Sammi: Good evening everybody and welcome to this evening’s Discreet Lives: HIV prevention, testing and linkage to care for men who have sex with men webinar. My name is Samantha and I am your host for this evening. Before we jump in, I would just like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.
Okay, now I would like to introduce our presenter for this evening, Dr Catriona Ooi. Treeny is a sexual health physician and a Clinical Director of the Northern Sydney LHD Sexual Health Service. She is also a Senior Lecturer with the University of Sydney medical school. We are also joined by our facilitator this evening, Dr Tim Senior. Tim is a GP at the Tharawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and Senior Lecturer in General Practice in Indigenous Health at UWS and an RACGP medical educator. We are also lucky enough to be joined tonight by Cherie Power. Cherie is from the New South Wales Ministry of Health, and towards the end of this webinar she will be having a chat to us and giving us a bit of information on the New South Wales HIV testing campaign. So, in saying all that, I would like to hand over to Tim now, to take us through our learning outcomes for this evening.
Tim: Thank you very much Sammi and I hope you do not get to use your voice for the rest of the evening. I feel guilty about having such a long biography now. Welcome everyone. This slide shows the learning outcomes which is the education-speak for what we are hoping to achieve in the webinar tonight. So by the end of this online activity, we should be able to identify the patients who are at risk of HIV, particularly men who have sex with men, that do not identify as gay or bisexual within our practices. We should be able to discuss HIV risk, prevention and treatment options with particular target risk groups and we will learn to utilise New South Wales Health tools and resources to deliver primary care for people with HIV. So I am going to hand over to Dr Ooi now to take us through the landscape of HIV in New South Wales, first up.
Catriona: Thank you very much everyone and welcome everybody to the webinar. They are quite ambitious learning outcomes actually, and I must say that there is no one easy way to identify men who have sex with men who do not identify as gay or bisexual, because often most of the problem is confidentiality and discretion. But I hope that by the end of this, we feel a little bit more confident in maybe bringing up the topic of HIV testing and perhaps the idea in your mind that people may not wear their hearts on their sleeves and may have hidden lives. So let us talk about HIV in New South Wales. And you can see from this slide that the HIV strategy that we are currently within which is the 2016 to 2020 strategy, the aim really is to end HIV by 2020. So that is an ambitious, very ambitious goal. So that is virtually eliminating transmission. And we are not doing too badly as far as that goes. But in order to achieve this goal, we really are focussing on our priority populations and I will go through a bit of who our priority populations are, one of which is men who have sex with men.
So, to that as well as priority populations we are looking at a particular range of priority settings and one of those is general practice and primary care. Now bringing it back to what we are hoping to achieve tonight, general practice is really one of the most likely places that the unlikely patient, so heterosexuals who may have homosexual sexual experience, so that is people who are married or who have girlfriends who may have sex with men on the side, they are most likely to be within general practice. Because they tend not to reach out to traditional, other traditional testing services like sexual health clinics for example.
So moving on to the next slide, if we look at the HIV data that we have, and this is the most recent data which came out in February of this year, we are doing quite well as far as transmissions go. And in fact the rates of new diagnoses have been decreasing over the last few years. And if we consider last year, 2018, less than 300 people. So only about 278 people were notified as newly diagnosed infections. So this was an improvement of 17% over the 2013 to 2017 average. So we are doing well. 38% of them were diagnosed in early infection, so that is less than were diagnosed in early infection previously. So we are doing quite well as far as prevention goes. I think one thing we need to consider is that a significant proportion of about 8% of people with HIV infection are undiagnosed who live in New South Wales.
The new diagnoses are mostly among men who have sex with men and are higher in suburbs that do identify with the gay community. So, the hidden diagnoses, or the hidden infections are probably outside of these typical postcodes.
So, next slide. We need to focus on targeted testing. So if we consider 2018, over two thirds of men who were diagnosed with HIV that year, had not had a test in the previous 12 months. So that is the majority of them. So we need to really ramp up and test people more often. By testing them more often we identify the infection earlier, which has a better prognostic outcome than those late diagnoses. So one of these groups who may not be diagnosed early are those who do not engage with conventional testing services. So they do not necessarily identify as gay or bisexual.
