Syphilis testing and management for Aboriginal patients

Sammi: Good evening everybody and welcome to this evening’s Syphilis testing and management for Aboriginal patients webinar. We are joined by our presenters, Dr Nathan Ryder, Dr Tim Senior and Ms Annette Slater this evening, and my name is Samantha and I will be your host.

Before we start, I would like to hand over to Annette. Annette is going to very kindly give us our Acknowledgement of Country this evening.

Annette: Good evening everybody. It is Annette Slater. I am based in Tamworth. I am a Murrawari and Euahlayi woman of North West New South Wales into South West Queensland. So I am mindful that there may be other people from over other states joining in this evening and also to be mindful of border town communities that might be working on different times to New South Wales. I feel privileged to acknowledge Country tonight on behalf of everyone that we are meeting in so many different places. I would like to recognise the traditional custodians of the land and sea on which we live and work, and on behalf of the facilitators this evening, to pay our respects to our Elders, past, present and emerging. Thank you.

Sammi: That is great, thanks so much Annette.

So I would like to introduce our presenters for this evening. Firstly we are joined by Dr Nathan Ryder. Nathan is a sexual health physician with 15 years’ experience in HIV management in urban and rural Australia. He is the Clinical Director of Sexual Health and HIV Support Program Coordinator for the Hunter New England Local Health District. He is also a Conjoint Senior Lecturer at The Kirby Institute at University of New South Wales and University of New Castle. So, thank you for joining us, Nathan.

Nest we are joined by Dr Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and Senior Lecturer in General Practice and Indigenous Health at UWS.

And lastly but certainly not least, Ms Annette Slater. Annette as you know gave us our Acknowledgement of Country, but Annette is also an Aboriginal health worker with the Hunter New England Local Health District of North West New South Wales. Annette works with different clinicians and agencies within a community setting to build on holistic health and emotional wellbeing. So thank you, Nathan, Tim and Annette for joining us this evening.

I will hand over to Tim now and he will take us through our learning outcomes for this evening and then we will work our way through the presentation.

Tim: Excellent. Thanks very much, Sammi. It is lovely to be joining you all. I am joining you from Tharawal land in South West Sydney where I live and work. I would like to acknowledge the traditional owners and Elders past and present and emerging where I am. So this is the learning outcomes. This is what we hope to achieve on the webinar tonight. So hopefully by the end of this online activity, we will be able to discuss the prevalence and incidence of syphilis in New South Wales and identify the high risk groups. We should be able to describe the recommended testing schedule and testing methods for syphilis including antenatal screening changes in Aboriginal and Torres Strait Islander people. We should be able to describe how we interpret syphilis results and how we base our treatment on that. We should be able to identify barriers and challenges in conducting syphilis testing and prescribing treatment, and we should be able to demonstrate how to incorporate new knowledge into routine clinical practice.

And so we are going to start with a case study. And this is Jane who is a 22-year-old Aboriginal woman who comes to see you in your practice and she is asking for the contraceptive pill. And she has been married for one year. And that is all the information I am going to give you at the moment, and we will find out more about Jane as we go through tonight and discuss syphilis testing and treatment. First of all, I would like to just ask you one of those scenarios. Would you offer Jane a syphilis test? And so you can select one of these and we will show the results afterwards.

Sammi: Yes we will just wait a couple more seconds. We have 60% of people voted, we will see if we can get it up to 80% before we close that off. A couple more clicks. A couple more seconds. Alrighty, wonderful we are at 80% so I will close that off now and share those results with you. So you can see that 76% of people said yes, and 24% said no.

Tim: Excellent. That is good to see and we will see what the recommendations are around testing for syphilis and who we should test. I guess there is always a little thing on the webinar about syphilis, whether predisposition will tested or a question like that. So if we move on, one of the important things that is the first step for doing anything in working with patients in Aboriginal and Torres Strait Islander health, is knowing which patients of ours are Aboriginal or Torres Strait Islander. So it is one of the standards in the RACGP standards, assessed by AGPAL and QIP and that has been in since the fourth edition. We are now up to the fifth edition. And so it is worth asking, do you ask your patients about their Aboriginality at registration or during their initial consultation and then how do you record that in your clinical records? And that depends on which software you are using, Best Practice, Medical Director. I use Communicare which for those of you who have worked in the Aboriginal Medical Service may be familiar with. It tends to be used just in Aboriginal Medical Services. And all the different software deal with that differently. It is important both that we know how to ask, but also that there are systems in practice for identifying our Aboriginal and Torres Strait Islander patients. And that our receptionists particularly, our practice manager, also know the importance of being able to ask, and also being able to say why they are asking. Because many patients who may have had bad experiences in health services before may be asking, well why do you want to know that? And being able to explain the reasons why, that it actually means we can provide the clinical care according to best recommendations for example in testing including syphilis, for example in immunisations, in calculating cardiovascular risks and renal disease risk, as well as access to some of the really important Medicare initiatives such as the PBS closing the gap co-payments or PIP payments for our practices or access to particular medications on the PBS. So, this is going to be the first thing that we all need to know about, knowing and asking are our patients Aboriginal or Torres Strait Islander?

