ARCSHS

BBVs and STIs

Social research into blood-borne viruses and sexually transmissible infections

Over the next three years, ARCSHS will seek to take a leading role in reviewing, analysing and building the research evidence for health promotion policy and practice to support implementation of the five linked national strategies focused on blood-borne viruses (BBVs) and sexually transmissible infections (STIs).

ARCSHS provides important research evidence that increases understanding of communities at risk of infection, and affected by HIV. This includes a focus specifically on gay men, culturally and linguistically diverse populations, and people living with HIV. ARCSHS’ research seeks to investigate sexual and social practices within the contexts of everyday lives, broader social structures and social histories, and to analyse the health and social environment of people living with HIV. ARCSHS’ research into health promotion involves understanding and promoting change at a community and social, rather than simply individual, level.

In Australia, the response to HIV has been framed as a population health issue in the context of STIs and BBVs. This has resulted in linked HIV, STI and viral hepatitis national strategies. ARCSHS’ focus in hepatitis social research is on building an evidence base on the lived experience of Hepatitis C as a chronic disease in order to broaden knowledge and acceptance of it as a public health issue, and also to conduct activities that promote effective public policy responses to Hepatitis B.

National STI strategies have increasingly identified young people as a target population for research, particularly relating to Chlamydia. ARCSHS’ research provides an evidence base to inform education/campaigns, policy development and service delivery for the diversity of young people at risk of the acquisition of STIs. It aims to improve understanding of the factors that inform risk and health-seeking behaviours, including health prevention, education and access to clinical services for those at most risk of STIs.

HIV Futures 7

Jeffrey Grierson, Marian Pitts, Rachel Koelmeyer

This national project is a self-complete cross-sectional survey of Australian people living with HIV (PLWH). The Seventh National HIV Futures Survey entered the field in late 2011 after extensive review and revision in collaboration with NAPWA, AFAO, ASHM and their member organisations. Data collection will continue through the early part of 2012 with the main report released mid year. Extensive community and HIV sector briefing on the findings and implications of the study will follow.

HIV Futures 6 achieved a sample of 1106 respondents. The sustained commitment to this project from the HIV positive population in Australia demonstrates the power of information to enhance the lives of HIV-positive people. The first HIV Futures Survey was undertaken in 1997, with a sample size of 925, the second in 1999 with a sample of 924, the third in 2001 with a sample size of 894, the fourth in 2003 with a sample of 1059 and the fifth in 2005 with a sample of 970 respondents. The survey aims to: establish and maintain baseline data on social, economic, cultural and clinically related aspects of the experience of living with HIV; and examine changes in, and newly emerging aspects of, the experience of living with HIV. Information collected through the HIV Futures Survey is used in the development and provision of education and support services for PLWH. This survey has provided valuable insights into the use of new therapies among PLWH as well as the social and personal impact of HIV on their lives. This study has added significantly to the discourse on living with HIV both nationally and internationally at both academic and community levels.

LifeTimes

Marian Pitts, Jeffrey Grierson and Anthony Lyons

LifeTimes is a national joint project between ARCSHS and NAPWA. It was developed in response to the rapid ageing of Australia’s HIV population and seeks to identify and understand the many challenges and experiences of ageing with HIV, particularly among gay men. In November 2010, a national online longitudinal survey was launched. The survey specifically targets HIV-positive and HIV-negative gay men aged 40 years and over with a detailed look at their health and wellbeing, sex and relationships, living arrangements, and the many things that bring happiness or challenges to their lives. Wave 1 was completed in April 2011 after more than 1,200 men from all states and territories participated. During 2011, findings from Wave 1 were presented at the EUROGIN Congress in Portugal, the International Papillomavirus Conference in Berlin, and the European Health Psychology Society Conference in Greece. Findings are also reported in three journal articles expected to be in print in 2012. Wave 2 of LifeTimes began in November 2011 and will continue until April 2012. Further 12-month waves will make it possible to keep track of the health and wellbeing of HIV-positive and HIV-negative Australian gay men as they continue to grow older. In addition, it is planned that NAPWA will conduct in-depth face-to-face interviews with older HIV-positive gay men to examine the experience of ageing with HIV in further detail. Findings from LifeTimes are expected to inform treatment and support strategies for older HIV-positive gay men and is therefore of interest to clinicians, policymakers, support organisations, and health service providers, particularly those in the aged-care sector.