So, how is general practice going with HIV testing? Very well. In fact, in 2018, almost half of new HIV infections were diagnosed in general practice and of those general practice diagnoses, the vast majority of them were diagnosed by practitioners who were not accredited to prescribe anti-retroviral therapy. So it is something that if you do not do on a regular basis you might consider doing as again, as I mentioned before, increased testing leads to earlier diagnosis and better outcomes.
So, have a question for you all. Are there men in your practice who keep details of their sex lives hidden and could they be having sex with other men? Okay, so overall about half of people said that they may have people in their practice who might be having sex with men but keep this hidden. 40% were unsure. Which maybe, you know, this might be the time to think about that. And 5% said no. I am hoping that those 5% only worked with women. Oh I do not know, primarily in family planning or something, I do not know.
Okay, so what do we know about this group of people? So, a lot of them do identify as heterosexuals. So it is important to understand that people’s sexual identity may not necessarily coincide with their sexual activity. So somebody may identify as a heterosexual and see themselves as heterosexual but still have sex with people of the same sex. This group of people are particularly concerned about discretion, confidentiality, very fearful of their family and friends finding out, and can keep these two lives very separate. And in my experience, having done screening in groups of men who identify as heterosexual, but who have sex with men, most of these people have not had testing because they are very fearful of how they will be judged. So this group are unlikely to be connected to social and sexual networks and they are very diverse. So there is no one particular type. Because they do not identify as homosexual or gay or within the gay community, the typical message of ad campaigns and safe sex advise tends not to have any resonance with them because they do not see themselves at risk. There is a variety of ways that people meet for sex, including beats so public, anonymous sex places, sex on premises venues, so venues which are very anonymous. And also online access to different people. And there is a high value placed on discretion.
Now there was some research that was done recently and it did look at how people identify and how they see themselves and whether they do access testing and what their knowledge of HIV and sexual health was, and they found that although it is diverse, many people had not had testing before. Many of them had very little understanding of HIV and still were haunted you could say by the grim reaper ads in the 1980s, particularly the older men. There was a real fear of being found out. And people, if they did have symptoms may drive to several suburbs away to get testing and felt very uncomfortable a lot of the time in accessing their regular health care provider who might see also their wife or their kids for example for fear of being found out and for fear of being judged.
So, moving on to the next slide, we have got just little case history that we are going to go through. We have got Greg who is a 35-year-old male, Australian born, works full time. Married with two children under five. You have been seeing him for the last two years but only for acute presentations. So he is kind of a typical man, he only goes in when he needs to. He came in recently with a widespread maculopapular rash and you referred him to outpatients ID at the local hospital. No diagnosis was made, no blood born viruses or STI tests were done. And he comes back. So he is still concerned about what it was. There is still no result.
Next slide. So, as his primary care provider, was there anything that we might think of in that history that would trigger maybe a risk of HIV? We have not asked him, not even gone anywhere near his sexual history yet. He has come in, he has got this whacky rash. We have done some, you know, done some screening, nothing has come up positive. We sent him off to infectious disease. Nothing was done and he has come back and there is still a bit of concern about what it was.
So, starting the conversation with Greg, how would you start this? It is a difficult conversation to start and first of all, I guess the first step is really to have that suspicion in your mind.
Tim: Someone is pointing out through the chat box that the widespread maculopapular rash could be a rash of early seroconversion and that is what raises their suspicions.
Catriona: Yes. Yes, that is right. It could also be anything else as well. But I think that is what these sorts of signs and symptoms are a trigger that perhaps this is something that you need to explore.
So going back to that research that I mentioned, so with men who have sex with men, who do not identify as gay or bisexual, and this was done in October 2018. It was a, participants were recruited by a social dating App, a men who have sex with men dating App, Grindr. They were given an incentive of $200 and there were 25 people who underwent some quite extensive interviews. Looking at beliefs and attitudes and behaviours around HIV testing. And I think the key findings of this and I think this is something we need to keep in mind, is that these men generally did not see HIV as relevant to them. It is a gay person’s disease. I am not like that. I am not promiscuous. So, consequently it is not concerning me, I am not at risk. So they do not test for it.
