STI & HIV: A Patient Tests Positive. What now?

SAMMY: Good evening everybody. It is now 7:30 so in the interest of staying on track and finishing on time we will make a start.

Welcome to night’s Patient tests positive: What now? webinar.

My name is Sammy. I am your host for this evening. Just to give a bit of an idea about tonight’s webinar; it is the first webinar, which will be a part of a series of two webinars. This webinar will explore via two different case studies, the next steps and support services available following a positive STI and HIV result.

We have been joined tonight by our facilitator, Dr Andrew Knight and presenter, Dr Nathan Ryder. Before we get started, I would like to make the acknowledgement of countries. We recognise the traditional custodians of the land and sea on which we work and live.

Just a bit of background. Dr Andrew Knight is a GP staff specialist at Fairfield Hospital GP Unit. He is the chair of the Nepean Blue Mountains Primary Health Network. He is the clinical advisor to the Improvement Foundation, a Conjoint Senior Lecturer at UNSW with academic appointments at Sydney University and Western Sydney University.

Dr Nathan Ryder has been a sexual health physician with 15 years of experience in HIV management in urban and rural Australia. He is the clinical director of sexual health at the Hunter New England local health district. He is HIV’s support program coordinator at the Hunter New England LHD and conjoint senior lecturer at The Kirby Institute at UNSW and the University of Newcastle.

Those are our introductions and housekeeping for this evening. I will handover to Dr Andrew Knight now to us through the learning outcomes for this evening and then we will get started with the rest of the presentation.

ANDREW: Hi everybody. Let me add my welcome. Great to have such a lot of people joining us. We are up to 133 participants online so that is great, really effective use of technology. These are the things we hope that you will emerge after this hour able to do. What are our responsibilities when we get a positive STI test result? Yes, it is to treat, but there are things as well and to treatment with what, so we will be exploring that and then we will be focusing in on HIV, which is one of those diagnoses I think we all remember when we make a diagnosis of HIV. It is such a significant thing and we will be focusing in on the excellent support that the New South Wales government now provides us and some of the content that we need to provide. We will look forward to hearing your assessments at the end of the session to see whether we have achieved that.

Here is that basic question on the next slide, which is why are we testing for STIs? Is that our responsibility as GPs or is that something that people should be doing in sexual health clinics? Do people discuss these things with us? The reality is in general practice we have the reach. We are in every community. People see us as the place they turn to for care and we are well placed to offer routine STI screening. Something I have learned as I have been thinking about these issues is that the Red Book that RACGP Resource actually recommends Chlamydia screening for everyone between the age of 15 and 29 every year. We know that the rate of Chlamydia and gonorrhoea are high in young people and they do come to us and we can focus on them. We also know that the rates of these diseases are actually rising and if we are going to stop the spread of this in the community it is really up to the General Practice. We know that most people do attend general practice frequently and are often unaware of the risk because a lot of these diseases can be asymptomatic so it is our job to be looking at this and watching for it. As I mentioned it is a good idea to have a look at the Red Book and just refresh your memory about some of the evidence-based recommendations on testing and in particular in this case testing for STIs.

What about HIV? Why should we test for HIV as GPs? Surely of all the diseases that is a specialised disease. Is not it? The reality is that there are heck of a lot of people in Australia who are HIV positive and they do not know and it is also true that most new HIV diagnoses are made in general practice and not specialised HIV general practice. They are actually made in general practice the sort of thing that I do and perhaps you do. We know that increased testing is really valuable for a number of reasons. Of course, it is really valuable for the patient in front of us if we work out that they got HIV because they get care early rather than late. Their health does not deteriorate and they do not miss out on work and all the other things that can happen in fact if HIV goes for a long time undiagnosed. We know actually most late diagnoses are made in general practice as well, so people are coming to us not knowing that they have got it and it is our job to find it, but we also know that it is important for the population because of course people when they are infectious spread the disease and if we are going to stop the spread of HIV and actually make an incredibly rare disease, which we are really pushing to achieve and it is looking like we will be able to do that with the newer treatments, we need to diagnose it early. We need to put it up in our index of suspicion when we see people in risk groups or with unusual symptoms.

Just to fill you in on some of the facts and figures on HIV I am going to handover to Nathan. He is going to run us through the latest of what we know about STIs and HIV. Thanks Nathan.

NATHAN: Just going to start with just giving a bit of background about what governs, what we do around STIs and HIV in New South Wales and there are the two strategies, the New South Wales STI strategy and the New South Wales HIV strategy, which is also known as Ending HIV, for reasons that we will get to in the future. So in the New South Wales STI strategy we are really aiming to reduce the amount of gonorrhoea and syphilis that is located in the community and to reduce the burden of disease that Chlamydia infection produces. The strategy is really to try and achieve this by identifying the priority populations, the populations that are at highest risk and also the priority settings where we want to focus our efforts and general practice and primary care is a really important priority setting both for STIs and for HIV. Interestingly, the goal of the HIV strategy is actually not just to reduce HIV anymore. It is now to virtually eliminate HIV transmission in New South Wales. That is quite a big change from many people’s understanding of HIV and this really came about from what Andrew touched on earlier that if someone with HIV is diagnosed early now and starts treatment, not only will they live a normal lifespan they will also be basically uninfectious to others and so while getting people on treatment we can stop transmission and hopefully eliminate transmission by 2020. So general practice plays a major role in that for the reasons that a higher proportion of people are diagnosed in GPs both for STIs and for HIV, but also importantly GPs are most likely to diagnose the unlikely patients. So gay men though, the lightest risk group in New South Wales, we know gay men get tested frequently and are getting diagnosed earlier and earlier but unfortunately for instance heterosexual people are more likely to be diagnosed late and more likely to be diagnosed in general practice and a really good example where GPs have a vital role in diagnosing those unlikely patients.

