The Positive Outlook Study: A Randomised Controlled Trial Evaluating Online Self-Management for HIV Positive Gay Men

The aim of this paper was to evaluate the effectiveness of an online self-management program in improving health outcomes and well-being for gay men living with HIV in Australia. 

The online Positive Outlook Program was based on self-efficacy theory and used a self-management approach to enhance HIV-positive gay men's skills, confidence and abilities to manage the psychosocial issues associated with HIV in daily life. The 7-week program was delivered in closed groups and comprised information modules, action-planning activities, moderated discussion boards, and weekly peer-facilitated 'live chats'. 

A randomised controlled trial was conducted to establish the effectiveness of the Positive Outlook program compared to a 'usual care' control. Participants were HIV-positive gay men 18 years or older living in Australia. Primary outcomes were evaluated at three time-points (baseline, post-intervention and 12-week's post-intervention follow-up) and included HIV-related quality of life (PROQOL-HIV), outcomes of health education (HeiQ) and HIV specific self-efficacy (Positive Outlook Self-Efficacy Scale). 

A total of 132 gay men with HIV in Australia were randomly allocated to the intervention (n = 68) or usual care control (n = 64) groups. Maximum likelihood marginal-linear modelling indicated significant improvement in the intervention group on the PROQOL-HIV subscales of body change (p = 0.036), social relationships (p = 0.035) and emotional distress (p = 0.031); the HeiQ subscales of health-directed activity (p = 0.048); constructive attitudes and approaches (p = 0.015); skill and technique acquisition (p = 0.046) and health service navigation (p = 0.008); and the Positive Outlook Self-Efficacy Scale on the subscales of relationships (p = 0.019); social participation (p = 0.006); and emotions (p = 0.041). 

Online delivery of self-management programs is feasible and has the potential to improve quality of life, self-management skills and domain specific self-efficacy for gay men with HIV.

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By:  Millard T1, Agius PA2,3, McDonald K4,5,6,7, Slavin S8, Girdler S9, Elliott JH10,11,12.

• 1Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia. tanya.millard@monash.edu.
• 2Centre for Population Health, Burnet Institute, Melbourne, Australia. pagius@burnet.edu.au.
• 3Judith Lumley Centre, La Trobe University, Melbourne, Australia. pagius@burnet.edu.au.
• 4Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia. karalyn.mcdonald@monash.edu.
• 5Judith Lumley Centre, La Trobe University, Melbourne, Australia. karalyn.mcdonald@monash.edu.
• 6Jean Hailes Research Unit, Monash University, Melbourne, Australia. karalyn.mcdonald@monash.edu.
• 7Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia. karalyn.mcdonald@monash.edu.
• 8Centre for Social Research in Health, University of New South Wales, Sydney, Australia. sslavin@afao.org.au.
• 9School of Occupational Therapy and Social Work, Curtin University, Perth, Australia. sonya.girdler@curtin.edu.au.
• 10Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia. julian.elliott@monash.edu.
• 11Centre for Population Health, Burnet Institute, Melbourne, Australia. julian.elliott@monash.edu.
• 12Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia. julian.elliott@monash.edu. 

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Improving the Identification of Priority Populations to Increase Hepatitis B Testing Rates, 2012

BACKGROUND:

It is estimated that over 40 % of the 218,000 people with chronic hepatitis B (CHB) in Australia in 2011 are undiagnosed. A disproportionate number of those with undiagnosed infection were born in the Asia-Pacific region. Undiagnosed CHB can lead to ongoing transmission and late diagnosis limits opportunities to prevent progression to hepatocellular carcinoma (HCC) and cirrhosis. Strategies are needed to increase testing for hepatitis B virus (HBV) (including culturally and linguistically diverse communities, Aboriginal and/or Torres Strait Islander (Indigenous) people and people who inject drugs). General practitioners (GPs) have a vital role in increasing HBV testing and the timely diagnosis CHB. This paper describes the impact of a GP-based screening intervention to improve CHB diagnosis among priority populations in Melbourne, Australia.