You know, there was this perception that HIV affects high risk groups, and that was the gay identifying men who have sex with men. And because they do not associate with those groups and they do not see themselves as that, they do not view themselves in that way, then they would not get HIV. So bringing up testing for HIV or the possibility of HIV infection can be a little bit difficult and assessing risk factors. You do not want to insult anyone. So I think it is one of these things you need to ask permission for. So, you know, I am concerned one of the things we need to exclude is HIV infection because this can cause this sort of rash. Overseas travel, sex overseas within high prevalence countries may also be a factor. Having sex with men on the side, definitely.
So moving to the next slide, we have got the HIV STI testing tool which is a clinical tool. It is available free online. You can download it. There are also hard copies. And it provides tips on starting a conversation and how to test for HIV, how to ask for HIV, so how to ask about HIV risk and sexual health risk. So it is user friendly, it is step by step and it really shows if you show it to the patient then I have found that people who are concerned or feel like they are being judged in any way, it just goes to show that anyone can be asked these questions. These are general questions that we can ask everyone. So that is very helpful and as I said it has just been updated so it easily can fit into your medical practice.
When it comes to testing, what testing options are available to Greg? Yes, sorry?
Tim: Sorry I was just going to say, we have had a few questions come through. Just someone asking about, if one of the questions it asks if they had had any unprotected sex and people wanting examples of questions of raising it, and I imagine the tool has that. I know one colleague of mine said that they had asked someone recently, do you have sex with women or men or both? And the patient looked at them and said, oh well only women up till now but I do keep my options open and they really opened the rapport for them, that it was not judgmental and that struck me as being a good, just straight forward way of asking.
Catriona: Yes. Yes, I think that is a really good point, Tim, because these things are, can be difficult. I mean, you are asking questions in a non-judgemental or even though we are not being judgemental, seemingly judgemental way so asking someone, “Are you gay? Are you homosexual?” can be viewed in different ways. Because they might not see themselves as gay or homosexual. But asking the gender of the people they have sex with, “do you have sex with men? Have you ever had sex with a man in the past?” is also a way to do it? When was the last time? And so these sorts of questions can open that sort of dialogue. And certainly form the experience I have had of testing and speaking to this group of men, then people may not give the, may not feel comfortable at first, but they will talk about it and they will think about it. And so it might be a week, two weeks later that they may return and have a test. But opening that dialogue and opening and making that introduction that it is okay to talk this, that I am understanding of this, is a really, really good point to make.
Were there any other questions, Tim? No.
Tim: No that is it for now.
Catriona: But as I said, there is no one easy way to do it and it is often that we have to find our own, where we are comfortable in asking the questions. I mean certainly for me, I work in a sexual health clinic, so people come expecting to be asked certain information. But I have worked outside of this scenario and still ask the same questions, and it is about how you pose it. I am going to need to ask you some personal questions, everything is confidential, stays between us. But in order to diagnose this rash, test this rash, to look and see what could cause this rash I need, I would like to have some honest answers. So I would prefer you did not answer rather than not tell me the truth. Have you ever had sex with a man?
So what testing options are available to Greg? Well, by far and away routine serology is the preferred test. It is cheap, it is efficient and it is very specific and sensitive. Currently in New South Wales the vast majority of labs are using combined antibody antigen tests so it is an extremely good test and the result is quite quick to turn around. There is the dried blood spot test. There is also the rapid HIV test which is a test that you can get at different venues and that is either an oral swab or a pinprick test and the result can be 15 minutes or 20 minutes. And also there is – excuse me – there is also a home test kit which is going to be available online. The cost will be about $25 plus postage and handling. It is also a pinprick test. It is only an antibody test and it was approved by the TGA in November last year and it is thought to be available sometime in March although having spoken to the company on several occasions, they are not really sure yet. So that may be coming pretty soon.