Ok we will go on to the next one. The basic message on this slide, we are not going to go, as you can see there are graphs in there, and in case it is not there you can see all the numbers there, that is really just to get the basic messages and that is the rate of STIs are increasing so for all the STIs that we measure they are becoming more common. In regard to HIV, we know that having a diagnosis of a sexually transmitted infection is strongly correlated with having HIV diagnosis. One of the real big triggers that we keep our HIV testing in general practice will be if the patient was diagnosed with a sexually transmitted infection. So the graph up here is the first one that has got the numbers there, that is around HIV notifications in New South Wales and this data has recently just been released. So you can see there, that in the last you have got full data. There were 317 cases of HIV in New South Wales and that does seem to have been declining since 2012 when we really pushing the more testing and more treatment and the big news really for the recent data was that there has been a large decrease already in gay and bisexual men and we think this is really the increased testing and treatment strategy is starting to payoff.

If we go on to the next slide, we can see that general practice really is contributing a large amount to this diagnosis rate, so as we go down the bottom there, so that is GPs that do not prescribe HIV and then if you add in the small colour third from the bottom you can see the GP is really contributing to almost 50% of HIV diagnosis in total and as I said before much more likely to diagnose people who are unlikely patients who were not expecting it and also much more likely to diagnose people with late disease who would otherwise potentially become unwell and be admitted to the hospital and suffer potentially irreversible consequences if they are not diagnosed by their GP. The main thing in New South Wales is in terms of the rate is really that it is still more common in males and it is still more common in men who have sex with men, but heterosexual people make up 15% of new diagnosis, which is a lot higher than many people think. Unfortunately, we still do have people diagnosed with advanced disease, which carries negative Impact for both them and their partners and we are really trying to identify the missed opportunities for testing, especially in primary care, is one of our major strategies we are trying to reduce the rate of people being diagnosed with advanced HIV.

ANDREW: Okay so what we are going to do now is actually get practical with that and we are going to focus on a case which examines a positive STI result and then following on that we are going to focus on if that patient's result actually was positive for HIV. So here is the case of Paul and he turns up asking for an STI check and that is what his sexual history reveals. As you carry out your sexual history you identify that he only has sex with men and that he had a check up six months ago. He has also got at-risk behaviours and that he has wisely been immunised for hep A and hep B. Alright now, we are going to ask you some questions I think.

SAMMY: We will launch up for you now and we will give you about 10 seconds to answer that before we move on so I will just launch that for you now.

ANDREW: Here you go, you can see it. Here it is in front of you. He has given his history. What tests would you choose? So I just you to tick the box according to what you think. 67% of people voted, 70%, 78% voted, 79% come on guys. Lets us get to 100% of votes. You are not going to lose anything. We will not know who you are and what you have voted, so you might as well let it go. 80% voted. 82. We will probably give you just a couple of more seconds if you want to vote. I do not know, how does it work Sammy? Do we go up to any time?

SAMMY: Yes, it has kind of slowed down so I will close that off now and we can move on to the next slide. Can you see the live poll?

ANDREW: I can actually see the results here so that is great.

SAMMY: Alright I will close off that poll now.

ANDREW: Okay, so I do not know if everyone else can see the results under the poll's section in your dashboard there.

SAMMY: No, I do not think so.

ANDREW: I can see the vast majority of people, well I can see it. The vast majority of people voted for bloods, urine, rectal swabs and throat swabs then 20% did blood and urine so some people added swabs.

Okay, so that is poll. What we want to present to you is another way that you could have answered that question, which I think is the next slide, Sammy. There we are, this is an incredibly useful tool that is continually updated and it shows that you can answer that question with complete confidence and quickly with the patient in front of you. In this case lets us have a look Sammy, at the next slide and there it is. That is the table from the resource, which if you Google STI HIV testing tool, it will easily come up on the internet and you can see there this is false category, men who have sex with men. These are the diseases that he is at risk of and with some advice on what increases his risk, so he is at risk of Chlamydia, gonorrhoea, syphilis and HIV so he should be tested four times a year for those. Seems if he has any unprotected anal sex in multiple partners, participate in group sex using other drugs or HIV-positive then hep A and hep B confirms that he has already done that very wisely and hepatitis C if he is HIV positive or history of injecting drug use, he should be tested for hepatitis C. Does that make sense to you Nathan?