METHODS:

A non-randomised, pre-post intervention study was conducted between 2012 and 2013 with three general practices in Melbourne, Australia. Using clinic electronic health records three priority populations known to be at increased CHB risk in Australia (1: Asian-born patients or patients of Asian ethnicity living in Australia; 2: Indigenous people; or 3): people with a history of injecting drugs were identified and their HBV status recorded. A random sample were then invited to attend their GP for HBV testing and/or vaccination. Baseline and follow-up electronic data collection identified patients that subsequently had a consultation and HBV screening test and/or vaccination.

RESULTS:

From a total of 33,297 active patients, 2674 (8 %) were identified as a priority population at baseline; 2275 (85.1 %) of these patients had unknown HBV status from which 338 (14.0 %) were randomly sampled. One-fifth (n = 73, 21.6 %) of sampled patients subsequently had a GP consultation during the study period; only four people (5.5 %) were subsequently tested for HBV (CHB detected in n = 1) and none were vaccinated against HBV.

CONCLUSION:

CHB infection is an important long-term health issue in Australia and strategies to increase appropriate and timely testing are required. The study was effective at identifying whether Asian-born patients and patients of Asian had been tested or vaccinated for HBV; however the intervention was not effective at increasing HBV testing.

Full article at:  http://goo.gl/ADG29j

By:  van Gemert C1,2, Wang J3, Simmons J4, Cowie B5,6, Boyle D7, Stoove M3,8, Enright C4, Hellard M3,8.

• 1Centre for Population Health, Burnet Institute, Melbourne, Australia. carolinevg@burnet.edu.au.
• 2Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia. carolinevg@burnet.edu.au.
• 3Centre for Population Health, Burnet Institute, Melbourne, Australia.
• 4Cancer Council Victoria, Melbourne, Australia.
• 5WHO Collaborating Centre for Viral Hepatitis, Doherty Institute, Melbourne, Australia.
• 6Department of Medicine, University of Melbourne, Melbourne, Australia.
• 7GRHANITE™ Health Informatics Unit, Health and Biomedical Informatics Centre, University of Melbourne, Melbourne, Australia.
• 8Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia. 
• BMC Public Health. 2016 Feb 1;16(1):95. doi: 10.1186/s12889-016-2716-7.

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A 'Test & Treat' Prevention Strategy in Australia Requires Innovative HIV Testing Models

OBJECTIVES:

HIV diagnoses among men who have sex with men (MSM) in several high-income countries, including Australia, have increased substantially over recent years. Australia, in line with global prevention strategies, has emphasised a 'test and treat' HIV prevention strategy which relies on timely detection of HIV through frequent testing by those at risk. We examined trends in repeat testing among MSM defined as 'high-risk' according to Australian testing guidelines.

METHODS:

HIV test records from MSM attending high caseload clinics in Melbourne 2007-2013 and classified as high-risk were analysed. Binary outcomes of 'test within 3 months' and 'test within 6 months' were assigned to tests within individuals' panel of records. Negative binomial regressions assessed trends in overall HIV testing and returning within 3 and 6 months. Annualised proportions of return tests (2007-2012) were compared using two-sample z tests.

RESULTS:

Across 18 538 tests among 7117 high-risk MSM attending primary care clinics in Melbourne (2007-2013), the number of annual HIV tests increased (p<0.01). Between 2007 and 2012 annualised proportions of tests with a subsequent test within 3 and 6 months also increased (p<0.01); however, by 2012 only 36.4% and 15.1% of tests were followed by another test inside 6 and 3 months, respectively.

CONCLUSIONS:

Repeat testing among high-risk MSM in Australia remains unacceptably low, with recent modest increases in testing unlikely to deliver meaningful prevention impact. Removing known barriers to HIV testing is needed to maximise the potential benefit of test and treat-based HIV prevention.

