-2016

Angie Pinto

This was interesting as the results showed more transmitted HIV drug resistant mutations  found in the rural and regional areas of NSW, in younger people, with <10% mutations found.  Although Ms Pinto suggested this could not be generalised to populations outside of the NSW research areas I think it highlighted the need for vigilance in remote, rural and regional Australia.

Fortunately living in a rich nation we are able to request HIV genotyping tests with each newly diagnosed HIV case  and this is usual practice. It is also very fortunate that there were no resistance mutations found in Tenofovir and only a tiny number against Emtricitabine  -  which of course are the 2 drugs used in PrEP.

“There has probably never been a population both more heavily impacted and less discussed at scientific meetings than the transgender population around the world” Dr Tonia Poteat CROI 2016

This was a recurring theme at the ASHM conference this year and not before time!  Zahra and Teddy spoke to a paper that they plan to launch on World AIDS Day this year.

As background, trans people have been severely underserved in HIV/AIDS responses worldwide, and in Australia, with Victoria as the only state listing trans people as a priority population.

There is a lack of data on the prevalence of trans people living with HIV worldwide, however figures presented were:  19.1% of trans women, limited data for trans men, and no data for non-binary people. Australian figures from the Kirby ACCESS data showed of 696 people, 5.2% were HIV positive - 8.9% for trans women and 4.5% for trans men. However 40% had no gender identity recorded.

An interesting comment was the lack of knowledge by health professionals about trans gender issues and how, as a patient, they end up educating their health providers about trans gender issues, especially when having to meet narrow medical models for care which doesn't always sit well.

I thought this presented quote summed up further risks for HIV for trans people very well:

“Other barriers to health and health care are the numerous socioeconomic determinants of health that legally, economically and socially marginalize trans people. These include discrimination in employment, education, housing, and relationship recognition: police harassment, often as a result of actual or assumed association with sex work; and identity document policies that deny many trans people legal recognition in their true gender. They also include aspects of structural violence such as racism, violence against women, and poverty.”  Open Society Foundation, 2013

So what can we do to support trans people in the HIV response?

•  Include trans and gender diverse people as priority populations in HIV strategies
• Start collecting gender and sexuality data better! See attached photo of a suggested way of collecting gender data
•  Positive interactions with medical community
•  Access, informed consent
• Meaningful inclusion in health promotion campaigns
• Meaningful engagement and decision making by communities

I’ve also included a photo of the fab presenters. Thank you for an articulate and engaging presentation and panel discussion. 

Warning: this report deals with torture, trauma and rape/sexual violence so a trigger warning is provided.

Lauren gave a strong, emotionally challenging presentation regarding the setting up of a specific service to cater for the needs of women who are refugees from the Democratic Republic of the Congo.

Wodonga in regional Victoria began receiving refugees via women at Risk Visa 204 of the Humanitarian Refugee Resettlement program in 2015.

Lauren spoke about the history of trauma, torture and rape that these women had experienced in their former lives and how this impacted on the service delivery model established. She spoke of how these women have been unwilling to engage and maintain engagement in care, and strategies used to resolve this situation.

The Democratic Republic of Congo (DRC) is incredibly unstable with wars that have been ongoing for more than 20 years. There are up to 70 separate militia, with internal mini-wars frequently occurring. DRC has the world’s largest UN peacekeeping force and is described as ‘dangerously unstable’.

Traditional cultural values regarding women’s status are vastly different to our own. For example,  DRC has legislated that a wife ‘owes obedience to her husband’ and  that marital rape is not an offence. Marital rape is common, with 1 in 3 women reporting this. Women have no right to own property or wealth.

Rape has occurred to many of the girls and women of women of the DRC regardless of marital status. The reasons for rape are many reflect both the incredible instability created by war and the powerlessness of the women in the society. These include: punitive rape – to punish or silence; status rape; ceremonial rape; exchange rape as a bargaining tool; theft rape –abduction; and survival rape.

All of the women in the service acquired HIV as a result of rape. Many witnessed the murder of their husband and other family members; kidnapping, rape and loss of their children; were subjected to extreme physical violence and often fled with children other than their own e.g. nieces and nephews. Families fleeing were separated with no knowledge of the whereabouts or outcome of family members.