NATHAN: Yeah, that is exactly right. So i you look at that and since 80% of people it shows correctly and incidentally the 20% shows the other answer so that is the answer that is correct of the general population. So for the general population we recommend HIV and syphilis testing and urine test for Chlamydia I mean requesting is great, so we add in the swabs from the throat and the rectum for all men that have sex with men regardless of what sort of sexual behaviour they report because we do find infection in the throat and the anus in men that do not report sex in that location and the reason why we are recommending the HIV in syphilis every time is that obviously gay men are at increased risk of HIV and syphilis.

ANDREW: I believe there is a rise in syphilis Nathan too, is that right?

NATHAN: Yeah so syphilis has been rising for quite some time and it does not show any signs of abating and that is I mean really we think the only way we can control that is through frequent testing and rapid treatment. Obviously we promote condom use and that sort of thing but it does not seem to be having the impact that we want and that is why that is sort of the second part of the test he will have around how frequently to test is really important. So when you are giving the result in and when you are doing the test initially it is a good practice to sort of think okay when is the next time this person should be tested and then advise them to make that appointment when they can or like in my clinic for instance we use SMS reminders to remind them when they are due to come back.

ANDREW: And the great thing is for us who are not doing it all the time you know sometime it is hard to remember exactly what needs to be done in every case. This gives us some ideas. Well that does not necessarily say here you need to do swabs. Does the tool actually go on and say it is time?

NATHAN: Yeah that is how always, it does tell you exactly what to do obviously.

ANDREW: Alright so hopefully that is a useful addition to your in terms in approaching this issue, but I think we have got another question to ask Sammy.

SAMMY: Yes, I will launch the second one now. If you want to give the first part of it, the answers will popup so the question is Paul's test results identify he is positive for rectal Chlamydia. The recommended treatment for rectal Chlamydia is…

NATHAN: Okay, so we have got up to high 80s in terms of voting.

SAMMY: So I will give you another five seconds and then I will close that one also. If you have not selected your answer you have got about two seconds left to do so. Alright I have closed that one off.

ANDREW: So the majority of us say, 66% of us say azithromycin, 30% is the doxycycline and then there are some other options down there too. 19:58 for Chlamydia treatment. Nathan do you want to walk us through this next tool, which can help us to know how to treat a positive test?

NATHAN: Yeah really the best way to go if you are wondering how to treat an STI is the Australian STI Management Guidelines for primary care so if you Google Australian STI Management Guidelines you can see it right there. I do it myself regularly and that is really easy to use. You just click on Chlamydia, you click on management and see for rectal it is actually doxycycline twice a day for seven days. Azithromycin used to be the treatment for all Chlamydia but quite recently for rectal Chlamydia it has been changed to doxycycline because research has shown the treatment by the rates are exceptionally high with that those of azithromycin. So yes do not feel too bad if clicked the azithromycin that was changed reasonably recently. So interesting is a few people picked ceftriaxone. So ceftriaxone is used for STIs, but it is for gonorrhoea, so gonorrhoea ceftriaxone.

ANDREW: If you really said azithromycin is that still indicated for urethritis?

NATHAN: Yeah, we still use azithromycin for the male urethral infection or female cervical infection. It is just the rectal infection that is recommended to have that longer course of treatment. We do not think the azithromycin penetrates the rectal tissue well enough and gives long enough half life to cure it there.

ANDREW: So you need to check the guidelines because we cannot keep up with everything that happens and if you constantly check the guidelines you are more likely to get the treatment right.

NATHAN: Yeah exactly, I mean I obviously use it all the time for things outside my area as well and even I mean I still look at these guideline myself sometimes to remember the details, which are some of the things we probably cannot during the course of tonight, yeah but so initially it would also remind you what else to do because you obviously focus on the antibiotic I mean that it what is going to cure the patient, but if you read the guidelines it also reminds you that you need to tell the person not to have sex for the next seven days because we do not want them becoming reinfected and the other thing is that they will need to let their partners know. Managing STI is about more than antibiotic and about managing that individual and the multiple partners.

ANDREW: Okay and I think we are going to explore that a bit more.

SAMMY: I will launch that Paul now.

ANDREW: So there are the options. How far back…we find that contact tracing is something that is of a real interest to GPs. It is a little bit foreign to us. We are not necessarily setup to do it well. So what do you think? Does anyone know how far back who should Paul be contact tracing? There are your options. Lets complete the poll.

NATHAN: This is one of the guidelines actually I look up myself sometimes because I need to do it for patient I see often. I cannot always remember exactly how long it is.

SAMMY: Alrighty, that one is going pretty well. We have got about 84% of people who have submitted their responses. I will give you another five seconds or so and I will close that one off. Alrighty I will close that one off now.

ANDREW: Thanks Sammy. There is a pretty confident majority saying six months there. Nathan do you want to speak to the issue of followup contact tracing?