So if we move on to the epidemiology. I will hand over to Nathan.

Nathan: Yes, thanks Tim. So I am going to give a bit of background I guess and we are going to start with the epidemiology. And some of you may have even seen in the mainstream media, that there is a massive change in the epidemiology of syphilis in Aboriginal people in Australia, with this extremely large outbreak. It started in the north in Queensland and then has subsequently spread through NT, WA and South Australia, and so far over 3,000 cases have been reported which is one of the largest outbreaks globally ever reported. In this outbreak, the vast majority of the people are in the younger age group with 65% less than 30 years of age. And there is a slight predominance of females but strikingly similar, and the slight predominance of females is likely because females are more likely to get tested than males as you will probably notice in your own practice.

So if we go onto the next slide, New South Wales has recognised this outbreak as a risk to Aboriginal people living in our state and has a raft of different responses to preparing and ensuring we can provide the best care. So there are a number of things listed on this slide. There has been a lot of training done by New South Wales Health and Aboriginal Health in conjunction with AHMRC to train staff in Aboriginal controlled health services and broader health staff. I myself, I think this is my third webinar I have given. And there has been a couple of specific clinical changes that have been alerted which we will come onto during the course tonight, but just to highlight it, the main two really are around an additional antenatal screen which we will cover in detail, and adding syphilis to what we would recommend for routine STI screens. So basically packaging STI screening to be the swabs or urine plus blood tests.

So if we go on to the next slide. So there are a few slides here that specifically look at what has been happening in New South Wales, and you can see that this is the total number of notifications of syphilis and the main message here is that syphilis has been increasing and continues to increase in its frequency. And so the latest full year of data that we have got which is 2018, around 2% of notifications were from Aboriginal people and we are going to break that down more as we go along.

Go onto the next slide. So in terms of the epidemiology in New South Wales by gender and age, we can see here that the overwhelming number of cases are in men. We believe from some additional data that most of those men will be men who have male partners and that remains the largest risk group. But down there at the bottom are the female cases. Whilst they are smaller than the male cases, they are increasing at a much greater rate. So the largest increase in syphilis cases has been amongst females. And you can see from the age distribution that younger people are at risk and that is particularly the case in females. That is a slightly younger group than the overall males, and we suspect if you could pull out the heterosexual males, they would probably match the female age distribution.

So if we go onto the next slide. So this is syphilis by Aboriginal status. It is age standardised so you can directly compare. And you can see the rates are broadly the same, the Aboriginal rate does jump a little around a little bit but that is due to smaller numbers, meaning a few cases can make a difference either way. But also because we are reliant on people identifying the Aboriginal status of birth of the person, at various times being more accurate than others. You know the take home message is that it is a broadly similar rate of infection.

New slide. So if we look at the syphilis cases in Aboriginal people alone, we can see that most cases are in the major cities and that is no surprise, it is where most people live. But there are a significant number of cases identified in regional and remote parts of New South Wales and that is not the case for non-Aboriginal people with syphilis.

New slide. And if we look at it by gender, you can see if you think back to the previous slide, overall the rate of female cases is higher among Aboriginal people than it is among the general population. We think there is a larger degree of heterosexual transmission. That has you know, very important implications for the risk of congenital syphilis and congenital syphilis is the most important complication I guess from syphilis that we are concerned about.

So if we go on to the next slide. So we are just going to pause a little bit there. That is the end of the epidemiology and move onto the biology of it I guess. It is hard to know how to pitch this because different people have different levels of knowledge. But trying to give an overview. So, syphilis is a bacteria. It is transmitted by direct contact on the whole. It can be transmitted by blood, but that is mainly when it is transmitted to the baby. So it is transmitted across the placenta. It is not an infection that occurs at birth like some other infections. It is highly infectious and particularly so in the early stages. It is infectious for up to two years. We believe the vast majority of infection is in the early symptomatic stages or the early asymptomatic stages where someone may not necessarily even know that they are infected. So after you have been infected by direct contact generally through some form of sexual contact, an ulcer will develop at the site of exposure. So that could be a penis in a man. It could be in the vagina in a woman. It could be in the mouth. It could be in the rectum. And so if it is on the penis it is fairly obvious. But if it is in one of the other sites, generally not. So generally, classically minimally painful and so people often do not know they have an ulcer. If that is not treated, around six weeks to a few months it will developed a non-specific viral-like illness and that is essentially the immune system recognising and trying to fight the syphilis unsuccessfully. And that lasts for you know, generally a couple of weeks and then they will enter what is called latent stage, where they are asymptomatic. Latent just purely means they have no symptoms. That stage by definition is divided into two. So early is the first two years and late is after two years. And it is divided into two for two very important reasons. So one, in the first two years we can get away with a single dose of treatment and once they have gone past those two years, while they are at risk themselves, they are not at risk of transmitting it sexually and they need a longer course of treatment to kill it. But, it can be transmitted to the baby or the foetus at any time, even in late syphilis, so it is far more infectious in the blood stream at that point. And then at any stage, the classically late syphilis but we know now can happen in early syphilis as well, syphilis can form very destructive lesions classically affecting the brain, the heart, any soft tissue and of course a foetus. And that are the main complications we see. So at the moment for early syphilis, not infrequently we will see people with hearing impairment or eyesight damage from early syphilis and that is I guess you know, the main downside of not treating syphilis quickly for the individuals themselves.