Attitudes to HIV were very fearful in this community. Fears included disclosure, death, transmission, ostracism and discrimination. Women with HIV are often blamed for the infection. This leads to lack of understanding for reasons both for ongoing monitoring of health but also engagement at all due to fears of being seen at any of the points of care. Some of the strategies to encourage the receiving of healthcare included: not having specific HIV clinics so that clients would not meet each other; flexible walk in model; not noting HIV on medical notes – the generic ‘immunocompromised’ was used instead; and care with interpreters – using only trusted phone interpreters, not using names nor using the term HIV.

Lauren talked about issues around pregnancy; so far they have had one baby born and another baby is due. This involved upskilling of staff – both community health and maternity staff. One GP decided to get her S100 prescribers approval which was a great outcome for the community. However pregnancy and parenting has provided further issues for the women such as questions about why they are bottle feeding,  questions about why the child is receiving medication and having blood tests, as well as fears of disclosure during the contact with health workers.

Lauren saw the future as education involving all those involved: Women living with HIV, men from the DRC, the community and healthcare professionals.

I was very keen to attend this presentation as I work in a sexual health service in a nearby town and state, and this service has offered further choice for HIV care in the regional community.  I congratulate Gateway Health staff – Lauren, Catherine and Ange on this successful ground-up initiative, which is inherently very difficult to achieve. I look forward to refugee women finding a voice to tell their own stories at future events.

Normal 0 false false false EN-AU X-NONE X-NONE

2.  Tuesday 7^th

Labiaplasty: factors leading to increased requests among women from a survey of GP experience.

Magdalena Simonis

This talk was really very sad in many respects.  In my own practice I have experience of young women (as young as 15yrs) wanting to have their labia modified, often without ever seeing other labia to know how normal they are.  With the adolescent body changing so dramatically at 15 it isn’t hard to understand the horror some young women must feel when they notice the changes to their genitals-  looks, skin, hair, discharge etc. Luckily these concerns can be addressed and reduce the health anxieties of the client with correct information.  Unfortunately, many young women in our society are not given any information about this – and certainly in my practice many women have no idea that they need a vaginal discharge every day for example.

Some of the concerns raised included the lack of knowledge of how these surgeries when done are going to affect the women as she ages – with atrophying of the labia during menopause.  There is now knowledge however on how it may cause considerable distress and discomfort if the surgery is not performed correctly or if there is some complication – bleeding, infection and pain etc. 

Some of the long-term effects may be hypersensitivity – especially if the clitoral hood is shortened to expose the clitoral bud. When even the wearing of clothes may be painful. There may be decreased sexual sensitivity if the edges of the labia minora are removed (there is a technique where the body of the labia is ‘wedge-resected” to avoid the more sensitive edges of the labia.) 

This procedure is the 4^th most common cosmetic surgery after the nose, liposuction and breast augmentation in Australia, the surgeon does not have to be a registered cosmetic surgeon and the client over 18 years does not have to have counseling or a cooling off period.  Women under the age of 18 have to have a 3-week cooling off period just in case they change their mind.

I have heard some arguments that this surgery is no different than having other parts of the body being modified  - the women's reasons for having their labia reduced is because of the physical look (aesthetics) or a functional concern but this talk that gave examples of the research around the psycosexual distress, relationship concerns and sexual assault that women have experienced when counselled. 

As part of the closing plenary, there was a panel on the role for STI prophylaxis and it's potential use in Australia. The concept of bacterial STI prophylaxis is similar to that of PrEP in preventing HIV infection, however the use of antibiotics instead of anti-virals (of course).

The consideration of this raises several differing points of view among panel members from a number of backgrounds. I myself initially considered the use of antibiotics in an age of increasing resistance to our current frontline antibiotics to be a potential issue. This was an eye opener into what could be a potentially very effective tool for prevention of bacterial STI's.

Facilitated by

Associate Prof. David Templeton, Senior Staff Specialist, RPA Sexual Health Clinic, HARP Unit, Kirby Institute.

Panel Members

Craig Cooper, CEO Positive Life NSW.

Dr Bridget Haire, Research Fellow, Kirby Institute, UNSW.