Tracking Changes

Jeffrey Grierson, Marian Pitts and Rachel Koelmeyer

This study examines treatment commencement and switching among HIV-positive individuals and employed an online cross-sectional survey with 254 HIV-positive Australians. The survey instrument covered demographics, health status measures, treatment history and experience, information sources, standardised symptom checklist, stages of change items on treatment commencement and switching and quality of life measures. In addition, 18 semi-structured interviews were conducted with S100 certified general practitioners focusing on decision making around treatment commencement and change. A report of the project presents a discussion of beliefs and understandings about ARV including treatment modalities, efficacy, treatment commencement and change algorithms, decision making around commencement and treatment switching.

MultiPoz: An Investigation of the Experiences of People from Culturally and Linguistically Diverse Backgrounds Living with HIV

Jeffrey Grierson, Karalyn McDonald, Tadgh McMahon (Multicultural HIV/AIDS and Hepatitis C Service) and Virginia Furner (Albion Street Centre)

MulitPoz is a modified version of the HIV Futures survey for culturally and linguistically diverse (CALD) people living with HIV in NSW. Due to cultural and linguistic circumstances they have not had the opportunity to previously participate in the national HIV Futures surveys. The survey contains questions on demographics, health, treatments, community and services, sex and relationships, recreational drug use, accommodation and finances. The survey was completed by a total of 42 culturally and linguistically diverse people living with HIV/AIDS via the Multicultural HIV/AIDS and Hepatitis C Service and Albion St Centre in NSW.

The CHI Study

Stephen McNally, Marian Pitts, Jack Wallace, Anthony Smith, Jen Johnson and Andrew Larner

The CHI study is a national cohort study charting the impact of hepatitis C over time on people infected with hepatitis C. In the first research of its type, the study will document the changes in health and social wellbeing following a diagnosis of hepatitis C, and how people respond to these changes. CHI is a web-based study using self-administered questionnaires. At recruitment, participants are asked about their health and wellbeing, their social and economic circumstances, and their experience of diagnosis and (if relevant) treatment. CHI will collect information on all aspects of living with hepatitis C, including decisions about treatment and the management of treatment side effects, the use of complementary therapies, and the impact of hepatitis C on health, work, relationships and family situations. Follow-up will generally occur at six-monthly intervals or more frequently where people are undergoing pivotal experiences, such as coming to terms with a recent diagnosis or undergoing treatment.

Regulating Hepatitis C: Rights and Duties

Marian Pitts, Anthony Smith, Meredith Temple-Smith (University of Melbourne), Ian Malkin (University of Melbourne), Stephen McNally and Jack Wallace

The Regulating Hepatitis C: Rights and Duties project, funded by the Australian Health Ministers’ Advisory Council, is nearing completion with the development of its first report: Regulating Hepatitis C: Rights and Duties, Preventing Hepatitis C Transmission in Australian Adult Correctional Services. Australian governments, at the local, state/territory and national levels have regulations seeking to limit hepatitis C transmission. These regulations relate to criminal and civil law, health acts, standards of care, codes of conduct and legal agreements between governments and professional bodies. This study recognises the priority populations detailed in the National Hepatitis C Strategy with its focus on needle and syringe programs, and within correctional settings with a focus on Aboriginal and Torres Strait Islander people.

The data collection activity for the project was daunting as there are substantial numbers of regulatory instruments from each Australian jurisdiction affecting the transmission of hepatitis C through needle and syringe programs and adult correctional settings. Key informant interviews provided insight into the context for and success of the implementation of these regulations.

The project has developed an Australia-wide audit of all regulations, guidelines and codes of practice governing hepatitis C-risk practices. The study has identified where regulations are missing and where conflicts and inconsistencies exist between different regulations, and has proposed a model of regulation in which hepatitis C prevention interventions are best implemented.

Hepatitis B Patient and Clinical Practice Survey

Jack Wallace, Behzad Hajarizadeh, Jacqui Richmond, Naomi Ngo

It is estimated that up to 200,000 people in Australia have chronic hepatitis B with more than half of these people born in the Asia-Pacific region. Other groups at greater risk of infection in Australia include people born in other highly endemic regions, Indigenous people, men who have sex with men, and people who inject drugs.

The hepatitis B virus is difficult to eradicate and the goals of pharmaceutical treatment are to permanently suppress replication of the virus, and to reduce the risk of progressing to advanced liver disease and developing complications such as cirrhosis, liver failure or liver cancer. Successful clinical management of chronic hepatitis B infection requires lifelong monitoring and for many people, pharmaceutical treatment. Up to one-third of people in Australia infected with the virus remain undiagnosed, and only a small proportion of people (approximately 2%) for whom clinical management is recommended access treatment services.

