NACCHO #HIV News : Treatment as Prevention Roadshow included eight meetings with Aboriginal and Islander Community Controlled Health Services.

HIVED

” The potential exists for HIV to escalate rapidly in the Aboriginal and Torres Strait Islander population – as has been the experience in other Indigenous populations globally. This potential is due to three main issues:

  • very high rates of other sexually transmissible infections (STIs) exist in many communities, and the presence of these increases the chances that HIV can be transmitted
  • increasing rates of injecting drug use – including increasing rates of methamphetamine (ice) use in Aboriginal communities, and
  • the close proximity of Papua New Guinea (PNG) to the Torres Strait Islands, and the mobility and interaction of PNG nationals and Torres Strait Islanders. PNG has the highest recorded rates of HIV in the Asia-Pacific”

Associate Professor James Ward is Head, Infectious Diseases Research Aboriginal and Torres Strait Islander Health at South Australian Health and Medical Research Institute (SAHMRI) and a guest editor of HIV Australia.U And Me Can Stop HIV

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” Currently the lifetime cost of treating someone with HIV ranges from US $250,000 to US $500,000 (2006 figures).

Our Treatment as Prevention Strategy we have reduced new HIV cases in BC from 700 per year to less than 300 – which has provided savings of around $50 m per year.

We have also managed to nearly eliminate AIDS and there’s an important distinctions between AIDS and HIV – AIDS is the result of being infected with HIV for many years without treatment while HIV is an infection we can now treat and control the virus and prevent it from becoming AIDS.

In addition, people with AIDS can also be treated and become healthy and contribute to society like anyone else.”

Assistant Director, British Columbia Centre for Excellence in HIV/AIDS Dr Rolando Barrios

The Queensland HIV Treatment as Prevention (TasP) Roadshow took place over the last week of July and first week of August 2016.

The Roadshow, supported by the Queensland Aboriginal and Islander Health Council (QAIHC) and the HIV Foundation Queensland, engaged with health professionals working in Aboriginal and Torres Strait Islander and mainstream services across north –eastern Queensland.

Speakers included Assistant Director, British Columbia Centre for Excellence in HIV/AIDS Dr Rolando Barrios (also principal investigator of the Pharmacovigilance Program and Co-Chair of the Therapeutic Guidelines Committee), Director of Operations British Columbia Centre for Excellence in HIV/AIDS Ms Irene Day , Positive Living British Columbia Mr Glen Bradford and South Australia Health and Medical Research Institute Associate Head of Infectious Disease Research – Aboriginal and Torres Strait Islander Health Professor James Ward.

The Roadshow was aimed at educating health professionals and raising community awareness, a job made more urgent because of the spike in STI and HIV among Aboriginal and Torres Strait Islander people in Queensland over past 12 months.

The Queensland HIV TasP Roadshow included eight meetings with Aboriginal and Islander Community Controlled Health Services, and evening dinner meetings for health professionals in the same locations, starting in Brisbane on Monday, July 25.

The Roadshow brought together latest practice and evidence from around the globe in HIV prevention including the concept of treatment as a prevention and new medications such as pre-exposure prophylaxis (PrEP), both of which aim to significantly reduce the number of new HIV diagnoses.

Apunipima caught up with Irene Day and Dr Rolando Barrios at the Wuchopperen Health Service workshop on 1 August.

Apunipima: Tell me about the Roadshow

ID: The Roadshow is travelling throughout north – east Queensland talking about our concept of Treatment as Prevention (TasP) which was introduced by the British Columbia (BC) Centre for Excellence in HIV and AIDS in 2006. We’ve had a great deal of success with it in BC, in terms of driving down the rates of new cases of HIV. We’ve virtually eliminated AIDS, which is, of course different than HIV.

Apunipima: Is this both in the Aboriginal and mainstream populations?

ID: Both, but let me be clear we have not done as good a job in getting our Indigenous populations into care and treatment so that’s an area we are committed to working on more diligently. The good thing is that our provincial and federal government is very supportive and have made a commitment to working with the Indigenous population on HIV.

The virus is an issue not just in British Columbia but there is a significant increase in HIV in our Indigenous population in our prairie provinces, particularly Saskatchewan, as well so we definitely have more work to do there.

Apunipima: Break down Treatment as Prevention for me

So TasP means reaching out, engaging individuals (those who have been diagnosed and those who are at risk of contracting the condition) earlier into care and treatment. The key is getting people into testing, treatment and management early. Sustained treatment, that’s absolutely critical.

If you’re not being treated, the virus will replicate, your viral load will go up, your immune system will drop and you’ll become ill. Also, when you put good treatment in place you’re making spread of virus less likely.

The Treatment of Prevention strategy was introduced by us in 2006 and has been adopted in other countries including by the Queensland Government who signed an MOU with us in 2014.

We still have more work to do though, as BC is the only Canadian province that has adopted this Strategy.

Apunipima: Good treatments are available now – are they considered affordable?

RB: Currently the lifetime cost of treating someone with HIV ranges from US $250,000 to US $500,000 (2006 figures).

Our Treatment as Prevention Strategy we have reduced new HIV cases in BC from 700 per year to less than 300 – which has provided savings of around $50 m per year.

We have also managed to nearly eliminate AIDS and there’s an important distinctions between AIDS and HIV – AIDS is the result of being infected with HIV for many years without treatment while HIV is an infection we can now treat and control the virus and prevent it from becoming AIDS.