Tim: Sorry, we have just got a question the rapid HIV test, how reliable it is?
Catriona: It depends which one you do. There are several rapid HIV tests which are available in Australia. There is a 10 minute, a 15 minute and a 20 minute. There is oral and there is pinprick. So, what they have found is, and some of them are antibody only and some of them are antibody antigen. Universally for the antibody proportion is fairly reliable, particularly but not within the window period of three months. The antigen test if it is early infections, tends to be less reliable. It is meant to be not a definitive test, but a screening test. So if somebody does test reactive on that, we do not call it positive or negative. If they are reactive then they are advised to have routine serology. So it is fairly good if they have not had a recent exposure and if they have waited and they have waited the window period.
So, what can we do to prevent. So we have done some testing for our friend Greg. We have done HIV testing and of course if he is at risk of HIV then he is at risk of other sexually transmitted infections. So because we are fantastic doctors, we also do screening for syphilis, hepatitis because he might need vaccinations for example, gonorrhoea and chlamydia from the pharynx, the urethra and the rectum because we are doing a full sexual health screen. But in the meantime while we are waiting what can Greg do to prevent getting infected in the future if he is not already infected or prevent ongoing transmission? Well first of all, there is old favourite, condoms. And no matter how you try to dress it up, a condom is still the condom. It is effective. But a lot of people are not that interested or they do not carry it with them. Or they have a condom accident, they break, they split. We also have pre-exposure prophylaxis now and I will talk a little bit about pre-exposure prophylaxis in a minute. We have post-exposure prophylaxis which has been around for many years now, that is taking anti-retroviral treatments, so HIV medicine within 72 hours of exposure for a period of a month to prevent infection. And there is treatment as prevention. So if you have a regular partner who is HIV positive, ensuring that they are taking their HIV medication, so they have an undetectable viral load or a viral load of less than 200 copies per mil which is thought to provide their HIV negative partner protection. So, undetectable is thought to be untransmissible. If that HIV person has an undetectable viral load then their risk of transmitting the virus is thought to be negligible.
So moving on to PrEP. What is PrEP? So, since the 1st April 2018, PrEP has been available on the PBS so you can write a script for a month with two repeats and then they come back for more. And pre-exposure prophylaxis is daily HIV medication. Next slide please.
Daily HIV medication that can be taken by negative people to prevent infection. So, the trials have been primarily with Truvada. So tenofovir plus emtricitabine, take one tablet a day and if people are adherent it is incredibly effective. In fact, there has only been a handful of transmissions internationally of people who have been compliant on their pre-exposure prophylaxis because they have been exposed to HIV viral strains which are resistant to the medication. And considering there are thousands and thousands of men having a lot of sex out there who are taking PrEP, then that is actually very effective. So, because PrEP is on the PBS it is available through any medical practitioner on the PBS to anyone who holds a Medicare card. So all GPs can prescribe PrEP. People can have one month and two repeats as I mentioned before and every three months when they come in for their repeat prescription we do a screening.
So when is PrEP appropriate? It depends upon the risk of the patient. They are eligible if they have a risk, if their risk of acquiring infection is medium to high. And there are eligibility criteria. Principally, the group which has taken up PrEP the most is men who have sex with men, and that is internationally. Other groups may be transgender or gender diverse individuals. Heterosexuals who have an HIV positive partner whose viral load is not undetectable, so they have a viable viral load or a viral load above 200. Depending upon the local epidemiology there might be other groups as well who may benefit from PrEP. So it really is an individual case by case basis.
So behaviour. When we are talking about behavioural risk, when you are assessing someone’s behavioural risk, we are asking people who they are having sex with. Are you having sex with men or women or both? Are you having sex with trans people? Are you having sex with sex workers? Is your partner HIV positive? Are they having vaginal sex, oral sex, anal sex? Because each orifice will come with accompanying different risks and are condoms used? So if you are using condoms all the time, then your risk of infection is fairly miniscule and you may not necessarily be eligible. But if you are having, if you want to take PrEP but you are anticipating that you do not want to use condoms, then PrEP may be appropriate. So there are PrEP decision making tools which make it easier for people so you do not have to have a guess. And if you go to these websites, then they will give you a real step by step guide on what to do, how often to test, what tests to ask for and how you can access PrEP. So if patients do not have a Medicare card, then they cannot get PrEP via the PBS but there are other options available. You can import it, you can import the medication online for personal use which is completely legal and there are some websites which are recommended if patients will not do this.