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Sex Transm Infect. 2016 Jan 22. pii: sextrans-2015-052421. doi: 10.1136/sextrans-2015-052421.

By:  Wilkinson AL1, El-Hayek C2, Spelman T2, Fairley CK3, Leslie D4, McBryde ES5, Hellard M6, Stoové M1.

• 1Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia.
• 2Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia.
• 3Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia Central Clinical School, Monash University, Alfred Hospital, Melbourne, Victoria, Australia.
• 4Victorian Infectious Disease Reference Laboratory, Melbourne, Victoria, Australia.
• 5Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
• 6Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia Department of Infectious Disease, Alfred Health, Alfred Hospital, Melbourne, Victoria, Australia. 

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Australia - PornHub 2015 Use Review

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Most Young Men Think You Have To Be Naked in Front of the GP

Background: In Australia, 15- to 29-year-olds account for 75% of all sexually transmissible infection (STI) diagnoses. STI rates among young men are rising, with most diagnosed in general practice. Young men less frequently attend general practice than young women, and rarely present with sexual health issues, making it difficult for general practitioners (GPs) to offer opportunistic STI education and screening. Little is known of the barriers preventing male university students accessing general practice for sexual health care, or what would facilitate this. 

Methods: Semi-structured interviews were conducted with young men aged 18-24 years attending university between 2012 and 2014. Interviews were recorded, transcribed and analysed using content and thematic analysis. 

Results: Twenty-eight interviews of 26-50 min duration found self-imposed views of masculinity, privacy and embarrassment as key barriers to accessing GPs for sexual health care. This was compounded by poor STI knowledge and not knowing when or where to go for care. Participants, except if they were international students, acknowledged school as an important source of sexual health education. The need for sexual health education at university was identified. While the Internet was a popular source, there were mixed views on the benefits of social media and text messaging for sexual health promotion. 

Conclusions: Current expectations of young male university students to seek sexual health care or acquire sexual health information from medical care may be misplaced. Universities have an excellent opportunity to provide young men with appropriate sexual health information and could offer novel strategies to help young men look after their sexual health.

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By:   Cameron Ewert A, Archibald Collyer A and Meredith Temple-Smith A B 

^A Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia. 
^B Corresponding author. Email: m.temple-smith@unimelb.edu.au 

 

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Provision of HIV Test Results by Telephone Is Both Safe & Efficient for Men Who Have Sex with Men

The aim of this study was to assess the impact of delivering HIV test results by telephone on HIV testing and subsequent risk behaviour of men, as well as saving on clinic consultation time. It was conducted at the Melbourne Sexual Health Centre, the main public sexual health clinic servicing Victoria, Australia. 

In 2013, a policy change was introduced so men could obtain their HIV test result via telephone. We compared the proportion of men testing for HIV and receiving results in the 24 months before (2011-2012) and the 24 months after (2013-2014) the policy change. There was a modest increase in the proportion of men having a HIV test of 3.2% (p < 0.001) after the policy change. T

he provision of HIV results by telephone more than halved the number of men re-attending (74.4% vs. 33.1%) which freed up 516 hours of clinic time and had no adverse outcome on subsequent risk behaviour, nor changed the proportion of men who obtained their HIV results (p = 0.058), or the period of time between testing and obtaining results for HIV-negative (p = 0.007) and HIV-positive results (p = 0.198). 

Telephone notification of HIV test results is a useful option given the potential beneficial effects shown.

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By:   Bissessor M1, Bradshaw CS2, Fairley CK2, Chen MY2, Chow EP2.

• 1Melbourne Sexual Health Centre, Alfred Hospital, Melbourne, Victoria, Australia Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia mbissessor@mshc.org.au.
• 2Melbourne Sexual Health Centre, Alfred Hospital, Melbourne, Victoria, Australia Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia. 