Dr Jeffrey Klausner, Prof of Medicine, Division of Infectious Diseases University of California.

Prof David Lewis, Director of Western Sydney Sexual Health Centre, NSW.

Chris Williams, Co-founder of PrEP'd for Change, Victoria.

Dr Kathryn Daveson, Staff Specialist, Canberra Hospital, ACT.

As with my previous reporting to panels, I will not attempt to assign particular quotes to people, lest I lose their ability to articulate their point, being from their particular backgrounds and expertise. Rather I will paraphrase the panel and draw attention to particular themes raised.

Pro

That there is great potential for a range of populations ie. MSM, but should be used in combination with other treatments.

Con

There may be issues with accessibility for clients to medications (rural/remote, clinics, ? GP's) and feasibility of executing programs effectively (time sensitive large scale dosing, organisation and adherence).

Pro

Targeted groups with Doxycycline could be effective. It has been proven to be safe for use (ie. treating acne in teenagers). There has been no documented resistance to Chlamydia or Syphilis (to doxycycline). The potential for doses post high risk episode has potential (ie. single dose 200mg doxycycline).

Con

From an antibiotic stewardship point of view, this can have issues. Already significant change in bacterial resistance to antibiotics, noted in some strains of STI's. Largely, Australia is yet to see this but it is becoming more of an issue.

Pro

There is a lot of interest from people in the PrEP community to opt into this type of treatment. Treatments such as this would help to diminish the stigma associated with STI infections.

Con

Outside of Sexual Health, antimicrobial resistance has already become a significant issue. Skin and soft tissue infections are becoming more significant and risks of sepsis from resistant bacteria causing significant issues in other areas of health.

Okay, I'll change my rule on quotes because there were two that were great.

"We think we're smarter than the bugs but we're not!" and (if you're concerned about microbial resistance "STOP EATING FACTORY FARMED MEAT AND FISH".

-------------------------------------------

This brings me to the end of my reporting from the ASHM HIV & AIDS Conference in Canberra, 2017.

I would like to thank ASHM for the opportunity to have attended this conference and recognise the efforts of all the organisers and presenters this conference. It was a fantastic conference with much learnt and I look forward to the conference next year in 2018 to be held in Sydney.

Thank you.

Dr Eric Chow is Senior Research Fellow at Melbourne Sexual Health Centre

Risk factors for gonorrhoea in heterosexuals

Eric came in after Praveena a research fellow at Kirby Institute discussed the rise in gonorrhoea infections in women aged between 20-39yrs in the period 2007-2016. She did not have any tangible evidence as to why the increase. One of her to do list was to research as to why?

 Eric timely came in to give possible risk factors that might have prompted the rise of gonorrhoea infections in this group of women. Possible factors were sexual partners and condom use, bisexual men, dating sites/apps, alcohol and drug use, travel and other unexplored factors.

There was not enough evidence on 5 of these risk factors to prove that they were the reason for the rise in Gonorrhoea. More information is required and its still work in progress.

Travel and sex to or from a high place of prevalence was the only reason why there is a rise in Gonorrhoea infections. 

Dr Praveena Gunaratnam

Research Fellow at Kirby Institute, UNSW Sydney

Praveena spoke on Gonorrhoea infections in women across all major cities, WA being on top of the list. She mentioned an alarming increase of 118% based on 2007-2016 statistics of women aged between 20-39yrs. She mentioned that the increase was not based on the increase in testing but an increase in infections.

Rates in Aboriginal and Torres straight islander women are higher than non-aboriginal women in all major cities.

Gonorrhoea is the major cause of pelvic inflammatory diseases and infertility in women. There is also a concern for increasing antimicrobial resistance.

Investigations via research into the reasons why the increase is the next step. Contributory factors are:

-changes in sexual behaviours e.g. dating apps

-a particular strain of gonorrhoea

-lower socio-economic factors

-inadequate health care access or a combination of these factors.

Lynda Carlye is a sex and relationship therapist and director of the Society of Australian Sexologists, Australia. Lynda has over 10 years experience in the field and presented a very engaging talk which looked at why 27.3% of women do not enjoy sex (Australian study of Health and Relationships)

Lynda kicked off her talk by going through the pathological and non-pathological reasons of vulvodynia which is a pain in one area of the vulva. Lynda established the importance of understanding the 237 reasons people have sex from the YSEX survey under the following four subcategories; physical, emotional, goal attainment and insecurity.