And I think we go back to Tim at this point for more about testing.

Tim: We do. We have just had a question. Can you tell us which are the four highest risk local health districts? I think that is a question of curiosity there.

Nathan: The four highest local health districts?

Tim: Yes. The four highest risk.

Nathan: Yes, so in terms of the number of cases it is going to be the city-based local health districts who are going to have the overwhelming number of cases. So South-Eastern Sydney, Sydney, Western Sydney. Because of the population. If you are looking at per capita and particularly Aboriginal people then it is quite evenly spread and does vary from year to year because syphilis will occur in clusters I guess. At the moment, you know we have cases in Hunter New England and I am aware that there have been cases in the south and some in the north as well. So really, I would be hard pressed if we focus on Aboriginal people to say there is any area that has not seen cases and it is not a problem.

Tim: So the next slide, and I will just answer one of the questions that came through after we posed the initial question, why do you offer syphilis tests if there is no risk factor identified? And there is a very good reason for doing that. And this is the guideline now for when we test for syphilis. So sexually active people under 30 (under 35 for Aboriginal people), people with risk factors for an STI or a blood-borne virus. So if they have risk factors for those things, they also have risk factors for syphilis. People with symptoms that suggest syphilis obviously. People diagnosed with another STI or blood-borne virus. Sexual or injecting partners of someone with an STI or blood-borne virus and as part of antenatal screening. So those are the groups that are recommended to do that. One of the things that I am aware of, is actually being a man working in an Aboriginal Medical Service, is I do not do that much antenatal care, and I see much more men’s business than women’s business. And I would just like to invite Annie to talk to us a bit about how much attention we need to pay about men’s business and women’s business, talking with patients about sexually transmitted infections and testing for syphilis.

Annette: So I would, as an Aboriginal health worker always say to people that it is about just a respect question. You know, treat people as individuals. You know, there is a very much big diversity in our Aboriginal people around the country and it could even come down to personal preferences as to what people’s individual comfort levels are. I have given examples of this at other training before that if you ask an individual what is their comfort level, do they really have a strong preference to go with a same sex clinician, or what is their preference and I have had Aboriginal men say to me, no for a number of personal reasons I do not want to be seen by a male clinician, I would prefer a female doctor. So, I very much like to promote that you ask people as individual people and you know, because our community knows that our clinicians are well aware of men’s business and women’s business and there are some things even my own family would not, you know make sure there is a hard and fast line, but there are other parts of health care they would like to be asked as an individual, what is their comfort level. And you cannot go wrong if you think of people as individuals and ask them that.

Tim: Thank you. That is really helpful and certainly my feeling would be that we cannot use men’s business and women’s business as an excuse of opt out of asking people this, discussing with people this sort of thing. Patients will tell us what their preferences are.

So if you we go back to Jane. Remember she is a 22-year-old Aboriginal woman presenting for the contraceptive pill which tells us she is sexually active. She has been married for a year and the recommendations are we should offer her syphilis test because she is under 35, the guidelines were actually and Aboriginal. And there are a series of questions coming through about why Aboriginal people and why the syphilis test is different, why the age is different. Again, it is the different epidemiologies that we were looking at where some of the risk factors among Aboriginal people are actually different compared to non-indigenous. The spread is slightly different so we need to be aware of that as clinicians. It is particularly important with regard to congenital syphilis.

So we do a test on Jane and those are the results that come back. Now this is actually a direct screen shot of some results that have come back and I must admit, these are the sort of results that I every time I see something like that I need to look it up in a book again to tell me how to interpret RPRs and TPPAs and what all of that means. So Nathan, guide us through that result, what it means.