This project uses qualitative and quantitative methods and will be undertaken in three stages to identify potential and perceived barriers to effective hepatitis B clinical management from the perspective of people with chronic hepatitis B. This project seeks to determine barriers to optimal clinical management from the perspective of patients by:

Describing the patient’s experience of hepatitis B clinical management in the tertiary health clinics, including any discrepancy between the expectations and reality of the process
Investigating knowledge, attitudes and practices of people with hepatitis B to the clinical management of hepatitis B
Identifying broader social and psychological barriers to undertaking or maintaining clinical management including treatment
Seeking patients’ perspective and understanding of the referral processes and experiences with general practice
Identifying other issues affecting treatment or clinical management compliance

Connecting the Clinic to the Community: The Role of GPs and People with Chronic Hepatitis B

Jack Wallace, Behzad Hajarizadeh, Jacqui Richmond and Stephen McNally

While the National Hepatitis B Strategy 2010-2013 identifies a central role for general practice in managing chronic hepatitis B, there has been little focus on the constituent elements of this role, particularly when compared to the general practice role described for the management of hepatitis C or the human immunodeficiency virus (HIV). General practitioners (GPs) are often the first health professional consulted by people with chronic hepatitis B and play a central role in the clinical management of the infection. GPs are essential in ensuring that people with hepatitis B understand and can respond effectively to their infection.

This study conducted qualitative interviews with 26 GPs to identify their understanding of their role, and perspectives on the barriers and challenges to the effective diagnosis and management of chronic hepatitis B in general practice.

GP knowledge about chronic hepatitis B was identified as a key challenge for providing an effective clinical response. Almost all GPs identified a need for further education. Knowledge deficits related to the changes in specialist practices over the past decade as a result of a better understanding of the natural history of hepatitis B and improved treatment modalities. While few GPs provided information about the infection to patients that they had diagnosed, they identified that poor knowledge and a lack of understanding about the impact of infection affected adherence to clinical management such as regular monitoring and/or treatment.

There were significant challenges identified by GPs in screening and diagnosing patients with hepatitis B. Most GPs reported not using screening protocols or official guidelines to direct screening decisions, with several expressing a need for an inclusive consensus based screening protocol. Only a minority of GPs conducted a comprehensive pre-test and post-test discussion as a part of the diagnosis process.

There was diversity in the views of participants about the involvement of GPs in treating chronic hepatitis B. Most participants were willing to be involved in treatment with chronic hepatitis B, and several suggested that this model was inevitable given the limited resources and capacity of liver clinics. Some participants believed that while a specialist should initiate treatment, GPs could play a role in continuing treatment.

The findings of this study support the development and implementation of a range of interventions including:

Comprehensive and accessible education including screening, diagnosis and clinical management protocols particularly targeting GPs working with the communities most at risk of infection with chronic hepatitis B
Develop an evidence-based screening protocol in partnership with GPs, specialists and representatives of communities most affected by chronic hepatitis B with specific guidance addressing concerns of auditing by Medicare for the over-servicing of patients
A nationally consistent chronic hepatitis B pre- and post-test protocol that provides guidance to GPs and other health care workers about patient education and support
Develop a model of care for general practice that increases access to clinical management for people with chronic hepatitis B
Community development interventions and educational resources describing chronic hepatitis B and its impact targeting the communities most affected by the virus
A clearer articulation of the role of General Practitioners in future national strategic responses to chronic hepatitis B

A Situational Analysis of Public Health Responses to Chronic Hepatitis B in the Torres Strait

Jack Wallace, Marian Pitts, Stephen McNally, James Ward (Kirby Institute), Yoko Nakata (Thursday Island Primary Health Care Centre) and Patricia Fagan (Cairns Public Health Unit)

It has been estimated that Aboriginal and Torres Strait Islander peoples comprise 2% of the Australian population yet they constitute 16% of those in Australia infected with chronic hepatitis B. Chronic hepatitis B prevalence among Aboriginal and Torres Strait Islander people varies according to place of residence, with estimates ranging from 2% for urban Indigenous populations to 8% for rural Indigenous populations, with particular remote Aboriginal communities recording prevalence rates up to 26%. Aboriginal and Torres Strait Islanders are identified in the National Hepatitis B Strategy 2010-2013 as one of four priority populations, while hepatitis B is included within the Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections. This study is based on an assumption that access to effective clinical management will reduce the burden of chronic hepatitis B on individuals, communities and the health care system.