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Screening for Partner Violence among Family Mediation Clients: Differentiating Types of Abuse

Family mediation is mandated in Australia for couples in dispute over separation and parenting as a first step in dispute resolution, except where there is a history of intimate partner violence. However, validation of effective well-differentiated partner violence screening instruments suitable for mediation settings is at an early phase of development. 

This study contributes to calls for better violence screening instruments in the mediation context to detect a differentiated range of abusive behaviors by examining the reliability and validity of both established scales, and newly developed scales that measured intimate partner violence by partner and by self. 

The study also aimed to examine relationships between types of abuse, and between gender and types of abuse. A third aim was to examine associations between types of abuse and other relationship indicators such as acrimony and parenting alliance. The data reported here are part of a larger mixed method, naturalistic longitudinal study of clients attending nine family mediation centers in Victoria, Australia. 

The current analyses on baseline cross-sectional screening data confirmed the reliability of three subscales of the Conflict Tactics Scale (CTS2), and the reliability and validity of three new scales measuring intimidation, controlling and jealous behavior, and financial control. Most clients disclosed a history of at least one type of violence by partner: 95% reported psychological aggression, 72% controlling and jealous behavior, 50% financial control, and 35% physical assault. Higher rates of abuse perpetration were reported by partner versus by self, and gender differences were identified. There were strong associations between certain patterns of psychologically abusive behavior and both acrimony and parenting alliance. 

The implications for family mediation services and future research are discussed.

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By:   Helen Cleak1, Margot J. Schofield2, Lauren Axelsen2, Andrew Bickerdike3

1. ¹Queensland University of Technology, Brisbane, Australia
2. ²La Trobe University, Melbourne, Australia
3. ³Relationships Australia, Melbourne, Australia

1. Helen Cleak, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 7000, Australia. Email: helen.cleak@qut.edu.au

 

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Mortality in the Melbourne Injecting Drug User Cohort Study (MIX)

Background

There are few studies of mortality amongst people who inject drugs (PWID) in Australia. In this study, we estimate mortality in a cohort of PWID in Melbourne and examine predictors of mortality including health service use, demographic characteristics, drug use and personal wellbeing.

Findings

We linked identifiers from the Melbourne injecting drug use cohort study (MIX; n = 655) to the National Death Index from 2008 to 2012 to estimate standardised mortality ratios (SMRs). Cox regression was used to examine the bivariate relationship between exposures determined at baseline and subsequent mortality. There were 24 (3.6 %) deaths over the study period. The mortality rate in the cohort was 1.0 per 100 PY (95 % CI 0.71–1.57), with an SMR of 17.3 (95 % CI 11.6–25.8). Baseline reports of four or more lifetime incarcerations (HR 3.65, 95 % CI 1.16–11.52), past month ambulance attendance (HR 4.43, 95 % CI 1.76–11.17), past month emergency department presentation (HR 3.44, 95 % CI 1.47–8.03) and past 6-month self-reported heroin overdose (HR 3.14, 95 % CI 1.24–7.96) were associated with increased mortality risk.

Conclusions

Contact with emergency services, particularly for drug overdose, remains a lost opportunity to provide referrals for harm reduction and naloxone training programmes to PWID at greater risk of mortality.

Full article at:  http://goo.gl/WDbQ27

By:  Dhanya Nambiar^12*, Paul A. Agius¹², Mark Stoové¹², Matthew Hickman³ and Paul Dietze¹²

¹Centre for Population Health, Burnet Institute, Melbourne, Australia

²Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia

³School of Social & Community Medicine, University of Bristol, Canynge Hall, Bristol, UK

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Patterns of, and Factors Associated With, Illicit Pharmaceutical Opioid Analgesic Use in a Prospective Cohort of People Who Inject Drugs in Melbourne, Australia

BACKGROUND:

People who inject drugs (PWID) are a key population engaging in pharmaceutical opioid analgesic (PO) use, yet little is known about patterns of illicit PO use among this group.