Nathan: Yes, sure. So you know, we intentionally took a screen shot of an actual result because we know that it is very confusing and I can vouch for that by the number of calls that I get from GPs requesting assistance with the interpreting which I am more than happy to do. So essentially in reading it, we need to break it up. And so, if we go onto the next slide, we should have some boxes appear. Okay. So, there will be three tests generally on any syphilis result that not negative. If it is negative, it just says negative and we move on. For anyone that is not totally negative, there will be three results. So there will be two. There is an antibody to syphilis, so your normal ITG antibody that you will make to any infection. And you would generally see either CMIA or CLIA. At the moment, they are the fully automated machine-based platforms that the labs use as their initial test. And if that is positive, they will then either themselves or refer on to the two additional tests and one will be either a TPA or a TPHA and that again is just a different way of measuring the same thing. Then they do a third test which is pretty much always an RPR or rapid plasma regain. Which is actually a test that is over 100 years old now. You know it is an antibody of the cardiolipin which is a product of the cell wall. And essentially we need both those two things plus the medical history to work out how we interpret it. So, the syphilis total antibody CMIA or CLIA. That indicates that you have got an antibody to syphilis so that could be that you have got a current infection, or as we know from any other infectious disease, after we treat someone they still retain their antibodies, so that means that they have been exposed at some point. And then the RPR titre, or number, will help us determine if the treatment is needed. So generally what will happen is they will start negative. You will increase during the course of primary and secondary syphilis. Untreated it will then decrease again, but generally not go back to zero. If we treat them, it generally goes back to zero once we treat them. So in terms of a simple approach, so to diagnose a case we would generally both the total antibody and the RPR to be positive and then we need to make sure that they have not been treated in the past, or if they have been treated in the past, that the RPR titre has not increased fourfold, so for example from two to eight, since their last treatment. So that is the essential way in which we approach it. So we need to know whether they have been treated and we need to know their past treatment results in order to put that all together. So that will generally mean looking through their records which will have their lab results and putting it together.

So if we move on to the next slide. So if we interpret Jane’s result. And we are assuming Jane has no symptoms at all, and I am just going to give you a little bit of extra information that is not on the slide. So she is a regular patient at your clinic and she was treated last year as part of a routine 715 health check and that was negative at that point in time. So if we look at her now, she has got total antibody reactive on both the CLIA and the TPPA, so we know she has been exposed to syphilis and we know she was negative a year ago. So we know this is a new infection. The RPR test is positive confirming it.

And so if we go to the next slide. This is early latency because she is negative within two years because she was negative last year. She has no symptoms, so she is by definition latent and the less than two years makes it early latent. And that titre of 256, that is reasonably high. She is highly likely to be around the secondary stage at this point in time. But that is detail. You really are just trying to say, okay this is a new infection, we definitely need to treat her.

Tim: Just on that, a question has just come through. Is there a time scale for the fourfold increase or is it just any fourfold increase?

Nathan: For the increase, no there is no time scale. So if you have got a person in front of you and they have got an RPR titre of one in 16, and you have got a previous result from last year that is one in two, that is an increase and that is an infection. There is a time scale on the decrease. So as you treat someone, it is reversed and we want to see a fourfold decrease to know we have treated them properly and they have not been reinfected. That can take up to a year to occur. We should not see an increase after you have treated them, that would be concerning. But it may take a full year to go either down fourfold or hopefully to negative.

So yes, treatment. So, treatment is mechanically easy. Some of it is a little bit tricky to get a hold of it I guess, but for early syphilis, so that is either someone who you know has clear symptoms of syphilis or has had a negative test in the last two years, we give 2.4 MU which is 1.8 grams in old style you might remember, but the box is now changed. We have got a picture of the box there because that causes a lot of confusion, which is two vials. So you want to give two vials. I usually give one in each buttock; you can use the thigh, as a once only dose. If you are not 100% certain that this is an infection that occurred within the last two years, you need to repeat that weekly for a total of three doses. So two jabs a week a part. A total of six vials is what you will need. In terms of cautions to think about, so anyone that has got any symptoms of neurological eye or ear, they should be referred to hospital because they need additional treatment intravenously. You could ring for advice first if you are not sure. Anyone that is penicillin allergic, we would usually recommend to get advice because we do strongly prefer penicillin if we can and in most people who have penicillin allergies you know we can generally use penicillin still. And for pregnant women, we would encourage people to get urgent advice. Urgently refer if required. You would treat a new case of syphilis in a pregnant woman as a relative emergency to ensure treatment.

And if we go onto the next slide. So I mentioned earlier that it can be quite hard to access benzathine penicillin and one thing that sexual health clinics do a lot of, is just treating people because GPs know full well what to do but they cannot get a hold of it. You can order it in advance in the Doctor’s Bag. It is also PBS listed. We see quite a lot of people with a private script which is over $300 but it is actually on the PBS and of course you can just close the gap. Not all pharmacies stock it unfortunately, so if you have any trouble getting a hold of it, jump on the phone and call your local clinic and they will be able to sort it out for you. I think that is back to Tim at this point.

Tim: Yes it is. So back to Jane. We treat Jane with a single dose of benzathine benzyl penicillin. Jane’s partner is also tested and treated. Jane is then tested again three months later and her RPR is now non-reactive. So my understanding is the significance of that is that we have successfully treated Jane’s syphilis. So two years later, Jane returns and is pregnant. So what syphilis testing will Jane need in her pregnancy?

Nathan: So it is back to me now to talk about syphilis in pregnancy. As I said before, syphilis in pregnancy is really one of the main things we are concerned about. The syphilis organism that will be in the mother can cross the placenta at any stage of pregnancy. And if the mother has early syphilis that is not treated, the foetus will almost certainly die, 50% in utero and 50% at birth. And therefore, really if a woman has got early syphilis in pregnancy we need to treat her as soon as possible, every day could be the day that that baby dies of syphilis. And of course even if the baby is not still birth, it will still be suffering damage in utero. So it is a short time to go through all the details of congenital syphilis, but essentially if it is not a still birth or in utero death, there is a high risk of major organ failure through the sort of destructive response to the treponemes. Babies can be born symptomatic or reasonably asymptomatically. Often they will have skin lesions or if you do x-rays they will have inflammation of the periosteum which can cause deformed bones over time. And in some cases if it is not detected, it will stay there and it cause essentially neurosyphilis and the baby generally ends up in early adolescence with developmental delay, cognitive impairment and that sort of thing.