Health services in the Torres Strait are provided by Queensland Health through the Torres Strait and Northern Peninsula Area Health Service District. Twenty Primary Health Centres are located in the region, with primary health programs and administrative support provided by the Thursday Island Primary Health Care Centre. This infrastructure provides the basis of the response to chronic hepatitis B throughout the Torres Strait Islands and the Northern Peninsula. Semi-structured in-depth face to face or telephone interviews were undertaken with 61 people providing health services to the Torres Strait including health workers, registered nurses, general practitioners, and public health and clinical specialists. They reported:

significant gaps in knowledge about chronic hepatitis B among health service providers
people with chronic hepatitis B are identified through regular screening interventions but a lack of guidance or a model of care to guide an effective clinical response to chronic hepatitis B, in addition to a poor level of knowledge in the workforce, meant this screening had little impact
a recall system that effectively incorporates and provides direction in response to chronic hepatitis B is required for health service providers to respond to the clinical needs of people with chronic hepatitis B
while the health status of many people living in the Torres Strait was complex, established chronic disease and sexual health programs, while under-resourced compared to their needs, provided a programmatic basis for responding to the needs of people with chronic hepatitis B
the unsystematic vaccination of household or sexual contacts of people diagnosed with chronic hepatitis B

This report recommends establishing a team consisting of a clinical nurse consultant and health worker located at the Thursday Island Primary Health Care Centre. The role of this project will be to develop an agreed model of care or clinical pathway, provide education to people with chronic hepatitis B, health service providers and the community, and link mainland specialist services with primary health care services on the Torres Strait.

Dean’s Research Roundtable Funding – Development of Funding Proposals

Marian Pitts, Jack Wallace, Behzad Hajarizedah, Stephen McNally, Jen Johnson and Jacqui Richmond

This work involved the preparation and submission of two major funding applications in 2011/12. In 2010, ARCSHS applied for a NHMRC Centre of Excellence grant application to generate strategic resources to consolidate and further develop ARCSHS’ existing strengths in social research on sex, sexuality and sexual health. While the application was unsuccessful, it was well reviewed and it is proposed to substantially re-develop this application. The data gathered for the NHMRC Partnership Grant was used to inform the development of an application to the Australian Research Council Linkage Project, Building an Effective Public Health Response to Hepatitis B in Australia and Asia: Challenges and Solutions. The study aims to improve Australia’s response to chronic hepatitis B (CHB) by identifying if and how the understanding and responses of people with hepatitis B living in Australia are informed by their experience of hepatitis B in their countries of origin. The study consists of qualitative interviews with people with CHB born in China, Vietnam and the Philippines alongside a review and assessment of policy responses affecting CHB within these countries. The project will use these data to identify the essential components of an effective public health response to hepatitis B. In addition, the study will develop a web-based database to allow this policy and analysis to be used by public health practitioners, policymakers and researchers across Australia, and throughout the Asia Pacific region. The study will be conducted in partnership with healthcare workers, healthcare providers, and community-based organisations working in viral hepatitis and with people with CHB. It will draw on and strengthen links and expertise across government, clinical, research, industry and nongovernment sectors in Australia and in key Asian countries.

Monogamy as an HIV and STI Prevention Strategy for Gay Men

Anthony Smith, Jeffrey Grierson, Garrett Prestage and Duane Duncan

Monogamy, however defined, appears relatively common among Australian gay men and yet is relatively under-researched. At present, little is known about the motivations of Australian gay men to enter into and maintain monogamous relationships. Drawing on data from face-to-face interviews, focus groups, and a nationwide online survey, this study will bring into clear view a phenomenon, and social and intimate practice, that has been almost entirely overlooked and will significantly advance the understanding of the dynamics of gay men’s sexual behaviour and sexual cultures. Regardless of the motivations for monogamy, its practice is by definition an effective means of interrupting the transmission of HIV and STIs, and is worthy of a substantive investigation. The aims of this study are particularly significant given the sustained increase in the reported incidence of new cases of HIV in most states in Australia. It would seem that the old ‘safe sex’ messages have lost their effectiveness and there is a need for innovative responses to the challenges of HIV prevention. The analysis of gay men’s social and sexual behaviour from this study will provide the basis for an effective and focused health promotion campaign.

REACH Partnership (Reinvigorating Evidence for Action and Capacity in Community HIV Programs)

Graham Brown and Kylie Johnston

REACH is a collaborative research and practice initiative to develop evidence building frameworks, capacity, tools and resources with the Victorian HIV community partnership. The aim is to facilitate the building of the evidence base for HIV prevention policy and program decisions in Victoria. The outcomes that the REACH Partnership aims to achieve in the first three years are:

increase organisational culture and capacity within the Victorian HIV partnership for sustained evidence building and evaluation;
collaboratively develop monitoring and evaluation approaches for identified HIV prevention programs and projects at the discrete project level as well as the collective policy level;
to contribute to building the evidence base about “what works” that informs policy, programs and agencies;
support and influence decision making at the policy and program level; and
contribute to the evidence base nationally and internationally in HIV prevention.