At a clinical service level, it is important that once organic causes have been ruled out, appropriate referrals are made within the multidisciplinary team which should include a solution focused psychosexual management/ treatment within a counselling framework for the individual and/or couple.  

Amongst many, Lynda recommended Dr. Anita Elias’s practical assessment and management tool that helps patients understand the connection between their thoughts emotions and physical sexual response.

Certainly psychosexual therapy is invaluable although public funding for this is limited and therefore a barrier for many. 

"There has probably never been a population both more heavily impacted and less discussed at scientific meetings than the transgender population around the world" Dr.Tonia Poteat CROI 2016

TGD are being recognised as a high risk population (WHO 2015)

Nineteen percent of Trans women world wide are HIV (+ve). Limited evidence about HIV among trans males is available due to the lack of data/evidence.

ACCESS (Kirby Institute 2017) Data shows out of 696 people 5.2% were HIV (+ve); 8.9% were trans women and 4.5% trans men. Trans women were more likely to report sex work

Barriers to Prevention: Methodological, cultural, social and system, geographical and under representation

Legal Barriers: Pathologisation and legal sex recognition

Trans and Gender Diverse people are a community of interest in UNAIDS/HIV elimination program.

They are not included in the National HIV strategy or included in STI/HIV reporting. This misses the opportunity to collect data of behaviors and STI/HIV testing among the TGD population

In a STI/HIV testing service a research project was produced to collect Sentinel Surveillance data via surveys that demonstrated the importance of the data collected

Three surveys were set up to collect the data between 2013-2017

The 3rd (2017) survey asking gender identity and sex assigned at birth: Of 1220 surveyed, 88 (7.2%) reported to be TGD, of which 61 of those reported to have a gender identity that was different to the one designed at birth 

Thirty nine has tested more than once at the service

* Take home: Simple changes to data collection based on community consultation had a considerable impact on the utility of surveillance to help guide STI/HIV prevention and care for TGD people

Anna McNulty presented about the New South Wales initiative of posted self collected HIV dried blood spot testing. This is of interest to me as I work in a sexual health clinic in a regional setting and I'm aware of how isolated some people are who could benefit from a HIV test.  In my setting I'm aware of isolated MSM who are not out in the local community and/or don't want to be seen at a sexual health clinic or are unable to travel to a local sexual health clinic. Some feel unable to discuss this with their GP or may not even have access to a GP.

 Background to this project:

• HIV New South Wales strategy identifies GBM and CALD  as priority populations for testing
• 11% of people with HIV in New South Wales are undiagnosed
• GBN are interested in self testing however currently not available
• Those from CALD communities are more likely to be diagnosed late 

 How it works: 

•  Dried blood spot test (DBS) test ordered via website
•  Person uses small lancet to prick finger and apply blood to small circles on blotting paper, 5 drops preferred
•  Sample is returned in the reply paid envelope to SVH lab
•  Negative results SMS via Sexual Health Infolink (SHIL)
•  Positive results via phone 

 Promotion: 

•  Promoted through social media and local initiatives
• Translated into 10 languages 

Results:

• November 2016 to end of September 2017 there were 505 registrations
• 77% MSM, 32% had partners from Asia or Africa, 26%  were from Asia or Africa, 14% CALD MSM, 11% CALD heterosexual, 4%had ever injected drugs or  5% Aboriginal. Note people could be for more than one group
• 58% kit return rate
• 54% have never tested or tested greater than two years ago
• Median kit return time was 18 days
• Reactive results: 1 confirmed and the person linked to care, another recent reactive result
• There were 39 repeat testers

Feedback from users of the test  in a post test survey:

• Test participants  were very supportive of HIV testing done this way and we're very happy they had the opportunity to test.  Feedback included: They  could test  in private, the test was was quick, free, convenient, no need to go to GP,  allows me to test ahead, it is less embarrassing, easy to do

Conclusions: 