Tim: Just before we move on to the next slide, I have just got a few questions coming through about testing and prevention. So, a couple of questions about the window period and how frequently we need to do another test to rule out infection?
Catriona: Okay, so when patients initiate on PEP, they need to have an HIV negative test ideally within seven days of initiation, and that is to ensure that they are not already HIV infected. It is advised that they test again for HIV in one month in case they are within that window period. If they are within a 72 hour window period of last exposure then they can start PEP first and then transition straight on to PrEP. Once they have finished their first script at three months, then every three months when they come for a new script, that is when you do HIV testing and sexual health screening. Because the medications have been associated with proximal tubular problems with the kidney it is advised to do an EGFR every six months. But this is all, all of these guidelines are available on the decision making tool.
Tim: It is very good, that tool. And just to confirm, someone is asking about allergies to condoms and I believe that is mostly allergy to latex and you can get latex-free condoms, those are available.
Catriona: Yes, there are quite a few now. There are polyurethane ones. For anal sex you can also use a female condoms although they are much harder to get. But there are these whacky, well they are not really whacky, there are these really interesting Japanese polyurethane ones that some of my patients swear by. Anyway, you know. Each to their own.
Tim: And someone is just asking, can someone request PrEP online for personal use? Is this available in all states in Australia?
Catriona: Yes, so it is available through the PBS. To order it online, they still need a script from their doctor, then they upload the script to the online site. And it is legal to import medications. There is a website which can suggest different PrEP sites, or different places to get PrEP and it can be as cheap as $21 a month. And it is called pan.org.au. So it is available online for personal importation which is legal.
Tim: Yes. Thank you.
Catriona: But they still need a script.
Tim: Let us move on to the next section.
Catriona: So what happens if you are prepping someone for PrEP, and oh my God, the HIV is positive because they have not had a test for so long? So, it depends really on what your experience with HIV is and currently within New South Wales, each new HIV diagnosis prompts an offer of local assistance. So what happens is, the result goes to the lab and there is an HIV support coordinator in every local health district. I am the HIV support coordinator for the Northern Sydney Area Health District, and what would happen is there is a positive test then the GP is contacted to see if they would like some support or part of the program. If you vote yes, then you get a call from me at a time of your choosing ideally. We try and do what we can and you are offered support with psychosocial support, giving the result, referral pathways, if you want any more information, contact tracing, ongoing testing. So, it depends upon, how you want to do it. It is completely in your hands. If you want to refer the patient on immediately then we can help you with that. If you prefer to do further testing and supports yourself then we can also facilitate that for you and help you with whatever you need. So, it is a really great system. We have had really good feedback about it. And it is there if you need it, you do not have to take it if you do not want to. So it is really, the ball is totally in your court.
So what happens if you have an HIV diagnosis and you have to give that to the patient? You have not done it before. Ideally, and this is common sense really, you give the result in person. Always, I mean if you have done a pre-test, if you have done some pre-test discussions then that will be helpful, what will they do if they are HIV positive? Have you thought about HIV? We would need to tell you sexual partners if you were positive but your identity will remain anonymous. I find it is really important to just give short, a small amount of information because often patients, even though they may suspect themselves, they are still quite shocked. Listening to what the patient wants and responding to their needs. Their needs may be something like, who am I going to tell? Or it might be, I am going to drop dead tomorrow. Those might be their beliefs. So, listening, responding to their needs and education where necessary. Reinforce that HIV is completely treatable. View it as a chronic infection. It does not need to affect their working life for example. They can still hold a job. You can still have children. You can still have a healthy relationship. You can still have a healthy sexual relationship. Making sure that they are supported and psychologically they are okay, so what are you going to do after you leave here, how are you going to get home? Are you going to tell anyone? Is there somebody available for you? Do you want some phone numbers in case things get difficult? Arranging ongoing appointments can often give them a sense of hope that there is something going to be happening; that I can get on treatment straight away. And doing a bit of follow up to make sure that they are okay within the next few days. Particularly if it is the weekend for example where patients, where people do not have to go to work and they may be sitting at home just ruminating. Certainly there are people that do not want to go to work if it is during the week, so you might say, “Do you need some time off to process this?” There is online counselling. There is also telephone counselling for anyone who needs it. So, both you as the diagnosing clinician and the patient is not left out there by themselves wondering what to do.