NATHAN: Yeah so six months is the correct answer for Chlamydia in any site. Basically, it is really recommended with any STI that once you treat the person you do schedule a followup session. And the purpose of that followup session is to check that contact tracing has been done and we will get on to that further in the coming slide. Ask about whether they have abstained for that seven days and if not, if they have had sex particularly with an untreated partner so think about treating them again, check they actually took it which is even more important now that we are giving non-single dose treatment with the doxycycline and then book them in for a test of cure. So for rectal infections and gonorrhoea we recommend test of cure and for the rest of the people which is the bulk of people you see so, mild urethritis and mild Chlamydia would be recommended three months retest as opposed to a test of cure.

ANDREW: We are just going to on the slide a little bit with the next slide. Here we go

NATHAN: Yeah so I think we have got a couple of slides here around contact tracing because it is really a very Important part of the management and it is probably the part that we all struggle with the most. If we look at the guideline we can manage antibiotics, but contact tracing can sometimes be plain tricky and I do not think it is as tricky as it often seems. So there is a medical legal responsibility for doctors under the public health back to initiate contact tracings for STI and just because it is so critical so it does two things. It prevents reinfection of your patient point of view, but it also has a population effect in reducing ongoing transmission so if you said partners of Chlamydia should be traced back to six months and we offer treatment to all their contacts not just testing. There are two ways of doing the contacting tracing. The patient initiated contact tracing is where the patient initiates it, the patient does it, so the patient rings their partner, the patient SMSes their partner whereas provider-initiated contact tracing is where a clinician of some sort would do that on the patient’s behalf and that is something that we probably have not used as much in Australia as they have in other places, but it potentially has a really important role and we have got a lot of new information and new resources there to try and use that more effectively.

If we go on the next slide. First we will discuss the patient-initiated contact tracing because this is going to be the overwhelming fold of contact tracing you do. A majority of people will choose to notify their own partners and the majority of people actually do that either physically or by telephone. Much more numbers do still via SMS or anonymous just send some, the majority of people do actually want to say that in person and the majority of people do let their partners know, but it makes a big difference if they get a bit of assistance and the things that have really been shown to help is if you provide them some written information that they can then read and potentially give to their partners. You notice particularly people with ex-partners or people that might be a bit tricky if you actually discuss then they can actually do it and make them practically think how am I going to do this? That makes the difference so you can walk out thinking he is going to notify them and then suddenly they will think that is going to may be lead to that and spending a little bit of time talking it through can make it seem a lot more achievable to them. Going through the different options can help though a vast majority of people will do it in person or by phone. That does not always apply and especially it does not apply for ex-partners and casual partners, much more likely to want to use some less personal or even anonymous means and the final thing that the research has shown is that if you schedule a followup visit where the person knows they are probably going to be asked about this they are much likely to follow-through, they are much more likely to remember to do it and then end up doing it rather than having good intentions but not acting as we all sometimes do.

We are going to the next slide? Yeah, so there are a couple of good websites there for that sort of situation where the person does not want to do it themselves so Let Them Know which is the general one and then Drama Down Under, which is targeted at other gay men and there is actually another one called Better To Know which is targeted at average 28:50 people. Obviously, you can either do that with the person or let them know to do it at home themselves. I think on the next slide you have got a picture from what it looks when you are about to do it, Let Them Know which is probably the most commonly used one.

ANDREW: Again this one shows the options you can sort it out. You can do it by SMS or telling them or sending them an e-mail or writing a letter and the site helps with the SMS and the e-mail one to do it anonymously quite easily.

NATHAN: Yeah, so I think the next slide has got a picture of what you need to put into the system so it is pretty amenable what you put in there. Dropdown box and the notification you choose the infection if you want to, you do not have to and they do log the IP address and make that clear of things, so they do get some misuse of it, but a very small proportion.

ANDREW: We actually tested this out at a workshop I was at the other night. It was very effective and worked very quickly and gives out an anonymous notification.

NATHAN: Yeah, I mean it is really popular as most people they, people mostly want to do it face-to-face but the casual partners it is really good and have a really vital role. It is important to think about it and promote it to patients. So the reason you supported it, I think you touched on earlier if you could turn to make that provider referral more doable. Obviously as a GP if the patient gives you permission you can notify their partners. There is nothing to stop you. You cannot breech confidentiality, but if a person gives you permission you can. But that is sometimes difficult in practice and so there is Sexual Health InfoLink, that is the New South Wales Health, sort of portal I guess where you can access assistance. You can either ring them or you can fill in a web-based form and you can hand over to them that contact tracing. They can even help you out if the person only has their Facebook details. If you provide enough information they will find that person and notify them.

ANDREW: Okay Nathan now a couple of questions just before you go on to the next slide that I thought we must just run through because there has been a few people asking questions and we have not dealt with them yet.

One question was, if I understood you correctly, did you say that throat swab and anal swab were advisable for all men who have sex with men?

NATHAN: Yeah, that is right, so even men who do not report sex at those locations we do find infections there. Of course we do not know whether that is because they were not otherwise reporting exactly what they do or probably more likely that it is actually transmitted through other means so we think deep kissing can probably transmit gonorrhoea. We think just things as in things around bottoms can transmit it as opposed to penis in bottom sex so just routine testing at those might be recommended. The opposite of that is it is actually not recommended to test females for anal infections unless they only have anal sex or they specifically request an anal test.

