Men’s Ochre Day

Aboriginal men’s Sexual Health

Darwin 2017

A/Prof James Ward

• Acknowledgements

• Overview of Presentation

– Sexually transmissible infections (why do we worry)

– HIV (everything is different)

– Hepatitis C (everything has changed)

– Strategies for addressing STIs and keeping HIV out

STIs- why do we worry

• Chlamydia, gonorrhoea, syphilis ( bacteria or bugs)

• STIs happen despite best intentions

• Takes 2 to tango

• STIs including HIV often don’t have no signs or symptoms

• Mostly occur in young people (15-29 years)

• Regional and remote communities particularly affected

• STIs generally are easily tested and treated and yet we have a major burden of disease

STIs why do we worry

• Outcomes for most STIs- shame, stigma, if untreated for men- pain, epididymitis, proctitis, infertility

• For women- no good in pregnancy- loss of babies during pregnancy, infertility, deformities

• Link between STIs and HIV if you have an STI and HIV comes into play– increases chance of HIV being transmitted by 2-5 times

Leading incident conditions

Indigenous 10 – 24 years

Chlamydia and gonorrhoea by

remoteness

0

500

1000

1500

2000

2500

3000

Major cities Innerregional

Outerregional

Remote Veryremote

Area of residence

Chlamydia

0

500

1000

1500

2000

2500

3000

Major

cities

Inner

regional

Outer

regional

Remote Very

remote

Ra

te p

er

10

0 0

00

Aboriginal and Torres Strait Islander

Non-Indigenous

Gonorrhoea

Notification rates of gonorrhoea infection in 2014 by Aboriginal and Torres Strait Islander status1, sex and age group

Source: State/Territory health authorities

0

500

1000

1500

2000

2500

0-14 15-19 20-29 30-39 40-49 50-59 60+

Age

sp

eci

fic

rate

pe

r 1

00

00

0

Age group

Male Female

0

300

600

900

1200

1500

1800

2100

2400

2700

3000

0-14 15-19 20-29 30-39 40-49 50-59 60+

Age group

Aboriginal and Torres Strait Islander Non-Indigenous

1 Jurisdictions (NT, QLD, SA, TAS, VIC, ACT & WA) in which Aboriginal and Torres Strait Islander status was reported for more than 50% of diagnoses each year in the past 5 years

STRIVE STI co-infections in remote Aboriginal

communities: females

0

10

20

30

40

50

60

16-19 20-24 25-29 30-34 35+

Females

Po

sit

ivit

y (

%)

CT, % with NG NG, % with CT CT, % with TV NG, % with TV

Guy et al STI 2014

STRIVE: STI co-infections in remote Aboriginal

communities: males

0

10

20

30

40

50

60

16-19 20-24 25-29 30-34 35+

Males

Po

sit

ivit

y (

%)

CT, % with NG NG, % with CT CT, % with TV NG, % with TV

Guy et al STI 2014

Syphilis outbreak in northern Australia 2011-2015:

the epidemiology and public health response

Syphilis outbreak northern Australia by

jurisdiction

ACCESS to HEALTH SERVICES

STI testing

Clinical guidelines

1. Guidelines recommend annual testing of 15-29 year olds for STIs

2. Test for reinfection

3. Full STI screening after a positive diagnosis

SHIMMER: Health care attendance over 3

years, 4 regional AMS in NSW

32

19

28 29

40

52

0

10

20

30

40

50

60

females males

Pro

po

rtio

n

every year 2 of 3 years 1 of 3 years

Health care access NSW sites

0

1

2

3

4

5

6

7

8

9

15-19 20-24 15-19 20-24

Males Females

Aboriginal sexual and reproductive program, NSW

2010 2011 2012 2013

Health service use, by sex and age, 2010 (

FNQ)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

16-19 20-24 25-29 30-34 35-39 40-44 45-49 50+

% a

tte

nd

ed

Age Group (years)

F

M

Total STI testing by calendar year

9,83010,660

12,73313,855

6,452

8,861

10,386 10,853

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2010 2011 2012 2013

Nu

mb

er

of

test

s

Year

Chlamydia Gonorrhoea Trichomonas

Retesting at 2-12 months after a positive Dx

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

16-19 20-24 25-29 30+ 16-19 20-24 25-29 30+ 16-19 20-24 25-29 30+

Overall Males Females

Pro

po

rtio

n r

ete

ste

d

Age group (yrs) and sex

n=2054 1288 females 15% within recommended 2-4 month period

Garton et al 2016

Repeat positivity at 2-12 months, by infection type and sex

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

CT orNG

CT only NG only CT andNG

CT orNG

CT only NG only CT andNG

M F

Pro

po

rtio

n r

ete

sted

Infection type and sex

Garton et al 2016

STI and HIV/syphilis testing

Any +

STI test

HIV and syphilis testing within

30 days of any positive STI test

(incl. same day)

HIV and syphilis testing within 30

days of any positive STI test

(excl. same day)

N HIV test <30

days

n (%)

Syphilis test

<30 days n (%)

HIV test <30

days n (%)

Syphilis test <30

days n (%)

Overall15260 4,858 (32%) 6727 (44%) 854 (6%) 1099 (7%)

Sex

Male 4190 2035 (49%) 2355 (56%) 208 (5%) 209 (5%)

Female 11055 2815 (25%) 4361 (39%) 646 (6%) 889 (8%)

Ward et al MJA 2016

Barriers and facilitators of STI testing in remote Australian

Aboriginal communities

• Distance to laboratories

• Patient recall system management

• Gender

• At one stage there were only two female nurses for a few weeks [while the male nurse and health worker were away]. You’ll find that they’re [men] asking for the men and if they’re not here they’ll just leave. They’d rather go in pain for 2 weeks and wait for one of the boys to comeback (RN20, female, worked remotely <1 year).