If we go onto the next slide. New South Wales Health released a number of alerts and so this is the first level around pregnancy. And that is really prompted by the fact that this large outbreak that is occurring across northern Australia and to the borders on two sides now, has been associated with a number of cases of congenital syphilis. So there have been 16 cases to date that meet the criteria. And of those seven have died. All of them have been in Queensland so far, but that is something that we are obviously quite concerned about. And so the alert came out in 2017 and it was developed in collaboration with the Senior Medical Advisor for Obstetrics, Professor Michael Nicholl and broadly falls in line with what was already the case in most jurisdictions in Australia which is adding the second test. So for as long as I am aware of, all pregnant women no matter what, get tested early in gestation usually at the booking visit for syphilis and then the additional thing is a test at the 24 to 28 week mark which is already a visit with bloods taken to do a repeat test for anyone at increased risk. Due to the epidemiology where we have shown already that in Aboriginal people there is an increased number of female cases and heterosexual cases, and associated with this outbreak that is at risk of spreading in New South Wales we deem all Aboriginal people to be within the high risk category and therefore quality for that 24 to 28 week test. And really encouraging people to seek advice around this to do this as best as possible.

If we go onto the next slide. So, to answer the question I guess that Tim posed a second ago – so next slide after that – so what we would do, we would test her today as this is the first day we see her, we know she is pregnant. But, we are going to put it in her antenatal care plan so that when she comes back for her 24 to 28 week visit we can test her again. Now we know when that result comes back, just thinking ahead what are we going to do when this result comes back? So we know Jane is going to test positive. So she has had syphilis in the past, she will test CLIA or total syphilis antibody positive. But, the RPR was non-reactive at our last test and we would expect that to be non-reactive again. Should that increase fourfold, and so non-reactive fourfold titre goes from non-reactive to one to two. So if Jane returned with an RPR titre of two or more, we would treat her.

If we go onto the next slide. So there was another alert that came out which was more specific and that really promoted broader testing which was increasing the testing in STI screening as we have said already for any Aboriginal people under 35. And I think there was a question earlier about why 35 and not 30 for Aboriginal people and that is in terms of the epidemiology, so the age range is greater in Aboriginal people in general. And the second thing was to really promote that syphilis testing should be a stand apart of 715 checks in anyone in a sexually active age group. And that is partly to destigmatise and make it routine. We need to move away from the idea that testing is only done in people that report specific risk factors, because for a number of reasons, one it is not very accurate ascertaining people at risk for a number of reasons. And secondly people do prefer testing to be made routine and de-stigmatised. Individual risk of any sexually transmitted infection is in a large part related to their age, their physical location and things that are sort of outside of their control, and the second part is the risk of their partners, which again is basically outside of their control. So we have got take it away from this moral idea of is this person doing something themselves that places them at risk, and think of them as a member of the population that is at increased risk in general. And then another alert which is syphilis in women. And so sorry, this is the second alert, the other two were the same. So as I said, there has been an increase in syphilis overall in women, non-Aboriginal and Aboriginal. I for one when I started my training near on 20 years now, I almost never saw a woman with syphilis, now I see a woman with syphilis not infrequently in my daily clinic practice, and so that has really made it very important to ascertain that all pregnant women get tested for syphilis. All women with syphilis get tested for pregnancy. And promoting contacting sexual health clinics and public health units for advice around women with syphilis.

Next slide. And this is the last alert now which is only hot off the press. And so there has been an increase in syphilis in the Mildura region reported. So as you may know, Mildura borders on to the Far West Local Health District in southern New South Wales. Those cases have seen 70% being women and more than expected being Aboriginal people so that is obviously a concern for us. So a reason for people to be aware of that. And of course when we think about this, a lot of the spread of the outbreak has been from contiguous areas, and the movement, the cultural movements, but throughout the whole period of this outbreak that I have now been involved in for five years, there has been sporadic cases everywhere because as we know, people fly and move all over the country and take their infections with them.

So, next slide. So we talked about testing and treatment, but of course I think most online are going to recognise that we also want to look at contact tracing for people with syphilis and the main thing here is to promote people to let their partners know. So we have got the time standards on there. I guess that is the detail I promote, because overall just make sure you are thinking about that and getting help, and there is a lot of help available.

There is a contact tracing tool that RACGP has put out in collaboration with New South Wales Health. We will not go through it in detail, but there is a link there and then it also tells you how you can go about getting help because there are tools to help you. So one example on the next slide is a website called Better To Know. So that is an Aboriginal targeted site where people or you or one of your staff can do it for them, where they can anonymously notify people which can break down barriers. And I think then Annie is going to talk about the specific Aboriginal issues.