ANDREW: Okay and then there was another comment from Geradinum about just reminding us about the option of a self-collected rectal swab. That is acceptable?

NATHAN: Yeah. The testing tool actually would say that is preferred.

ANDREW: Okay.

NATHAN: I do hundreds of anal swabs and I almost never do a clinician-collected. I would only do it if was examining the person for some other reason, but basically you give the person swab. It is a good practice to moisten it or at least have somewhere that they can moisten it themselves. They insert it 2 cm into the rectum, put in the transfer tube and it is still done. Better if it is the patient obviously and the less embarrassing and it will obviously benefit the clinician both time ways and you are not having to go there.

ANDREW: Yep and I think there is a resource around that I have seen that actually helps patients with these. I am not sure if it is available Cherie or Sammy but may be we can make that available to the group after the session.

NATHAN: Yeah I mean all of these sources, if you go to the STIPU site and look at GP resources, they are all there. There is great A4 colour things you can print out. The one you have spoken about is excellent. It has got other basic samples and it is all, not just the anal, it has got the throat swab, the anal swab, the urine samples or vaginal. It has got some like cartoons, pictures. They can just put it up in your toilet.

SAMMY: Absolutely and we will send a follow-up e-mail with that link and the resource as well. We will e-mail that out to all of you tomorrow.

ANDREW: One of our listeners told us that there is a guideline, which is recommending a gram stat of azithromycin and repeat in a week. I assume that is for rectal gonorrhoea. Are you aware of that Nathan or it is now that the doxycycline is the recommended treatment?

NATHAN: That is probably an acceptable option for rectal Chlamydia so remember the issue we have…

ANDREW: Gonorrhoea and not Chlamydia.

NATHAN: Yeah 1 g of azithromycin stat which is the standard Chlamydia treatment, probably does not last long enough in the rectum. If you repeat it at one week it is probably okay, but it probably would not be considered first line at the moment. We still do use that sometimes if the person really does not think they are going to be able to comply with the doxycycline, but a reasonable second line option but it is not the recommended first line option in the Australian guideline.

ANDREW: Okay. There is another question here about Chlamydia and gonorrhoea lying dormant. I am not sure what that question is about, but they are asking does Chlamydia lie dormant in the body for a period of time. Do you know anything about that?

NATHAN: Well I guess it depends on what you mean by dormant, so the majority of women and 50% of men do not have symptoms so we are guessing that way it seems dormant but as far as we know neither gonorrhoea or Chlamydia can lie dormant in the sense that it cannot cause any adverse effects. It is just not noticeable to the patient. Asymptomatic would probably be a better description than dormant.

ANDREW: Yes. Okay. One person is asking about you might know but this is contact tracing. It is same old story. We always worry when we have made three phone calls and mailed a letter and then you feel that the person still has not been told because they have not responded. Do you guys have an approach to that sort of think Nathan? At what point do you give up?

NATHAN: So is this you try and notify a partner and they are just not responding to contact?

ANDREW: Yeah I guess so.

NATHAN: Well I mean..

ANDREW: Or if patient is positive too.

NATHAN: We have that situation all the time so we take a risk based approach. You have got a duty of care to attempt to contact that patient as best as you can. We always make sure we contacted them at least three times by at least two different methods and then we make an assessment of what we need to do so if it is untreated HIV or HIV contact that does not know we will go above and beyond for that whereas for Chlamydia and it is extremely common and not as harmful, we will probably as well align it there. If you are unsure you can just ring up your local clinic and they are more than happy to give advice and take over if necessary. In a case of HIV if you had sex with someone with HIV that was not contacted or a partner we would go out to their home or find them through databases and that sort of thing if required whereas obviously we are not going to do that for Chlamydia. Syphilis we will go a bit more, so you know what I mean, we try and prioritise based on the risk of the individual and the population.

ANDREW: Makes sense. And so our last question. Test of cure testing Chlamydia, in the months later what samples do you need to collect? Do you need to redo the anal and throat swabs?

NATHAN: We usually recommend that you test at the site that 37:17 originally infect that for a test of cure. That would have been a one month one per rectal. If you are doing a retest, a three months later retest, I would just recommend you do the full screen for that, whatever that population group indicates because a retest is partly about reinfection, but a lot about just epidemiological risk but that person is probably in a network that has got Chlamydia circulating there. They are at higher risk so I would just screen them again.

ANDREW: Okay we better press on. So a slightly different scenario now. Paul's test has come back positive. Got a poll about this as well I think Sammy.

SAMMY: We do and I will launch that poll for you now and give you about 15 to 20 seconds for people to submit their responses for this one.

ANDREW: Is that quickly because we are running late Sammy?

SAMMY: Pardon?

ANDREW: Is it 15 seconds because we are running late?

SAMMY: Oh it is a yes or no one so it should be easy.

ANDREW: Oh okay yeah. Is going to be easy.

SAMMY: Yes.