•  Successful implementation however slowper uptake than anticipated
• Difficult to reach heterosexual CALD
•  Expected 1% HIV positivity
• Marketing is the key to uptake

Future:

• Phase 2 site specific projects including addition of hepatitis C RNA testing and Aboriginal and PWID added as populations to be targeted
• SOPV
• NSPs
• D&A services 

The Implications of HIVSTI on Sex Workers

Udesha Chandrasena - Policy Officer at Scarlet Alliance, Australian Sex Workers Association

This was an very interesting session focusing on the accessibility of "self-test" HIV test kits that are currently available online and that have been made available to people in rural areas of Australia. With the changes and increase in availability of technologies that will allow for fast results, with some accuracy, to determine someone's HIV status, Udesha presented that this has potential to impact positively and negatively on sex workers.

The ability to have people attend tests at non-clinical locations can have great potential benefit in allowing for confidential testing in a private setting but can also have potential for significant issues.

Sex workers in Australia have been shown across Australia to have lower rates of HIV than the general population and also when compared to rates of sex workers overseas. This has been made possible through strong peer group programs in Australia and can only be measured in this population as a success, something that should be recognised. However this is not new data and across Australia every state and territory has it's own legislation regarding sex workers and a persons HIV status. This has potential to impact this population at risk with emerging new technologies that laws may not be keeping up with.

The advent of technologies with the ability to test a person on site or that need to be sent elsewhere for results may lead to an increase in the number of people tested but could also open workers up to potentially dangerous practices in their workplace. This could lead to bullying within brothels to be tested, to have workers be coerced by other workers, clients or brothel owners or managers to test in their presence. This has potential to impact on the workers safety, ability to work or force people to change practices or even be stopped from working. With differences between testing kits, techniques and potential technical issues with these technologies, this could lead to issues with false negative outcomes which would be managed differently in a clinical setting or with more "traditional" testing techniques.

Udesha argues that the current high rates of voluntary testing among the sex worker population be acknowledged and that changes to legislation across the country be made to ensure safety for workers.

In conclusion, there is potential for an increase in the numbers and scope of testing, however this can also negatively impact on sex workers. Changes in legislation across Australia is necessary to accompany this new technology.

Presentation by Maria Dulce Natividad

Maria gave a disturbing presentation about the current state of HIV prevention work in the Philippines. There has been a frightening shift in the landscape since President Duarte took the reins in June 2016.

Between 2010 and 2016 the Philippines has seen a doubling of HIV infections from 4300 to 10500. Maria noted that prior to that time progress on HIV prevention in the Philippines was “low and slow”. While most of the rise is seen to be amongst young MSM, there is also concern for those who inject drugs. Prevention for this group under the current Government will be very difficult.

After taking office President Duterte declared a ‘war on drugs’ , which has been marked by harsh condemnation of drug users and Presidential ‘permission’ to punish and kill drug users. Maria presented several quotes from the president, which including the words “free to kill idiots” (IV drug users). The impact on the ground was the beginning of extra judicial killings which have led to an estimated 13000 deaths. Maria described this as a “shoot first, ask questions later” approach.

She noted that the political message represented a harnessing of fear and social discontent, with its roots in social inequality. It has enabled the institutionalisation of fear through promises of cleaning up society. Maria argued that for Duterte it has led to a consolidation of political support.

The resulting discrimination means that drug users have been driven further into the shadows, with people avoiding health care because they fear for their safety. Harm reduction has become much more difficult. Programs such as clean needle distribution have been discontinued, drug use is poorly documented, and activists/advocates are afraid to get involved.

Drug use and HIV interventions are treated separately, so there is no cross linking.

The situation in prisons is very concerning, with greater overcrowding and a subsequent rise in health issues, which is likely to include blood borne infections.

Overall it appeared to be a grim picture which does not present much room for optimism, however Maria discussed some areas of hope. While dialogue is not possible nationally, change may be initiated at the community level. Some communities and smaller organisations are stepping in to help despite the risks.

IV drug users have the most to fear in the current climate. Perhaps Australian health workers and their peak bodies can find ways to support those communities which are brave enough to help people affected by these depressing government policies, and through this keep alight the flame for HIV prevention. 