Annette: Yes. So just following on from that. It was good doctor that you made mention that we cannot be complacent if are outbreaks are happening not exactly in our state, but then you mention Mildura. It is because that state is in the fluidity of our people whose homelands actually you know, cross over the state boundaries and so, us in Hunter New England, we are very much aware that with our North West communities, you know our border town communities that border with Queensland, that a lot of fluidity happens you know, back and forwards over the border. So the consideration for Aboriginal contact tracing is we always try and ensure that you have got the right person that you are communicating with on the phone or that you will be messaging. If other people have got access to that phone is that the best way to contact them? I had a great little duty statement written up years ago that the doctor said that she would value us to do professional loitering is what she called it, and it is where you know, sometimes we have got to keep our ears to the ground without putting it out there that we are looking for particular people, but if we think we are going to find a couple of young men for example, we might just go down and watch the football training one night for example. Or catch them at the TAB on the weekend or at the local football match, and just to see if people are still in town. Knowing when to time your home visits if you know that maybe the next door neighbours might be looking out the window to see who is pulling up to their neighbours and getting a visit. It is all about kind of community safe links that you want to try and keep rolling and happening and so that you are not in any way just in trying to perform your job you might be breaching somebody’s confidentiality. The Knowing the Community Safe Links with your local service providers, also I have said over the years, as I am getting older, I feel a lot more safer and comfortable with talking with, looking for men you know, sometimes women will want to know what are you looking at my partner for, or my boyfriend or whatever. And so sometimes it can make it a bit uncomfortable with you know, you being the direct contact if you are a worker of the opposite sex. And other times, as I said as I have got older, people have felt more comfortable with me and I have been good at telling white lies over the years – I’m just calling them up to see if they wanted to participate in our Men’s Health program, you know? But in actual fact I am trying to get for a contact or something.

You have people with the same name and I give the example there on the slide, three generations of the same name living in the same household, but could all be very sexually active. And so you know, if you are going to ask for Tom Smith or whatever other name, you make sure you have got the right Tom Smith before you give over any health information or what you are following up about.

Lots of frequent change of mobile phones and numbers I have found over the years, so you know it comes back to your knowledge and your understanding of what is going on in the community as to whereabouts those people that you are looking for might be. Be careful of written mail. You know, I probably even have the same problem as this within my own immediate family where other people think, oh I wonder what someone has contacted them about? You know, the family member and they may be the person that opens the mail. So, or they have gone away and you know they think I better read it just in case it is something that I need to tell them that they have got to follow up about.

Aboriginal health worker use of the service providers and the community networks to see what is happening and you know people could be away for cultural obligations or for seasonal work, or in a lot of cases, sadly it could be that myself in particular cannot find someone because they have become incarcerated. So I do not know, a lot of you may be familiar with the term Murray Grapevine? It is very good for finding out where people are and what they might be doing, but we also need to be mindful of this because how and when you approach individuals about that kind of stuff, or you visit them at their homes or seem to be asking too many questions during work time, you might actually just be outing that person by asking those questions 9 to 5. You might be best asking that question when it looks like a social question on a weekend, or after hours of an evening or something.

Next slide. So, bearing in mind you know I am out there and other people are out there like myself that work in Aboriginal sexual health and blood borne viruses. We are always saying to people to get them to build a comfort level around the importance of well person’s sexual health checks. You know, saying to people you can have something serious happening for you without any signs or symptoms, so do not wait till you have got something that is making you feel sick, or signs or symptoms that give you pain or whatever else. You know that could be at a more serious stage of something. So if people could just realise that you know, being a sexual being, at least an annual health check-up, may be that needs to be more frequent if there have been risk factors where maybe not always condoms have been in use. And even for the point that people might for penetrative sex and they do not use it for oral sex, and so you know, you have infectors that go up into the mouth area. A lot of people still assume that sexual practices would keep them safe, you know, oh well I do not do that because I am not guy, or I do not do that. So the stereotyping where people’s sexual practices do not meet their sexuality, that conversation still has to happen. And the fact that a lot of our local health areas have high rates of men who have sex with men who do not identify with the gay community. And to be able to respectfully and sensitively be able to put that across to a young female whose partner may be incarcerated, but could also be bringing something home to her from you know, from jail time. You know, these things do happen. I have talked to a lot of men over the years and they do not associate emotion with sexual release and so then they might just get what they need from that particular time from whoever is closest to them, but then you have got to get them to understand that they are going home and they might be taking some infections home with them as well.

Definitely reassure people that what the tests you are doing with them are specific for this and this only. Too many of our people are reluctant to give urine screens and blood screens, especially if they might have in their mind breached their parole or corrective services, you know previsions that have been given to them, and so they think, oh no if I give over urine for a sexual health screen they might pick up that I have been smoking marijuana last night. And so if you can reassure people that sexual health tests are very specific and the test will only be showing us whether or not they have come into contact with a sexual health infection and that we are not the police or anybody else that is going to be dobbing them in for whatever else is happening in their life, and to then make them feel comfortable to you know, say well if I can have that and know whether or not I have got something or I have got a baseline test now so that if I have one in another 12 months’ time, if the next one comes up as positive, well then it might be that oh well, I can probably predict the time that was the risk factor that gave me that infection or whatever.