So what are your responsibilities? I guess some of the things we need to make sure we do, are alerting the patient to their public health responsibilities. So, most people in my experience are not going to necessarily go out and have rampant sex after they have been given an HIV diagnosis or donate blood. These are things we need to consider. So, if they are a breast feeding mother it might be, we will test your child, no ongoing breast feeding for example, using condoms if they are going to have sex. No blood donations, things like that. And protecting others, which means reasonable precautions. The Public Health Act of New South Wales has recently been updated and so patients do not need to disclose their HIV diagnosis if they take reasonable precautions when having sex, and that includes using a condom, or having a viral load less than 200 because undetectable is untransmissible. And detectable is thought to be less than 200. Or if their sexual partner is taking PrEP which protects them against infection. So, if it fulfils any of those three criteria, they do not need to disclose that they are HIV positive.
Now, contact tracing is something we also need to consider and take care of. And contact tracing is also called partner notification for those of you who know it as that. And this is where we tell people or alert people that they may have been exposed to HIV and need to have testing. Now, in all areas of partner notification for all sexually transmitted infections, the index patient’s identity remains anonymous. So often, the patient does not feel comfortable in contacting their partners themselves in the case of HIV, in which case a third party can do it which is the sexual health clinic or the Sexual Health Information Line can also help with that. There are other online sites for contact tracing for other STIs but you cannot do HIV via the online sites.
So, as how to trace back for HIV, you trace back as far as you need to. So, since their last HIV negative test. So if my HIV, if I was diagnosed positive today and my last HIV negative test was five years ago, if my history did not indicate that I had a seroconversion type illness which may indicate a new infection, then we would need to test everyone in the last five years. So you try and time how long somebody has been infected for, or when they may have been infected and you have to trace back to that occasion.
Okay, so linking patients to care. They can get treatment from a local sexual health clinic, an HIV outpatient service or an S100 GP prescriber and there are lots of these dotted around the state. Quite a few of them in Central Sydney, but there are a reasonable amount throughout New South Wales. If you do not have a local sexual health clinic or outpatient service and you are looking for an S100 prescriber, ASHM has, the Australasian Society for HIV Medicine and Sexual Health, has a list. So psychological care is also really important, depending on the needs of your patient. Sexual health services and community organisations can often offer peer support. So we are talking AIDS Council New South Wales, now called ACON and also Positive Life and there are different organisations in different areas.
If patients do not have Medicare for example, then they can go to their sexual health clinic. We see all patients. But you know, there are less sexual health clinics in rural and remote New South Wales, but they are dotted around the State. If you are concerned about where to send your patient, if it is not appropriate for them or convenient for them to go to a sexual health clinic, you can always ring a sexual health clinic who can source someone to look after them for you.
Making sure the patient attended their follow up appointment I think is really important also, because there are a reasonable amount of people who get lost between the diagnosis and follow up. And these people may be at real risk of HIV progression and negative consequences of that.
So moving back to our friend Greg. So Greg’s results come back. We have done a lot in the week intervening since we first saw him when he came back from the ID people, and he is positive for syphilis. So, it is time to think about treatment, partner management and follow up.
So if we go to the next slide. So, the question is, what is the recommended first line treatment for syphilis in Australia? Please select one of the following.
Sammi: And we wait till we have got a few more. We have got 50% of people voted right now. So we will give that another couple of seconds for you.