Presentation by Professor Monica M Lahra

Monica gave a fascinating and thorough summary of global concerns relating to anti microbial resistance [AMR]. Resistance is predicted to be a big problem by 2050, and is considered to threaten health and health care provision.

AMR is essentially a problem of overuse. Bacteria which come into contact with antibiotics, but are not killed have various means of developing resistance. Resistant organisms are now global and endemic in some countries. Some organisms have become resistant to last line antibiotics. AMR presents a threat to medical procedures and treatment, including chemotherapy, complex surgery and transplants.

Factors leading to resistance include:

• Mass food production. Antibiotics are needed to control disease, particularly where large numbers of stock are raised in minimal space as happens with large scale fish and pig farming. This is considered a major contributing factor.
• Large scale antibiotic dumping by manufacturers.
• Inappropriate prescription /overuse where antibiotics are not necessary /availability of non prescription antibiotics. The latter uncontrolled use is estimated to be even greater than current studies indicate as many countries do not collect data on non-prescribed supply.
• Travel. Global travellers are colonised with resistant bacteria which they bring home with them. (here Monica threw in a comment that we should avoid eating pastry or ice cream when travelling ).
• Lack of data. Inadequate surveillance has led to an inadequate understanding and response to the problem.

Peak global health organisations see AMR as a real threat as evidenced by a 2016 UN high level meeting on the subject and subsequent global planning to stem resistance. WHO have released a list of priority organisms and these have been categorised according to their threat level as urgent, serious, or concerning.

Responses required for tackling the problem include:

• Improved knowledge and awareness of the issue at all levels. This should include building awareness amongst industries such as food production.
• A solid global and national policy response, including workable frameworks and accountability.
• Optimisation of antibiotic use through stewardship, and reduction of antibiotic use through lowering infection rates.
• Investment in research and development.

Monica argued that now was not a time for complacency. We need to be careful about how we use this precious commodity. We need a workable road map of what to do, and commitment from business, which is likely to require strong governmental policy. 

At a clinic level, it raised questions for me about the wisdom of contact treatment where risk is low, and the contact indicates their willingness and ability to abstain from sex until results are received. We currently advise contact treatment, so is it too controversial to wait?

It also raises questions about any rollout of antibiotic prophylaxis for high risk groups

The presentation was a confident and engaging call to action.

On the throw away line regarding the risks of global dining, a friend who I informed about the presentation commented “deliciously infected by an Italian Gelato”.

The talk was presented by Dr Jeffrey D Klausner, Professor of Medicine, Department of Infectious Disease, University of California, Los Angeles, USA

Outline

·         What is self – testing?

·         How is self – testing Adopted?

·         What is the fidelity of self – testing?

·         Where can self – testing can be disseminated?

Self – Testing for HIV Infection

Only US FDA approved in Home HIV testing kit which used similar technique of Western Blot

Used by over a million consumers and same device used by health care professionals recently

The technique is simple oral swabs, no blood, and results will be in 20 minutes

24 bilingual customer phone support and details product website offering information, referrals to care, product usage instructions and more

Higher consumer satisfaction

Self – testing adoption

Influenced by user’s perception of costs, benefits, personal need and convenience.

Users greatly prefer painless oral testing over finger stick or venepuncture

Additional benefits include increased confidentially, privacy and reduced social stigmatization

Self – testing Fidelity

Original studies by manufacturer < 2 % failure

-          Limited by use of select population (MSM)

-          US adult vs trained providers ( Sensitivity 92.9% vs 99.3 % )

Singapore, error rate 0.6 %

Atlanta, 9 % error rate

China (non – Oraquick) 10 % difficulty swabbing, 17.5 % difficulty reading results

In NYC young MSM and transgender women reported concerns of anxiety, test correct use and instructions

Self – testing Dissemination – Los Angeles

-          Vending machines

-          Vouchers

-          US Priority mail

-          Online

Vending Machines in sex clubs which are located at private areas with self – contained unit that can be monitored remotely as well as posted instruction how to use the kit

Initial Concerns for Vending Machines

·         Cost of HIV home test kits

·         Emptying the vending machine

·         Conflict with existing testing programs

·         Home test kit window period

·         Result anxiety

Results summary over 7 weeks, in 2014

-          1176 hours and 312 tests for Vending machines versus 64 hours with 58 tests for traditional testers with clinicians