We also worry about healthy relationships when we are talking with our communities around sexual health and blood borne viruses. We do not want people doing the blame game on each other if we have to tell a person that they have got a positive sexual health feedback and what does that mean to them in regards to their regular partner. What does it mean for you knowing that you have got it and you know that you have been maybe the person who has not and any other extra partners. But it is the way someone else has had that intimate relationship, then what does that mean for you? Will there be safety around you being able to tell your partner that they need to be tested or treated because of your positivity at that particular time. So sometimes, an Aboriginal health worker may have to go just a bit further than what they normally would to ensure that they engage people with services who can help them with that, the rest of their holistic healthcare around being safe and being in a healthy relationship.

The thing that I picked up on before was you know, obviously there is a standard where people will ask someone if they are Aboriginal. I am just wondering if it is a regular, if someone says no, and for example in the antenatal or prenatal sessions sorry, is it a regular question that you would ask, is their partner of Aboriginal descent? Because it may mean that you know, the mother who is pregnant might not be Aboriginal, but they might have an Aboriginal partner who they are having their baby with.

So I do a lot of engaged share care, follow through care, making sure you know, cultural work and obligations always stay in play. I think I am on the next slide, sorry. I have got that far. Yes, and be aware of the movement that we were talking about earlier, that you know I might go north west to a community and someone will say no, they have gone out further west to do grape picking and by the time I get to have someone connect with me in that community, no they have gone down further south for anther lot of seasonal work. So sometimes, as much as you try to be as quick as you can with contact tracing, it does not always work very fast because it takes a while to catch up with some people if they are moving about for seasonal work or cultural or family obligations.

Yes, so I have written on there, the concept of infidelity. That is something that we do worry about for our community. We do not want to be putting any more negative around there around sexual health especially, or people thinking, oh well I do not have anything because I have no signs or symptoms. So just to reassure people that you can have something serious without knowing about it.

Advice from family and cultural advice should go hand in hand is a good thing to promote with clinical advice. You know, we come across a lot of young mums over the years where they have got a big family circle that supports them with their pregnancy and you know, their mother, their grannies have all had children before them and they give them that kind of steering advice, but to reassure people that you know, we also need you to see the importance of clinical check-ups because there could be something happening to you or your baby that you will not know about. Just because things are looking good, feeling good, your belly is growing and everyone is supporting you through that kind of part of your life with the baby coming along, something could be happening on the inside, so it has been really hard to keep on educating people over the years about you know, that serious things can be things that do not ever give you any signs or symptoms. They could be something that, what happens to you today, how you feel today, might not affect you straight away, but down the track it will if you have not been having your well person sexual health blood borne virus checks.

So have I done sexual health and the whole person annual sexual health BBV checks? Sexual practices not matching sexuality in the stereotyping definitely have done that. We do not want to worry about the blame game. We want to make sure that we get people just you know, saying well it has happened, it is best to have your check ups and get treated and we are going to support you around doing that. And to always reassure your patients on how specific the blood and the urine tests will be. They are not going to pick up everything that you might have been doing in your social or family life. I hope I made sense then.

Tim: That was really good, Annie, thank you very much. And I think this is just some practical tips really around making syphilis testing less stigmatised to become more a sort of a normal part of just what we do, a normal part of STI testing. And so, doing it as a routine part of health assessments for those under 35 years. Displaying material in waiting rooms or on practice websites or on Facebook could be really useful because you then have a conversation that says, oh, did you see the posters we have got up in the waiting room? Yes, we started to talk about some testing for syphilis. So it just makes it sort of a normal conversation that is not targeted at an individual’s behaviour, it is just part of what we are doing more routinely.

Making use of the specimens that you already have. So someone was talking in the question box about parallel testing and making use of those, and doing it at the same time as other testing so that we are not doing multiple needles on people. Being able to have access to free condoms and I will show you a website where you can request those in a minute. And I think all of those go to how important it is, Annie I am sure you will back up this, that almost all of your Aboriginal and Torres Straight Islanders will have had a bad experience in the health service somewhere, as well as many of our other patients. To be conscious of that and to say, that is not something that is going to happen here and allowing people to make decisions for themselves and ensuring that people understand the testing that is being done and the reasons for it in a non-judgemental way I think is really important. And then as part of that, is people being willing to come back to see you and using recall systems for repeat testing and recall systems for testing partners of people as Annie was saying as well, people’s partners and testing them. Those are often the most effective measures of finding untreated cases. Is there any practical advice you would add to that, Annie?

Annette: No. So long as people see the importance of you know, we are not judging people by offering the test to them. You know we are just trying to give a holistic screen test for this stage of your life because of this, and so normalise it and say it is just another small part of your body that you have got to keep well and keep well looked after, just as much as we have got to keep an eye on diabetes or kidneys or heart in our communities.