Catriona: Excellent. I will let everyone know as well. I do not know if people are aware of this, but today in the National Day of Swallowing. I know, it is gold, isn’t it? National Day of Swallowing today, thank you speech pathologists Australia.
Sammi: Alrighty, so we might close that off there and I will pop those results up on the screen for you all to see now.
Catriona: Excellent. So, benzathine penicillin 1.8 grams stat. Yes. If you have got early syphilis, that is the first line recommended. Procaine you can give but the compliance and the discomfort of the patient for 10 days of injections and it is quite inconvenient, is not as useful. And also azithromycin, there have been treatment failures with azithromycin internationally. So, ben pen 1.8 grams.
Okay, so the other things we need to consider are contact tracing. So you are looking at contact tracing for early syphilis and I will talk about that in a minute. Also, the Jarisch Herxheimer reaction, so that is for early syphilis within in the next 24 hours you can feel very, very unwell. And no contact for seven days post-treatment. And then we will talk about follow up.
So, contact tracing or partner management. How far do we trace back? Depending on how early their syphilis is. So if they have got primary syphilis we do three months plus the duration of symptoms. So primary syphilis they might come in with a shank cut for example. So secondary syphilis, six months plus duration of symptoms. So rash, patchy alopecia, they could have condylomata lata. So in our case, Greg would have maculopapular rash probably due to syphilis. So we would be contact tracing for six months plus the duration of his symptoms. And for early latent syphilis, is 12 months. So that is somebody who had a negative test two years ago. We would be tracing back for 12 months.
So, things to remember for Greg. Syphilis is highly infectious when it is early and with most syphilis it is totally asymptomatic. Now contact tracing for Greg, or partner notification can be done online if Greg is happy to do that. And it comes from an online platform so the sender remains anonymous. And if we look at the online platforms that we have for example, there is the Drama Downunder site and there is also the Let Them Know site. So I will talk about the Drama Downunder site first of all and you can see this is what, you go online to the Drama Downunder. Greg can do this by himself. You might want to show him how to do it, so the first person he has had sex with is one of his contacts in the clinic room and then he can go and do the rest if he has had sex with more than one person. He puts in their first name if he has it and their mobile phone number. And then you click on what infection they have and push submit. And the message that that person will get will be “Hey, AJ” if AJ was the person that Greg had sex with “you may have been exposed to” and in Greg’s case it will say “syphilis and need a sexual health check-up.” So the Drama Downunder is aimed at men who have sex with men, but if you look at the Let Them Know site, it is aimed at heterosexual people.
Next slide please.
Sammi: Sorry Treeny, there is a bit of a delay in the screen sharing so thanks for bearing with me, everybody.
Tim: Just while we are waiting, I will also mention that there is a specific Aboriginal and Torres Strait Islander contact tracing site as well, which is BetterToKnow.org.au.
Catriona: So all of these different platforms do the same thing. They just have different, it is really just different graphics. So we have got another poll. So when should Greg have repeat syphilis serology? And we repeat the RPR and the VDRL to see whether or not his treatment has been effective, if he has a reasonable level to start with.
Okay. So, the answer is three months afterwards. One month afterwards he can come in and make sure that everything is okay, well you know he took his medication because you gave it to him in his butt, whether he has had sex with other people, whether his symptoms have resolved. But it is usually three months. So, three months, six months and 12 months. And you need a four-fold drop in the RPR and VDRL after the 12 months for effective treatment.
Okay, so what do we do with our friend Greg? After we have treated him ideally we want to review him in a week. So ideally we have reviewed him in a week to ensure that he has done his contact tracing, to make sure he has not had sex with anyone and to reinforce safe sex messages. The other thing to consider is his wife, if he has had sex with his wife in the last six months how he is going about addressing her testing needs. Also to make sure that he knows he has to come back in three months for retesting. And if you do need help, there is also always help available. You can refer to a sexual health clinic and that is for people who are more complex or who have problems with contact tracing. Other presentations, so people who might not have Medicare or who are interested in PrEP but not taking it daily who want to take intermittent PrEP or PrEP on demand. If your sexual health clinic is not local or it is difficult for the patient to get to it then you can always call and we can give you, we can help with whatever you need. So there is always help available.