Providing Vouchers for the free test kit that can available at Pharmacy is also very positive outcome 

Social Medical Promotion commenced since 2014 through Periodic advertisements

In General, among three choices; vouchers, vending machine, priority mail to home 

Approximately 2/3 used Mail services and 1/3 of other consumers accessed through free vouchers, 67 % and 30 % respectively. Only 3 % used vending machine to get the self – testing kit  

Linkage to care for community

HIV Self- test added as a reported element in HIV Surveillance and also follow up management goes through by receiving the positive test kit photos taken by consumers

STD Self – Testing

·         Self -collection urine send via mail for STD testing

·         Self – referral syphilis lab testing

·         Commercial home – based collection and shipping

·         True home – based collection and self – testing.. .. not yet but coming soon.

Among all, using Mail for screening is the most cost effective method

Summary

·         HIV self – testing is desirable, safe and effective – WHO recommended

·         Need more evidence on outcomes, impact and cost effectiveness

·         STD home – specimen collection and self – referral options

·         True STD home – based self – testing …. Coming soon and waiting approval from FDA

The trainees presentations were a highlight of the conference for me - some fascinating cases, presented superbly with an audience including some great HIV clinicians made for a stimulating and highly educational session. It would have been easy to continue the discussion on any of these cases for a good few more hours. 

The first case, from the Alfred Hospital was of a young man recently arrived in Australia who presented with a rash and pulmonary infiltrates. The rash was eventually found to be histoplasma - an important diagnosis to consider, although much more common in other parts of the world, locally acquired cases have been reported.

The next case, from Perth, was of another visitor, this time from Zimbabwe, who was diagnosed with HIV after presenting with sinus pain. Investigations found haemophagocytic lymphohistiocytosis, and she was diagnosed with orbital NK/T cell lymphoma. Due to her status as a visitor, there were issues associated with payment. Whilst her HIV care was paid for as an STI according to a state government undertaking, therapy for the cancer proved an entirely different matter. She was given second line therapy in order to contain costs. On her return to Zimbabwe, again HIV treatment was easily available, however the treatment of the cancer was again not possible and she died 3 months after her return.

A case of gummatous tertiary syphilis, presenting as lesions on the back and arm was presented from inner city Sydney. Again, advanced HIV, known this time for a number of years but untreated, was present, however in this case, syphilis had also been diagnosed on numerous occasions over recent years but remained only partially treated. The case presented numerous issues including diagnosis and management of tertiary syphilis, the difficulties in managing patients with psychiatric comorbidities as well as complex social circumstances and itinerancy. This was a sobering reminder of the difficulties that are faced in clinical practise, and the presentation ended with the case being unresolved (patient absconded with partial syphilis treatment and having not picked up ongoing HIV medication scripts).

Finally, from the Royal Melbourne Hospital, another late presenting individual with advanced immunosuppression, newly diagnosed with HIV and started on treatment, presented to hospital with cryptococcal meningitis, and, despite treatment, deteriorated with multiorgan failure and decreased conscious state in ICU. Fortunately, he recovered to be discharged well form hospital a number of weeks later. The analysis focused on the reasons behind the deterioration in health after treatment commencement, with the most likely explanation believed to be unmasking cryptococcal IRS. An important question about whether rates of IRS are increased on INSTi was raised, with George Behrens- guest from Germany and one of the judges of the session, announcing an impending clinical trial in severely immunocompromised new presenters starting on treatment , comparing rates of IRS on treatment with PIs compared with integrase inhibitors.

In addition to the medical complexities of the cases, common themes including late presentation, still a not infrequent problem, and the difficulties in management associated with challenging socio-demographic circumstances, including itinerancy, psycho-social issues, and medicare -eligibility. 

Plenty to think about.

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

HIV response in PNG. Are key populations being reached?

Dr Angela Kelly-Hanku, Senior Research Fellow, Papua New Guinea Institute of Medical Research /Kirby Institute, UNSW, Sydney Papua New Guinea

An interesting discussion around whether key populations are being reached in terms of the HIV response within Papua New Guinea (PNG).