ANDREW: Okay we have got 77, 78% answered and we have got the trend really here I think have not we. About two-thirds of us have not heard of the HIV support program and that is absolutely not surprising because making an HIV diagnosis is unusual for us. It is not a common disorder. However, when we make that test it is really important, is it not. It is one of those big diagnoses that we make and how we are going to manage it. So I will pass over to you, no I am going to make a comment on this.

It is really important to be patient-centred and when you make a diagnosis the good thing is there is a system being setup that will automatically organise, trigger a prompt for an offer or assistance so in each region of New South Wales there is an HIV support coordinator. He will be in contact with you to assist you. The way it has been expressed is that every person who has a diagnosis of HIV should, has the right to five key support services, which will come up on slide next.

There you see them. This is the program. This is how it works. The doctor tests the patient and the specimen goes to the lab. The lab notifies you about your test that it is positive but also notifies the New South Wales Health HIV Surveillance Officers of a positive diagnosis. The HIV Surveillance Officer provides the details of you, the doctor that ordered the test to the local coordinator and that person is based in your local region, in the same health district and so the HIV Support Coordinator, doctor or nurse with special training in the area and that person then contacts you and tailors the support to you and then here are the five key support services that will help you to provide, a good appropriate management, psychological support, prevention of infection to others, partner notification and specialist and community services. You will get that call, but also if you are concerned and the call is not coming through you can also get in contact with the person and there is a number there that you can call.

So Nathan I think you are going to talk a bit to us about interventions for prevention of HIV and STI infections.

NATHAN: Yeah so we thought before we get right in that HIV support program and how it works we will just go a little bit here off to the side, what about if you had a test that is negative, which is obviously the more likely scenario and there is actually a really good tool on the STIPU website talking about great interventions for HIV and sexually transmitted infections. The same way you do a brief intervention around smoking you can do brief intervention around STI risk. I really encourage them to have a look at that. And if we go on to the next slide just going to very very briefly go over a really new thing in HIV prevention called PrEP. So PrEP is like PEP. You probably all heard PEP, working out a needlestick injury, you can get post exposure prophylaxis so we are impressing the PRE, the preparing before the event, but essentially it is taking anti-retrovirals everyday to reduce the risk of HIV and it is almost 100% effective. So high-risk gay men particularly we definitely recommend now that they start PrEP.

So if you just switch over to the next slide. There are three ways if you see high-risk gay men, so a high-risk gay man will be a gay man, essential gay men having unprotected anal sex. You can get it through a study called EPIC-New South Wales and many GPs are actually part of EPIC-New South Wales study. You can also personally import from overseas, which is becoming quite common and you can in theory buy it on a private 43:00 over and we have a couple of people doing that because it is quite expensive. The GPs have a role here. Some GPs being part of EPIC study and actually giving the PrEP out but a lot of things about the identifying high-risk gay men and referring them to a place to collect the PrEP and we get a lot of PrEP patients from GPs. So if we go onto the next slide

ANDREW: Nathan, what is an S100 prescriber?

NATHAN: That is a good question. An S100 prescriber is the GP who has done the training to be able to prescribe HIV medications. I do not normally use the word S100 myself but I say HIV prescriber but technically it is an S100 prescriber.

ANDREW: Thanks.

NATHAN: Basically I think I am going to miss the couple of slides now on my screen, anyway does not matter. The EPIC study is an implementation study where patients can access PrEP subsidised because at the moment it is not on the PBS and so really New South Wales will help asking any GP that has some patients that might qualify whether they would like to be part of it. The information is out there. If you would like to be part of it, get in contact with Cherie and she can give you all the details. I think we have got one more slide on PrEP. I guess it is to bear in mind we strongly believe that it is going to become available on the PBS next year. It will probably be reasonably cheap to the country because it is a generic now and we think it is probably going to be listed in S85. The S85 is a general schedule meaning anyone can prescribe it. What we are thinking is PrEP is probably going to become a part of routine practice in the not too distant future. If you think about it, it is preparing yourself or prepping yourself for the future. I think it is back to our person has tested positive now.

ANDREW: Yes we are going to do a little role play here. Nathan you are a HIV support program coordinator or provider and so you are going to actually demonstrate for us what it is like and I am going to be the GP that gets the phone call so over to you.

NATHAN: Yes. Basically I would have been sitting here and I would have got an e-mail from New South Wales that has the identified information. I do not know the patient's name or anything but I do know the GP's name. They are normally nominated a time to call which is almost always is 5 to 5, so I would ring up so ring-a-ring and normally the receptionist answers and I do get put through and Andrew would answer.

ANDREW: Hello, yes, Dr Andrew Knight here.

NATHAN: Hi, Nathan Ryder. I am calling from Hunter New England Health District. I have given your name to someone who has got a HIV case and would like some assistance.

ANDREW: Yes someone from New South Wales Health called about that. That is great. Thanks a lot for calling. I really appreciate it.

NATHAN: Okay great, so have you got the result there already?

ANDREW: Yeah, I have got it here. It says it is positive.

NATHAN: Okay, yes, alright, it was conferred to me, so it is definitely a positive result.

ANDREW: Yeah I got that earlier result that said that they are going to send me a confirmatory result and I have received the confirmatory result saying that it is positive.