So I guess in conclusion, GPs really have a key role in HIV testing and prevention and I think this cannot be overstated. You are in an ideal position to really identify some of these groups and although it may be difficult and it may be daunting, even introducing that conversation can start people thinking and can give them permission to talk about things that they really feel uncomfortable about or they have not told anyone. And from my experience, once people start talking about it or get the courage to start talking about it, and disclose this sort of hidden sex life, the relief is just extraordinary. Extraordinary. So they might not identify themselves at risk but they still may be at risk. So it is important to let people know it is okay to talk about it, that you are okay to hear these things.
There are tools available to prescribe PrEP if somebody is diagnosed, to assess and testing and management. There is also online support. There is also telephone support wherever you need it. And that is me. Were there any more questions, Tim?
Sammi: There have been a couple that have come through, but we might move Cherie’s slides quickly first, then if we have got time we can field them, otherwise we can get back to them off line so we do not keep people overtime. So I will hand over, thank you very much Treeny, to Cherie now to talk to us about the New South Wales HIV testing campaign.
Cherie: Hi everyone. I am Cherie Power. I hope you can hear my okay. I am a Senior Policy Analyst at the New South Wales Ministry of Health. I hopefully will not keep you too long tonight. I just wanted to tell you about an upcoming HIV testing campaign that the New South Wales Ministry of Health is launching, and that will run from mid-April to the end of the year. The target audience as we have spoken about tonight is heterosexual men who have sex with men, including CALD, a very important group who are coming high up in the notifications as we have discussed, and men who have sex overseas. So the aim of the campaign is just to change the attitudes within these audiences to increase testing for HIV for these men to come forward.
So next slide. I will skip the next two slides, and the next one because that is just detailed information about our target audiences. Treeny has covered a good amount of heterosexual MSM information so that was really great. So this is the creative. It is only going to be displayed in what we call the trigger moment, so it is where our heterosexual MSM are seeking sex. So, we are going to be displaying it in hook-up Apps and websites as well as posters in sex beats. The headline, Discreet Life? is a reference to how heterosexual MSM view and live their lives, and the key messages are there; so testing is easy, get a test, call to action. And we provide a link to the New South Wales Health website which then links to the GP locator and other ways to test. So we are telling you about this campaign so hopefully you know, these men present to you for testing.
Next slide. The other creative is targeting our men having sex overseas with men and women in high prevalence countries. This will be displayed in men’s toilets in Sydney International Airport arrivals, and again similar messages. Get tested. So we are, this is to men having sex with anyone without a condom overseas, and it points to the campaign’s key message that it is sexual behaviour that puts a person at risk of HIV and not sexual identity. So we are really trying to cut through that.
Next slide, thank you. So this is my last slide. It is just a reminder really that we do a lot of other collateral and a reminder about the New South Wales Health website. So if you do a Google search, health professionals, so HIV testing for health professionals, and there is some information there if you have not seen it before. And we will also be sending you out a poster for all GPs in June to assist with testing in HIV testing week in your clinics. So that is it from me. It is 8.31 so I will hand back over to Tim.
Tim: Thank you very much you did a great job there. So these, we just need to remind ourselves of the learning outcomes again that we did earlier and that hopefully we have covered all of those things we have talked about. Identifying patients who are at risk of HIV, particularly men who have sex with men who do not identify as gay or bisexual. We have discussed HIV risk prevention and treatment options and we have looked at the New South Wales tools and resources briefly at the end there. There have been a few other questions which hopefully will be addressed. I know one or two of them have been addressed by the PowerPoint and the resources in there and others are up for discussion and we might circulate those afterwards.
I would like to thank Dr Ooi and Cherie and Sammi particularly who has struggled through with a voice that has got us through to the end. Thank you all very much for attending. Please fill out your evaluation forms afterwards and have a very good rest of the evening. Thank you very much.
Sammi: That is great. Thanks Tim and Treeny and Cherie as well. Thank you everybody and enjoy the rest of your evening.