Levinia Crooks

Mobilisation, politics, investment and constant adaptation: lessons from the Australian health-promotion response to HIV

ISSUE ADDRESSED The Australian response to HIV oversaw one of the most rapid and sustained changes in community behaviour in Australias health-promotion history. The combined action of communities of gay men, sex workers, people who inject drugs, people living with HIV and clinicians working in partnership with government, public health and research has been recognised for many years as highly successful in minimising the HIV epidemic. METHODS This article will show how the Australian HIV partnership response moved from a crisis response to a constant and continuously adapting response, with challenges in sustaining the partnership. Drawing on key themes, lessons for broader health promotion are identified. RESULTS The Australian HIV response has shown that a partnership that is engaged, politically active, adaptive and resourced to work across multiple social, structural, behavioural and health-service levels can reduce the transmission and impact of HIV. CONCLUSIONS The experience of the response to HIV, including its successes and failures, has lessons applicable across health promotion. This includes the need to harness community mobilisation and action; sustain participation, investment and leadership across the partnership; commit to social, political and structural approaches; and build and use evidence from multiple sources to continuously adapt and evolve. So what? The Australian HIV response was one of the first health issues to have the Ottawa Charter embedded from the beginning, and has many lessons to offer broader health promotion and common challenges. As a profession and a movement, health promotion needs to engage with the interactions and synergies across the promotion of health, learn from our evidence, and resist the siloing of our responses.

Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.

Demand for HIV clinical services is increasing in Australia but supply is decreasing

BACKGROUND HIV clinical service planning requires accurate estimates of the number of people living with HIV (PLHIV) and the capacity of existing clinical services, each by geographical location. The aim of this study was to quantify current HIV clinical service capacity in Australia. METHODS This study was a retrospective analysis of records of HIV clinical service capacity in Australia. Participants were general practitioners who completed an annual survey in 2007-2009. Information on the number of hospital departments, sexual health services, antiretroviral-prescribing general practitioners (ARV-GPs) and shared-care services providing expertise in HIV management from 2007 to 2010 were also available. RESULTS From 2007 to 2009, the proportion of ARV-GP survey respondents treating 2-9 patients with HIV per week increased from 36.5% to 49.1%, with a corresponding decrease in the average proportion who saw less than one patient with HIV per week. The estimated number of PLHIV has increased by 12.5% in metropolitan areas, and 16.5% in rural and remote areas over the period 2007-2010; however, the total number of services with at least one HIV ARV-GP has decreased over the same period. CONCLUSIONS Current methods to estimate clinical service capacity reveal decreasing supply in the workforce in Australia despite increasing numbers of PLHIV. Further training of HIV clinicians and their placement in regions of greatest supply-demand deficits are required. Further studies are required to precisely quantify and locate the capacity of the HIV clinical workforce with expertise in HIV case-management to enable efficient service planning.

Sexual transmission of HIV and the law: an Australian medical consensus statement

Introduction: Criminal cases involving human immunodeficiency virus transmission or exposure require that courts correctly comprehend the rapidly evolving science of HIV transmission and the impact of an HIV diagnosis. This consensus statement, written by leading HIV clinicians and scientists, provides current scientific evidence to facilitate just outcomes in Australian criminal cases involving HIV.

Challenges of providing HIV care in general practice.

As the management of HIV changes and demand for HIV health services in primary care settings increases, new approaches to engaging the general practice workforce with HIV medicine are required. This paper reports on qualitative research conducted with 47 clinicians who provide HIV care in general practice settings around Australia, including accredited HIV s100 prescribers as well as other GPs and general practice nurses. Balanced numbers of men and women took part; less than one-quarter were based outside of urban metropolitan settings. The most significant workforce challenges that participants said they faced in providing HIV care in general practice were keeping up with knowledge, navigating low caseload and regional issues, balancing quality care with cost factors, and addressing the persistent social stigma associated with HIV. Strategic responses developed by participants to address these challenges included thinking more creatively about business and caseload planning, pursuing opportunities to share care with specialist clinicians, and challenging prejudiced attitudes amongst patients and colleagues. Understanding and supporting the needs of the general practice workforce in both high and low HIV caseload settings will be essential in ensuring Australia has the capacity to respond to emerging priorities in HIV prevention and care.

Obstacles to prescribers' initiation early antiretroviral therapy : a barrier to achieving 90-90-90 goals

www.thelancet.com/hiv Vol 3 December 2016 e559 for under-registration in vital registries, garbage codes (deaths assigned to causes that cannot be underlying causes of death), and misclassifi cation of HIV deaths. We do agree with Kelly and Wilson that to improve HIV estimates further, especially for developed countries, other types of data are needed, which include case reports on HIV/AIDS. However, the quality and complete ness of such data are diffi cult to assess, and other signifi cant assumptions need to be made such as the duration from infection to diagnosis. We think that close collaboration among GBD, Optima, and the European CDC will improve estimates derived from diff erent approaches.

HIV service capacity: identifying current and future areas of clinical shortage

UNLABELLED Background The capacity of HIV services to meet the clinical needs of people living with HIV (PLHIV) has not been evaluated. Similarly, whether HIV services are positioned to respond to increases in patient demand outside metropolitan centres over the next decade is unknown. METHODS A novel statistical methodology was used to estimate HIV clinical service capacity in Australia. A survey of HIV services was conducted. Geostatistical analysis was used to identify significant regions of clinical service undersupply relative to the estimated number of PLHIV in 2010 and 2020. RESULTS In 2010, an estimated 2074 PLHIV (9.7% of all PLHIV) resided in regions more than 15km from a clinical service provider; 485 PLHIV (2.3% of all PLHIV) live >50km away. By 2020, this is estimated to rise to 3419 and 807 (11.5% and 2.7% of estimated PLHIV) for 15km and 50km, respectively. To meet this demand, the establishment of new HIV services are required in the areas of greatest HIV clinical undersupply. In 2010, these are northern Sydney and western New South Wales, the Queensland mid-north coast and the outer suburbs of Melbourne. At the current estimated rate of increase in PLHIV, areas that will become critically undersupplied by 2020 include south-west Sydney, the outer suburbs of Brisbane and Western Australia. CONCLUSIONS This study provides a quantitative assessment using modern statistical techniques to identify HIV clinical service gaps that is applicable in developed and nondeveloped settings. Training of new HIV clinicians should be directed towards undersupplied areas.