• Health centre layout

• Living and working in small communities-trust, but also mistrust (non-disclosure)

• High staff turnover

• Strategies to overcome kinship and small community issues

Xpert® (Cepheid) Molecular POC Test

for CT & NG

Laptop

Xpert machine

Xpert cartridge

Single use test cartridge

Urine specimen

Swab specimen

One final thing- STIs and CSA

• STIs being related to sexual abuse? - T/F

• STIs in <16 yo is a sensitive issue

• From 2010 – 2014, a total of 3 428 and 6 670 cases of chlamydia were reported among Aboriginal and Torres Strait Islander and the non-Indigenous populations aged less than 16 years respectively.

• In the same period 1983 and 362 cases of gonorrhoea and 68 and 2 cases of infectious syphilis were reported in the Aboriginal and Torres Strait Islander and non-Indigenous populations aged less than 16 years respectively.

STIs and CSA

• Among Aboriginal and Torres Strait Islander population, the majority of these notifications (95% for chlamydia, 94% for gonorrhoea and 93% for infectious syphilis) were among people aged 13 to 15 years. Similar proportions among non Indigenous people

• The majority of diagnoses of STIs in the young Aboriginal and Torres Strait Islander population occurred in areas of known high endemicity of STIs, and where screening for STIs is routinely carried out.

• Caution should be taken in describing these data as related to child sexual assault; as it is likely that a significant proportion of these notifications are the result of early sexual debut and/or sex with peer-aged partners.

HIV Everything’s changed

• HIV rates are increasing

• They are being diagnosed in areas where we have never seen HIV before

• We have high rates of STIs- that make it easier for HIV to be transmitted

• However testing and treatment and prevention has changed

• HIV is still not curable

• However the medication has changed

0

10

20

30

40

50

60

70

80

Number of HIV diagnoses since 1992 by 2 year periods among Aboriginal & Torres Strait Islander People

HIV notification rate in the Australian-born population, 2006-

2015

3.1

6.8

0

1

2

3

4

5

6

7

8

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Age

sta

nd

ard

ise

d r

ate

pe

r 1

00

00

0

YearAustralian born non-Indigenous Aboriginal and Torres Strait IslanderSource: State and Territory health authorities

Lessons from Canada

Aboriginal and First

Nations, Metis and Inuit

make up 4% of the

population

Where reported

Aboriginal peoples

make up ~20% of HIV

diagnosis

Saskatchewan- Canada

Hepatitis C and Aboriginal and Torres

Strait Islander peoples

• Estimated between 16,000-22,000 Aboriginal and Torres Strait Islander people living with HCV

• Representing 8% of total people living with hepatitis C in Australia

• Disproportionate rates among women

• Disproportionate rates among younger age groups.

Hepatitis C notification rate, 2011-2015, by Aboriginal & Torres

Strait Islander status

33

2011 2012 2013 2014 2015

Non-Indigenous 44.4 42.0 43.1 39.5 40.4

Aboriginal and Torres StraitIslander

115.3 128.5 139.2 158.0 164.9

0

20

40

60

80

100

120

140

160

180

Ag

e s

tan

da

rdis

ed

ra

te p

er

10

0 0

00

Year

Hepatitis C notification rate, 2011-2015, by age group

and Aboriginal and Torres Strait Islander status

34

2011 2012 2013 2014 2015

0-14 0.0 3.2 1.6 4.8 3.2

15-24 155.5 177.7 197.2 247.2 247.2

25-39 258.4 281.4 273.7 350.5 350.5

40+ 107.3 125.5 152.9 139.2 148.4

0

50

100

150

200

250

300

350

400

Rat

e p

er 1

00

00

0

Year

Aboriginal and Torres Strait Islander

2011 2012 2013 2014 2015

0-14 0.4 1.3 0.2 0.7 0.5

15-24 33.5 38.8 40.2 33.3 30.4

25-39 82.4 74.6 76.2 69.0 68.5

40+ 48.1 44.7 46.5 43.5 46.2

0

50

100

150

200

250

300

350

400

Rat

e p

er 1

00

00

0

Year

Non-Indigenous

Hepatitis C

• Mostly acquired in Australia through injecting drugs and in prison

• Treatment has changed in the last year

• Cure rates 90-95%

• 8-12 weeks couse

• Can be prescribed by GPs ( ACCHS)

• People living with disease can be free of HCV

Translating our work

youngdeadlyfree.org.au

www.atsihiv.org.au

Education-

Health literacyCommunity empowerment

NSPsOST

Detox/rehab

Adequate PHC –BBV testing treatment

Much more in the toolbox- combination

prevention

TasPART and

DAAsPEP and

PrEP

Drug reform

Key points

• Test test, test for STIs 16-24 but not at expense of none in 25-39 for CT, NG and TV

• Encourage young men and those who don’t come to clinic

• Be alert for syphilis

• HIV testing after a positive diagnosis

• HIV testing

• Alert for injecting drug use (IDU, meth, other)

• Finally STIS and BBVs absolutely need to be included in both local and national Aboriginal and Torres Strait Islander Mens Health Strategies.

• We cant rely solely on mainstream approaches to address this issue.

A/Prof James Ward Head Infectious Disease Research Aboriginal Health SAHMRIjames.ward@sahmri.com 0881284270 0439605227