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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Treatment of Latent Tuberculosis in Migrants to Victoria, Australia

The proportion of eligible persons identified who are tested for latent tuberculosis (TB), offered treatment, and complete treatment are performance indicators in tuberculosis control. We report a retrospective database review of the Migrant Screening Clinic, Department of Respiratory and Sleep Disorders Medicine at Western Health Footscray Hospital during the years 1996-2006. 

Of 7,225 migrants aged less than 35 years, tuberculin skin testing (TST) was performed for 3,589 (49.7%), including 2,641 (65.6%) of 4,024 migrants under 35 years with an abnormal chest radiograph, and 2,297 (59.0%) of 3,893 migrants born in a high-burden country. Of 3,589 persons with both chest radiograph and TST results, 1,487 (41.4%) were referred for follow-up, including 81.3% of those with TST ≥10 mm. Outcome data were available for 1,047 persons considered for treatment of latent TB, of whom 12.5% did not attend an initial appointment, 21.6% attended and were not offered treatment, 65.9% attended and were offeredtreatment, and 41.7% completed treatment for latent TB. 

The Victorian program for treatment of latent TB in migrants has testing, treatment offer and treatment completions rates similar to other published studies. The impact on TB control is limited by the small proportion of migrants referred to this program.

Table 2: Outcomes of referral for treatment of latent tuberculosis

Outcome	n	%
Did not attend initial appointment	131	12.5
Attended initial appointment but treatment for latent TB not offered	226	21.6
Treatment of latent TB offered but patient refused	144	13.8
Started but failed to complete treatment for latent TB	109	10.4
Completed 6 months isoniazid	224	21.4
Completed 9 months isoniazid	205	19.6
Completed 2 months rifampicin + pyrazinamide or other treatment of latent TB	8	0.8
Total	1,047	100.0

Full article at:   http://goo.gl/x01QfT

By:  Flynn MG1, Brown LK2.

• 1Physician, Department of Respiratory and Sleep Disorders Medicine, Western Health, Footscray, Victoria.
• 2Manager, Tuberculosis Control Program, Department of Health, Melbourne, Victoria. 

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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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Was an Epidemic of Gonorrhoea among Heterosexuals Attending an Adelaide Sexual Health Services Associated with Variations in Sex Work Policing Policy?

BACKGROUND:

A review of historical trends in gonococcal diagnoses made at the Adelaide Sexual Health Clinic (ASHC), South Australia, identified a substantial rise in diagnoses among heterosexuals between 2006 and 2010. Sex work is illegal in South Australia, regulated in Victoria and legal in New South Wales. This and other factors that could have influenced the epidemic were explored in this analysis.

METHODS:

Retrospective analyses of gonorrhoea diagnoses made by sexual health services between 1990 and 2012 in three Australian state capitals, Melbourne (Victoria) and Sydney (New South Wales) were undertaken.

RESULTS:

At the ASHC the proportion of gonorrhoea diagnoses was higher between 2006 and 2010 among heterosexual men (5.34% vs 0.84%, p<0.001), non-sex worker women (0.64% vs 0.28%, p<0.001) and female sex workers (FSWs) (1.75% vs 0.24%, p<0.001) compared with other years. This relationship was not seen at the Melbourne Sexual Health Clinic and corresponding data from the Sydney Sexual Health Centre showed that FSWs were less likely to have gonorrhoea between 2006 and 2010 than the other groups (p=0.746, p=0.522, p=0.024, respectively). At ASHC FSWs were significantly more likely to be diagnosed between 2006 and 2010 (OR 2.8, 95% CI 1.48 to 5.27, p=0.002). Charges against sex workers peaked in 2007/2008.

CONCLUSIONS:

A substantial, self-limiting rise in diagnoses of heterosexual gonorrhoea was seen in Adelaide FSWs between 2006 and 2010. Removing barriers to condom use is vital to the prevention of HIV and STI transmission.

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By:  Li B1, Bi P2, Waddell R3, Chow EP4, Donovan B5, McNulty A6, Fehler G7, Loff B8, Shahkhan H8, Fairley CK4.

• 1School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia Adelaide Sexual Health Clinic (ASHC, known as Clinic 275), Infectious Disease Unit, Royal Adelaide Hospital, Adelaide, South Australia Australia.
• 2School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia.
• 3Communicable Disease Control Branch, SA Health, Adelaide, South Australia, Australia Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia Microbiology and infectious Diseases, Flinders Medical Centre, Adelaide, South Australia, Australia.
• 4Central Clinical School, Monash University, Melbourne, Victoria, Australia Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.
• 5The Kirby Institute, UNSW Australia, Sydney, New South Wales, Australia Sydney Sexual Health Centre, Sydney Hospital, New South Wales, Australia.
• 6Sydney Sexual Health Centre, Sydney Hospital, New South Wales, Australia.
• 7Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.
• 8School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. 

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High-Frequency Drug Purity and Price Series as Tools For Explaining Drug Trends and Harms in Victoria, Australia

Methamphetamine-related harms in Victoria have increased recently in the context of stable or declining use prevalence. We determine how changes in price and purity of methamphetamine compared to other drugs such as heroin may, in part, explain these divergent patterns.

Detailed methamphetamine and heroin purchase price data from 2152 participant interviews from the Melbourne Injecting Drug User cohort study were used to generate drug price series for the period January 2009-June 2013. Data on drug purity from 8818 seizures made within Victoria were used to generate drug purity series during the same period. Purity-adjusted price data for methamphetamine and heroin were obtained for the period 2009-13 by combining the two data sets.

• While the average purity of heroin seizures remained consistent and low, the average purity of powder and of crystal methamphetamine seizures increased from 12% to 37% and 21% to 64%, respectively. 
• Crystal methamphetamine purity was bimodal, with observations generally less than 20% or greater than 70%. 
• The average unadjusted price per gram for heroin decreased from $374 to $294, powder methamphetamine did not change significantly from $252, and crystal methamphetamine increased substantially from $464 in 2009 to $795 in 2011. 
• This increase was offset by an even greater increase in purity, meaning the average purity-adjusted price per gram declined. 
• Furthermore, pure prices of both methamphetamine forms were similar, whereas their unadjusted prices were not. The pure price of heroin fluctuated with no ongoing trends.

Decreases in methamphetamine purity-adjusted price along with the bimodality of crystal methamphetamine purity may account for some of the recent increase in methamphetamine-related harm. For a given amount spent, methamphetamine purchase power has increased and the presence of extreme purity variations may challenge individuals' control of consumption.

Below:  Average price [Melbourne Injecting Drug User Cohort Study (MIX)] and purity-adjusted price [MIX prices adjusted by average Victoria Police Forensic Services Department (VPFSD) seizure purities] per gram of heroin and methamphetamine, January 2009 to July 2013

Below:  Average purity of Victoria Police Forensic Services Department (VPFSD) seizures, January 2009 to July 2013

Below:  Price series and 95% confidence intervals for 1 pure gram of heroin and methamphetamine based on regressions controlling for quantity discounts, Melbourne Injecting Drug User Cohort Study (MIX) prices adjusted by Victoria Police Forensic Services Department (VPFSD) seizure purities, January 2009 to July 2013. Crystal methamphetamine series has been slightly right-shifted for clarity

Below:  Purity of Victoria Police Forensic Services Department (VPFSD) seizures, 2008–12

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By: Scott N1, Caulkins JP, Ritter A, Quinn C, Dietze P.

• 1Burnet Institute, Centre for Population Health, Melbourne, VIC, Australia.

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