OBJECTIVES:

The aims of this research were to measure the prevalence and frequency of lifetime and past-month illicit PO use and injection in a sample of regular PWID, to examine patterns of past-month illicit PO use within individuals over time, and to identify factors independently associated with past-month illicit PO use.

METHODS:

Data were drawn from a prospective cohort study of regular PWID (N = 666) in Melbourne, Australia. Data from five waves of annual data collection (including baseline) were analyzed descriptively and using generalized estimating equations (GEE).

RESULTS:

At baseline, 59% of participants reported lifetime illicit PO use and 20% reported past-month use, predominantly through injecting. Most illicit PO users at baseline transitioned to nonuse of illicit POs across the study period. In multivariable GEE analysis, factors associated with past-month illicit PO use included past-year arrest [adjusted odds ratio (AOR): 1.39], opioids other than heroin as drug of choice (AOR: 5.14), experiencing poorer physical health (AOR: 0.98) and a range of other drug use variables.

CONCLUSIONS:

We found little evidence of ongoing illicit PO use among those followed up, with illicit PO use linked to polydrug use more broadly. Nonetheless, trends in illicit PO use among PWID should continue to be monitored and harm reduction interventions implemented to reduce the associated public health risks.

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By: Horyniak D1,2, Agius PA1, Degenhardt L3,4, Reddel S1, Higgs P1,2,5, Aitken C1,2, Stoové M1,2, Dietze P1,2.

• 1 Centre for Population Health, Burnet Institute , Melbourne , Victoria , Australia.
• 2 School of Public Health and Preventive Medicine , Monash University , Melbourne , Victoria , Australia.
• 3 National Drug and Alcohol Research Centre , University of New South Wales , Sydney , New South Wales , Australia.
• 4 School of Population and Global Health , University of Melbourne , Melbourne , Victoria , Australia.
• 5 National Drug Research Institute , Curtin University , Melbourne , Victoria , Australia.

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Summer Heat: A Cross-Sectional Analysis of Seasonal Differences in Sexual Behaviour & Sexually Transmissible Diseases in Melbourne, Australia

To date, no study has correlated seasonal differences in sexual behaviour with the seasonal differences in sexually transmitted infections (STIs); and no seasonal study of STIs has been conducted in the southern hemisphere. Our study aimed to describe seasonal differences in sexual behaviour and correlate this with seasonal differences in STI diagnoses in Melbourne, Australia.

This was a cross-sectional study of individuals attending the Melbourne Sexual Health Centre over a 9-year period from 2006 to 2014. We conducted separate analyses for men who have sex with men (MSM) and men who have sex with women (MSW), and women. Seasonal patterns of sexual behaviour and STI positivity were examined within each group.

All groups reported a higher number of partners over the preceding three months for consultations in summer compared with winter (MSM mean 5.48 vs 5.03; MSW mean 2.46 vs 2.31; women mean 1.83 vs 1.72). Urethral gonorrhoea diagnoses among MSM were higher in summer compared with winter (OR 1.23, 95% CI 1.04 to 1.46). Similarly, non-gonococcal urethritis (NGU) diagnoses among MSW were the highest in summer (OR 1.11, 95% CI 1.03 to 1.20), but there was no seasonal difference in NGU diagnoses when we adjusted for partner numbers. In women, pelvic inflammatory disease (PID) diagnoses peaked in autumn, when rates were higher than in winter (OR 1.30, 95% CI 1.09 to 1.55).

Our results describe a peak in sexual partner number and STI diagnoses during consultations in summer in men and a rise in PID in autumn in women.

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By: Cornelisse VJ1, Chow EP1, Chen MY1, Bradshaw CS1, Fairley CK1.

• 1Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.

 

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Substantial Increases in Chlamydia & Gonorrhea Positivity Unexplained by Changes in Individual-Level Sexual Behaviors among Men Who Have Sex with Men in an Australian Sexual Health Service from 2007 to 2013

To determine the risk-adjusted temporal trend of gonorrhea and chlamydia positivity and associated risk behaviors among men who have sex with men (MSM) attending a sexual health clinic in Melbourne in Australia.