Tim: Absolutely. And that is a really good important point. Someone was asking, doctors check for chlamydia and gonorrhoea in the sexually active under 30 and should we check for syphilis as well? Yes, it becomes part of your routine STI screening and in the same way it becomes part of your routine antenatal testing as well. So as GPs we are always looking holistically at not just a single condition, but across the whole person. So it becomes a routine part of our other testing.

This is about the Play Safe Pro. Nathan, I gather this is where we can actually get free condoms for our practices?

Nathan: Yes. So Play Safe is a website aimed at young people that is very popular. And Play Safe Pro is the version that aims at I guess, us. The main thing that we want to promote here is that you can actually order free condoms. The link is on the screen there. You can have a look and a play around there. There is quite a lot of stuff there if anybody online is not strictly clinical and does any educational stuff, there are some great tools on there.

Tim: That is brilliant, thank you. Just quickly over the next few slides, one of the things I know in practice is I do not rely on my memory if I am asked to remember to do a test each time, I will forget. But if we add it to for example in Medical Director, favourite tests, you can actually have a list of tests and it puts them all in the box. So for example this is my STI check and we can add syphilis into that. This is my antenatal screening, and we can add syphilis into that. This is my under 35 health assessment set of bloods that I do, and I can add it into that. So it actually becomes a routine part of the pathology that we are asking. I do not use Medical Director, we use Communicare. I am not going to go into the detail about how you set up the favourites, but most of you I am sure would already know that anyway. But this slide and the next slide just demonstrate that we are able to do that in Medical Director, and there are YouTube videos on that as well. There are links guiding you through screen shots on how to do that. And similarly is the case for Best Practice. Those of you working in Aboriginal Medical Services as well, if you are using Communicare, then there is also ways of doing that in Communicare too. So get to know your software to use that for requesting the tests and for using it to do recalls and then the computer does our remembering for us. It comes out of the practice system as opposed to us just individually remembering each time.

So I think that is all the slides that we have got. We are running well to time. I have just been seeing the questions come through. Someone has asked a question which I think is a little bit difficult to go into in any useful depth tonight, how to approach the sexually abused paediatric age group Aboriginal and Torres Strait Islander community. I think that is the sort of scenario where you go very carefully. You get specialist advice and you get Aboriginal health worker advice on that as well, because I think that could be a particularly difficult scenario. Bearing in mind too, our status as mandatory reporters, which puts some legal obligations on us. So that is a particularly difficult scenario I think to tackle tonight.

Annette: Can I just say something about that, that sex infections happen in healthy relationships as well. You know, it is not just from sexual abuse. I think a couple of times over a period of years, I have heard every now and again people think that it only happens to people who are having negative sex, whereas our whole education and promotion in the community is around being sex-positive, and that infections do not know whether you are in a good relationship or a bad relationship, it does not know if you are black or white, rich or poor, gay or straight, that these kind of infections can happen to anybody and not to take away from the importance of making sure people are having or being sexually active with people’s consent, but these things do happen, or can happen to anybody. And it does not mean anybody who has had the most amount of sexual activity, just one sexual practice for someone to come into contact with an infection.

Tim: Yes, I think that is a really good point and we need to be aware of our tendency to make things pathology sometimes and to just back away from that and not everything we see is particularly bad. We have actually come to the end of our time, it is 8.30 now. I am just going to go over the learning objectives again to see that we have covered everything. Oh, one question if the partner is Aboriginal not the mother, are we going to treat her as Aboriginal? No, so if the partner is Aboriginal and not the person themselves, they are not eligible for things like Closing the gap PBS co-payment and not eligible for PBS medications or an Aboriginal health assessment as those things are based on Aboriginals, however they would be caught as contact tracing and I think you would use your clinical judgment. So say the patient was 34 and non-Aboriginal but had a 34-year-old Aboriginal partner, you may use your judgement to say okay, there is possibly a need for syphilis testing there. That would be a clinical judgement question.

So these are the learning outcomes, and hopefully we feel we have succeeded in discussing the prevalence and incidence of syphilis in New South Wales and identified higher risk groups. We have described the recommended testing schedule and testing methods for syphilis including antenatal screening changes in Aboriginal and Torres Strait Islander people. We have described syphilis results interpretation and treatment. We have identified barriers and challenges in conducting syphilis testing and prescribing treatment. And we have demonstrated how to incorporate new knowledge into routine clinical practice.

So on that note, I would like to thank very much both Nathan and Annie for a really helpful presentation and Sammi for running all the IT, and also to Tim Lockwood who you may have seen popping up in the questions there who has been present just helping out behind the scenes and in developing the webinar. So thank you very much to all of you for being here tonight.

Sammi: That is great. Thanks Tim. And just from the RACGP as well I would like to say another huge thank you to our presenters Nathan, Tim and Annette, thank you so much for joining us and thank you to everybody that joined us online as well. We really hope that you enjoyed it and enjoy the rest of your evening.