NATHAN: Excellent, okay, now, I always start out just have you already told the patient or are we?

ANDREW: No, I have not. I was really pleased that you were going to call the patient. We called for him to come back. He is actually coming in for this thing tomorrow.

NATHAN: Okay so really the main point of this call at the moment is just to get you prepared for giving that result to the patient and for the early stages of where to go next really. From what you are saying I am sure you have not diagnosed a lot of people HIV and this is not a common thing for you.

ANDREW: No it is not. I have had one many years ago.

NATHAN: Okay.

ANDREW: Yeah. But things are very different and I am not sure how different. I have not managed anyone with HIV for some time.

NATHAN: Well it is generally not as bad as what you think it might be. The first thing to bear in mind is you can really strongly communicate to the person that whilst they are HIV infected and it is not curable they are likely to live a lifespan that is basically normal, but they will need to go on treatment fairly soon and stay on that treatment for life.

ANDREW: Yes.

NATHAN: Is the person expecting the diagnosis?

ANDREW: No I do not think they are. He is a bloke who just came for a routine set of tests.

NATHAN: Yeah.

ANDREW: And he wanted an HIV test done. I did some other STI tests and they tell it has come back positive.

NATHAN: Right yes. So in that sort of scenario where it is not someone who is testing frequently and might have had a suspicion they might test positive, it is really just important at the moment that you do not give excessive information. Make sure they understand what HIV is, how it is transmitted, how it is going to affect their health and where they go to next. Do you know if they have got any mental health problems?

ANDREW: I do not think so. I mean not particularly, he is a professional guy.

NATHAN: Of course. It is very uncommon. Most people cope reasonably well, much better than we as doctors expect them to but just bear in mind if you have anyone who does have a history of mental health issues or self-harm that we need to identify that early, the risk early and obviously you can use all of the normal mental health services you have got available and there are some specifications or reruns that we can put you in touch with if you need to but if it is a crisis obviously, using the health crisis line.

ANDREW: Sure.

NATHAN: So obviously you are going to call him back. I definitely recommend that you do that in person and you go through that as mentioned. Really what I recommended at the first visit are really only two things that you need to get moving. The first thing is you need to make sure they understand where they go to next in terms of their care because obviously that is what they are going to be focused. In my area they know they have got two options. They can go to the public sexual health clinic or the hospital. In either way you can send through a referral and it will be prioritised and they will be seen usually within a couple of days but definitely within the week.

ANDREW: Okay.

NATHAN: And the other side of it is just thinking about how the people that might be at risk. If they have got a partner that they are with now, a sexual partner or a drug-injecting partner depending on the person, make sure that they know they can transmit it and they should not have unprotected sex or share needles. We also obviously will need to think about letting other people know in the path but that is less critical. They may bring this up when you may go down that path immediately, but more than likely that is going to be done at the place you refer them to.

ANDREW: Yep.

NATHAN: I always, just have them think about what we are going to do in the future. So is this the person that you have seen as a part of like a clinic or service?

ANDREW: No, he is not particularly. He came and it is the first time I have seen him actually earlier in the week.

NATHAN: Right okay. Yeah that is good. Probably I think if you have regular patients versus not so the majority of people with regular patients they want to stay involved in the person's care and we can do shared care of five set ups. Alternatively, obviously they may not want to see you. I guess we can wait that out later on. You can definitely get a letter back from us when we have seen him so you will know but I would like to make arrangements with you that if we have not seen him within the week that I will follow you up and just check out though that he was referred and we can get in contact with him and make sure he does come in because we obviously do not want anybody getting lost in this initial stage.

ANDREW: For sure. That is fine. That is great. Good to know that you do that.

NATHAN: Okay. Well I mean that is pretty much all we need to do in this call.

ANDREW: Okay.

NATHAN: Depending on how things go I will give you more information later.

ANDREW: Great. Thanks a lot. That is our role play. Nathan, do you want to just run briefly, I think I described the process which is on the next slide. Any comments about that?

NATHAN: Yeah I would just say for a more practical sense so we already said exactly what happens. Practically the pathology lab is calling you 51:52 and then I am getting the identified patient information and normally at that point you somehow have liaised with that doctor and worked out okay when is it right for that doctor so we do not just call you up in the middle of the clinic. Normally, we can do that because we are a public clinic it is almost always me in my area but I am busy or away we have got no shortage of other doctors that can step in. We do have a bit of process, so there is a form I fill in while I am talking and we try and be reasonably structured and like no call is the same. Every GP has expertise in different parts of this and it is completely dictated by what that GP needs at that time. Unless I am implementing that call, some GPs really want to be right involved, know exactly what is going on. Other GPs have just seen the person once. They do not think they are going to see him again, really just want someone to take them over and we can do that almost immediately. Obviously in my area we see them the same day to be honest but my understanding is that in the whole of New South Wales HIV is considered urgent enough by all of the public services that that person will be seen really quickly.

ANDREW: I am just conscious of time Nathan that we have got five minutes to go. There are a few more slides particularly around the important parts of the support programs so we should probably just quickly run those slides. I think we discussed them in part.