Gonorrhea and chlamydia positivity by anatomical site adjusted for year of test, age, number of sexual partners, and condom use among MSM attending Melbourne Sexual Health Centre from 2007 to 2013 were calculated using generalized estimating equation regression models.

A total of 12,873 MSM were included with a median age of 30.0 years. The proportion with pharyngeal, urethral, and anal gonorrhea was 1.7%, 2.3%, and 2.9%, respectively. The adjusted odds of gonorrhea positivity increased by 9%, 11%, and 12% per year, respectively. The proportion of MSM who were infected with anal chlamydia was 5.6%, with an average increase of 6% per year; however, no significant change was observed in urethral chlamydia positivity . Increases in gonorrhea and chlamydia positivity were primarily restricted to MSM who reported more than 10 partners in 12 months. The number of partners in the last 12 months fell from 16.6 to 10.5, whereas consistent condom use with casual partners decreased from 64.6% to 58.9% over the study period.

Gonorrhea and chlamydia have increased among MSM despite the decrease in the number of sexual partners and are occurring primarily in MSM with high numbers of partners and persist after adjusting for known risk factors, suggesting that unmeasured factors (e.g., more assortative mixing patterns) may explain the observed changes.

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By: Chow EP1, Tomnay J, Fehler G, Whiley D, Read TR, Denham I, Bradshaw CS, Chen MY, Fairley CK.

• 1From the *Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia; †Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia, ‡Centre for Excellence in Rural Sexual Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia; and §Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia.  

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The Impact of Sex Work on Women’s Personal Romantic Relationships and the Mental Separation of Their Work and Personal Lives: A Mixed-Methods Study

Very limited research has been undertaken on sex workers’ personal romantic relationships and the impact the nature of their work has on their relationships. This exploratory study aimed to explore the impact sex work has on women’s personal romantic relationships and the use of mental separation as a coping mechanism to balance the two aspects of their lives.

Fifty-five women working in the indoor sex industry in Melbourne, Australia, were recruited to complete a self-report questionnaire about various aspects of their work, including the impact of sex work on their personal relationships. Questionnaires were completed anonymously and included both closed and open-ended questions. A further six women were interviewed to ‘member check’ the accuracy of the questionnaire findings.

Most women (78%) reported that, overall, sex work affected their personal romantic relationships in predominantly negative ways, mainly relating to issues stemming from lying, trust, guilt and jealousy. A small number of women reported positive impacts from sex work including improved sexual self-esteem and confidence. Just under half of women were in a relationship at the time of the study and, of these, 51% reported their partner was aware of the nature of their work. Seventy-seven percent of single women chose to remain single due to the nature of their work. Many women used mental separation as a coping mechanism to manage the tensions between sex work and their personal relationships. Member checking validated the accuracy of the questionnaire data.

This exploratory study identified a number of ways in which sex work impacts negatively on women’s personal romantic relationships. The findings of this study support the need for further studies to be undertaken to determine if the findings are reflected in a larger, more representative sample of Australian sex workers and should be considered in the context of any future intervention and support programs aimed at addressing the tensions sex workers experience between their work and personal relationships. Greater public awareness and education programs aimed at addressing the negative stigma associated with the sex industry may go some way towards easing the issues faced by women in their personal relationships.

Below:  Member checking—Single Women

Below:  Member checking—Women in Relationships

Full article at: http://goo.gl/ihPNG9

By:

Clare Bellhouse, Christopher K. Fairley, Jade E. Bilardi

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia

Clare Bellhouse, Susan Crebbin

School of Health Science and Psychology, Federation University, Ballarat, Victoria, Australia

Clare Bellhouse, Christopher K. Fairley, Jade E. Bilardi

Central Clinical School, Monash University, Melbourne, Victoria, Australia

Susan Crebbin

Nexus Primary Health, Melbourne, Victoria, Australia

   

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