Dr Kelly-Hanku explained we need to ‘unpack’ the term key population and posed the question of exactly ‘who’ are the key populations.

Sexual identity: How one claims their sexual identity is changing in PNG. From bisexual to gay to men who have sex with men (MSM), to men of diverse sexualities.

Attraction: Who one is attracted to; only women, only men or mostly women for example, however this does not mean they are having sex with who they are attracted to.

Sexual behaviour: Who did they last have sex with? Male, female and so on.

These complexities around sexual identity may indeed be the reason why some key populations are not being reached in PNG, claiming the picture is far more complicated than people wanted to know.

Dr Kelly-Hanku suggests we learn how to work with it, through the different layers of diversity, attraction and ethnicity. Much more work needs to be done in order to reach the global targets for HIV and increase levels of testing and treatment, however PNG is up for the challenge, showing it can be done, where some financial donors have said no!

Perhaps one of the more applicable talks to my experience in Timor was that given by Angela Kelly-hanku on challenges reaching key populations.

In PNG its the church groups who often provide the most stable centers to operate health interventions (different from in Timor), and these have been the platforms from which international health programs have carried out their work.

The talk highlighted just how difficult it is to define the 'key populations', in that many who present to these facilities do so as they want non-judgmental care, where they won't be labelled as MSM, FSW and so on. I do wonder if its similar to the situation in Timor, where the largest HIV clinic is run by a private NGO, as foreign staff (and possibly church groups) are less likely to know the patient and their family. But defining key population can be so much more difficult... An interesting chart revealed 20% of MSM in PNG didn't report being attracted to men, and 40% reported being attracted to both men and women. We may see a fairly similar pattern in Timor once again, where a high percentage of the MSM (>50%) also have female partners. This could be related to the horrendous level of stigma and discrimination against them.

However the ultimate answer to the question are we reaching the key populations was revealed towards the end of the presentation with confronting statistics revealing 60% of the MSM in PNG have never been tested, and 32% of the FSW have never been tested. So No is the answer.

I can't imagine Timor is any better with the horrendous supply chain issues encountered over the past year...

PrEP has been a major discussion point in the 2017 ASHM conference. In a joint symposium with the 2017 Sexual Health Conference, multiple speakers spoke of the rollout of PrEP in Australia and New Zealand. A/Prof Edwina Wright discussed ‘PrEP in Future Australia: How will it look?”

Edwina invited us to imagine the future of PrEP in Australia if PBS listing were to occur in 2018. One of the key points made was the need for rapid up-scaling of PrEP provision in the community. There have already been signs of over-saturation of clinics involved in the current PrEP studies, and PBS listing of PrEP would likely further overwhelm these resources. This leads to the question of which providers would be able to assist in providing appropriate PrEP counselling  – other practitioners besides medical practitioners could play a role here, including nurse practitioner and pharmacists. Criteria for PBS prescribing would likely exist to obtain authority – this would be based on the recently published ASHM guidelines on PrEP and would require individuals to be HIV negative, have normal renal function and aged over 18.

Another key issue raised by Edwina as well as numerous other speakers during the conference relate to inequity of access. Currently those accessing PrEP come from a similar demographic – gay, educated, Australian-born and employed individuals. Individuals from culturally and linguistically diverse backgrounds, those from lower socio-economic status, and those in rural communities are under-represented. Further strategies are required to try and reach out to these communities.

Another issue that requires further investigation is that of potential toxicity. As PrEP contains TDF, the long-term risk and toxicity to renal function or bone health remains to be determined. A PrEP registry could play an important role here to allow long-term follow-up of potential toxicity. Continuous follow-up of individuals on PrEP also remains vital, not only in assessing for potential complications, but also for ongoing routine screening of other STIs.

This session highlighted the need for increasing preparedness of clinicians in the community in being able to manage and counsel patients requesting PrEP, the number of which is likely to increase if/when PrEP becomes PBS listed. In addition, those currently accessing PrEP through clinical trials may prefer to see their general practitioners or other health practitioners in the community to continue receiving PrEP once the trial ends. Several PrEP resources are available to clinicians including the ASHM PrEP guidelines and an online PrEP module available on the ASHM website.