NATHAN: Yeah so what they are. I guess this is where I am saying that it is a bit loosely structured and we do not actually really do it quite structurally in real life but obviously, the management is a really important thing so we do not generally get into on a call exactly how you manage HIV, it is more about the basics, yeah we start treatment almost immediately these days. The treatment is one pill once a day almost no side effects, the person lives essentially a normal lifespan. The psychosocial support, so I guess that has got two parts to it. It is the immediate coping and not very people have dramatic decompensation but they do, so it is both accessing mental health crises. Also there will be people in touch with the ongoing psychosocial support. Obviously preventing infection to others is really important so there is that with both ongoing partners and past partners who obviously are at much higher risk of undiagnosed HIV and might be putting others at risk. We definitely need to warn them about current partners straight away because we do not want to walk out of our office not having told them to not have sex and then their partners test positive and we wonder what is that and why. We want to do that, but the contact tracing with past partners like I said is not of urgency. That is something we jointly do together generally. In terms of specialist community services there is a whole raft of different services. Obviously this main strength though is just depending on what the person has got but there is also HIV specific counselling. There is HIV specific peer groups where the different groups, there is obviously heterosexuals, there is obviously many of the gay men. So it is really I guess working with your local expert to see what sort of steps might be right for that person.

ANDREW: Right. And then I think the next slide is important which is just, well not so much that one because that just really is saying you can, if you do not get support that you can ring that number and get support.

NATHAN: Yeah and through that way particularly as you said you might get a result, but you are not sure about it, unconcerned so yeah people do request.

ANDREW: Okay the next one is about referral pathways. We really talked about the fact that your local sexual health clinic can help with that and usual will help extremely promptly with this problem. It is important for people, some people really I guess want to be connected in the peer support and others not so much but you need to explore that and then the idea of responsibility to make that people do followup and get treatment is really important.

And then that next slide Sammy lists a number of places where support can be accessed particularly the patient.

Alright the next slide is really asking you about your experiences as an HIV support provider. I guess I really like this program Nathan. I think it is a clever way that New South Wales Health has particularly addressed HIV and providing that support at the very moment that the GP needs it. I mean often we are left with sort of what, having to scramble and get about two weeks for an appointment for a patient with a really serious disease that we do not handle much. I think it is a very good example of the way integrated care between specialists and primary care services can work. What is your experience been like in providing these sorts of services?

NATHAN: Yeah I mean I found it excellent. This is really well organised from both perspective. The feedback I have got from GPs has always been extremely positive and I guess it streamlines the whole process really where it is a very patient-centered process and the patient gets what they need really quickly and it is totally streamline one way.

ANDREW: There are a few questions coming through. One interesting one is someone asking with this treatment is AIDS prevented or just pushed back? And I think the answer is that AIDS is prevented pretty much these days.

NATHAN: Yes AIDS is when your immune system is impaired so much that you get unwell and that just does not happen anymore. I mean we do think they are with AIDS. They are the late diagnosis we touched on earlier that have not been tested early enough, but if you start treatment you will not get AIDS.

ANDREW: Yeah, so I really need to get on those anti-retrovirals. There is a question about pre-test counselling too and I think it is true that an HIV test now is pretty much treated as any other test. Any test that you need to get a signed consent for, the patient needs to know they are having it, but you do not need to go through all the complex pre-tests and post-tests counselling these days. Is that right, Nathan?

NATHAN: Yeah, we do not even use that terminology and all that has been removed from all the policies. So informed consent is required as you said, as for any other test, and the informed consent go out in person so if you are doing a HIV test in a pregnant woman you need to give very little information because it is just routine. If someone comes in and you see they are really high risk well you might want to spend a bit of time talking there.

ANDREW: Sure. Well we have used our time. I am aware that there are some questions that we have not addressed and as Sammy said we will go through those and make sure that we give you an answer as such as we can, but in conclusion I hope it is pretty clear that we have a really major role in STI testing and treating and in HIV and also that there is tremendous support with the resources to make that we are doing the right tests and giving the right treatment and when it is an HIV diagnosis and if you are in New South Wales and I do not think it is Canberra, that was another question Nathan, but it is certainly a New South Wales initiative that you can expect to get a call and be offered support directly to provide your patient with really high quality care and those five key support services. It is now 8:32. Sorry we have gone two minutes over, but I really appreciate your attention and your questions and I will hand back to Sammy to just finish things off.

SAMMY: That is great. Thank you so much Andrew and Nathan for joining us tonight. I hope everyone online has found it a really valuable learning experience. As we mentioned earlier, we will send around an e-mail to you tomorrow with that resources we discussed earlier. If there is any questions that you feel have not been answered that are pressing and you do want answered, you can just respond straight back to that e-mail with your question and we will then be able to get back to you that way, but otherwise thank you for joining us tonight. Please also note this activity does attract 2 QINCPD points. To be eligible for those points you will need to complete the evaluation that is at the conclusion. When you close down your webinar software it will pop up on your screen. If you can complete that, that would be fantastic.

Again that brings us to the end of the session. Thanks very much and enjoy the rest of your evenings.

ANDREW: Good night.