In addition, people with AIDS can also be treated and become healthy and contribute to society like anyone else.

Our Government has made the investment because, as our Director says, you make a decision now and pay it off or you mortgage your province and pay it off over many years. If we don’t do anything the infections will continue.

Apunipima: What are your key messages for Aboriginal and Torres Strait Islander populations when it comes to prevention, testing, treatment?

It’s no different than other parts of the world including BC, we experience the same issues in terms of marginalisation, low education, low income, drug use, mental health issues and so on. The key element, the message that we are giving to people is know your HIV status.

We know that when people know their HIV status they will immediately change their behaviour and there are studies in the US that show that 58 per cent of people who have been diagnosed immediately change their behaviour to lower risk behaviour.

Also, most people care about others so if you know that you are infected with HIV or you become aware you are HIV positive, you are going to try and prevent the transmission of the virus towards your loved ones.

And we know the importance of families for First Nations people, so it is an important area to consider and lastly, the earlier you are aware of your HIV status, the greater the benefits of the treatment so by starting treatment earlier, you prevent not only AIDS but other things as well as HIV may effect kidney, heart lungs and so on.

Apunipima: I’m old enough to remember what a big story this was in the 1980s , however things have changed since then and it is no longer a hot button issue or, in the West, a fatal disease. How hard is it to get HIV the attention it deserves?

ID: I think your comment is correct because people aren’t seeing the number of deaths related to AIDS. Unfortunately what people are missing is the issue HIV is having on particular populations. The Indigenous population, for sure, are on the cusp of a huge epidemic which needs to be addressed. Men who have sex with men, injecting drug users and sex workers also still experience have high rates of HIV.

RB: That said, what a wonderful situation we are in – in the late 80s, we had a condition we didn’t know the cause of. We now have extensive therapies and can extend the life of people with HIV so it’s not on top of the radar but things have improved and we are making a huge difference. We still have work to do but that is one of the reasons why we are here, the raise the profile and call people to action.

Apunipima: How did you link up with the Aussie mob?

ID: In 2014 we were in Melbourne for the International AIDS Conference but prior to that we were working with HIV Foundation for a strategy we could work collaboratively on and that was the treatment as prevention strategy.

So we signed an MOU with QLD who adopted the TasP strategy and as part of the MOU we committed to a knowledge exchange strategy. So we had a group that came from QLD to the BC Centre for Excellence in HIV and AIDS last year who stayed with us for about a week and a half and now we’re reciprocating and doing the roadshow with the HIV Foundation.

Apunipima: Is your goal to eliminate HIV?

ID: We will never eradicate it HIV because of human behaviour but what we want to do is to drive as many cases to undetectable levels as possible because if you are undetectable you don’t transmit.

Apunipima: And that’s doable now with the current treatments?

ID: I think it is doable now, yes.

RB: We have a toolkit of different interventions we can use and combined, this will help us control the HIV epidemic.

Apunipima: Do you think that because of things like PrEP, and effective treatments, people are taking condom use, not sharing needles and things like that less seriously as it’s not a deadly illness anymore?

RB: This was one of our early arguments in 2006 when we brought up the idea of treatment as prevention. If you think about on the back of decreasing HIV rates in BC, there was an outbreak of syphilis and other STIs and increasing rates of hepatitis C. This led us to believe that condom use and education alone are not effective when it comes to preventing HIV transmission. People who don’t want to use condoms and want to behave in certain ways will continue their trajectory in life.

Apunipima: Is this similar to the argument that if you put condoms in men’s jails you’re promoting homosexuality or if you provide safe injecting rooms you’re promoting drug use? But everyone knows that people will do these things anyway so you may as well do it safely? It’s not like if it’s not there it won’t happen.

RB: We know that condoms are highly effective in preventing HIV and STIs when used – the problem is if they are not used. Similarly what we would say, through using things like PrEP and Treatment as Prevention is that we are offering harm reduction. What we learn from sexual behaviour is that people don’t always carry that behaviour for the rest of their lives…

Apunipima: … so if you can just get them for that dangerous window?

ID: We look at the value of TasP in terms of four Ps.

Implementing TasP is good for public health policy, good for the public, good for politicians and good for the public purse because if you have people engaged in treatment, sustained on that treatment, and not transmitting, you are actually being cost averting to your healthcare system and I think there an opportunity when there’s limited healthcare dollars which have to be spread over a wide range of things, look at where we can have an impact in a short space of time – it’s like paying off a mortgage, you pay off a lump sum and then you’re able to move on to something else with that money down the road.

The other thing about TASP in BC, we’re applying that strategy to HIV but we’re also starting to apply it to Hepatitis C as well, and we think there’s an opportunity to expand that to addictions so we will be doing further work on that in the coming years.

RB: Treatment a Prevention is good for the person, good for public health in terms of avoiding transmission. Good for the purse because it saves cost for the healthcare system and good for the politicians, but in addition to that, antiretroviral therapy has shown to significantly decrease other medical conditions just because people are actually coming to treatment so we can diagnose diabetes earlier, we can diagnose high blood pressure earlier and several studies showing there is a decrease in co-morbidities particularly tuberculosis in Africa and actually there are a couple of studies in the US showing people with HIV are living longer than mainstream population because they are so engaged in care!

All our evidence points to TasP as a powerful preventative – people think that clients might not be adherent, they might not engage but we have proven this not to be the case with our program: people are highly adherent and committed to the program.

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