Overall, the focus of the REACH Partnership is to build a shared evidence base that is recognised in policy and practice as credible, applicable and useable. The role of ARCSHS is to facilitate this process in collaboration with the key organisations in the HIV prevention partnership in Victoria. The detail of the program will be developed in collaboration with the HIV community sector. However the approach and principles guiding the REACH Partnership are:

Evidence building in partnership
Realist evaluation approaches
Participatory action research, capacity building and sustainability
Continuous contribution to the published evidence and literature in HIV prevention
Partnerships for policy, practice and governance

Collaborating organisations include: ALSO Foundation; Country Awareness Network; Family Planning Victoria; Gamma Project; Gay and Lesbian Health Victoria; Multicultural Health and Support Service; People Living with HIV/AIDS Victoria; Positive Women; Straight Arrows; Victorian AIDS Council; Victorian Department of Health; as well as the supporting research programs of ARCSHS, Burnet Institute and Partnership Solutions. The role and participation of each organisation will vary in relation to the resources and capacity of their programs, and appropriate timing of active participation. The project commenced in April 2011 and is funded by the Victorian Department of Health.

ESAPP - Evidence Synthesis and Application for Practice and Policy

Graham Brown, Kylie Johnston and Marian Pitts

This is a collaborative research and practice initiative to review the recent and currently developing evidence base (and evaluation tools) for community based HIV prevention programs. This 12-month project will:

draw from community practice, health promotion theory and evaluation research from Australia and internationally to audit the evaluation and evidence building approaches currently being utilised in programs targeted to PLHIV, MSM and priority CALD communities;
review recent developments and recommendations in evaluation of HIV prevention and social programs;
identify gaps in the published evidence that create barriers to translating the evidence into practice within the community sector;
develop recommendations for future work in evaluating HIV prevention and building a useable evidence base for policy and practice in Australia.

The project utilises realist approaches in analysing evidence, ongoing liaison with current national and international evidence building programs, and community and policy consultation. The project is funded by the Commonwealth Department of Health and Ageing and commenced in September 2011. It is expected to continue until December 2012.

Risk, Motivations and HIV among High Risk Gay Men (Pleasure and Sexual Health Study: High Risk Men Who Have Sex with Men and Understandings of Risk)

Garrett Prestage, Michael Hurley, Marian Pitts and Graham Brown

This study measures current attitudes toward HIV and other STIs, and beliefs about relative risk among gay men known to be at highest risk for transmission of these infections, including both HIV-negative and HIV-positive men as well as recent seroconverters, and a subsample of male-to-male sex workers. It explores in detail these beliefs about relative risk, both in terms of their understandings of the relative risk of transmission and the relative priority this understanding of risk takes with respect to other aspects of their lives such as sexual needs, the desire for intimacy and connectedness, a sense of adventure, personal relationships and broader issues of health and wellbeing.

This study recruited gay and bisexual men across the country, with 2306 complete questionnaires for the survey component, including 640 Victorian men and 764 from NSW, as well as 352 Queensland men, 162 South Australian men and 219 men in Western Australia. In addition, fifty in-depth interviews with gay men who are at high risk of HIV infection or transmission were conducted. The qualitative and quantitative arms of the study included HIV-positive and HIV-negative men. Participants were recruited using a variety of methods, both online and through community organisations, social groups and venues. Recruitment focused on, but was not restricted to, men at highest risk of HIV transmission. There was also some targeted recruitment of men engaged in male-to-male sex work and high-risk behaviour, and men who had recently seroconverted. Data collection was completed in September 2009 with the analysis ongoing. A community report was published in 2010.

HIV Seroconversion Study

Garrett Prestage, Ian Down, Graham Brown and Jeanne Ellard (NCHSR)

This study identifies demographic, behavioural, social, situational, and other characteristics in individuals who have been recently diagnosed with HIV infection. An understanding of those factors associated with HIV infection will lead to improved preventive education both at a level of individual counselling and community-wide strategies. The study aims to recruit at least 100 recently diagnosed individuals across Australia each year, who will complete a self-administered online questionnaire. In addition, about 20 in-depth interviews with individuals who have recently been diagnosed with HIV will be conducted. Participants will be recruited through community organisation programs servicing those who have recently seroconverted, and through clinic sites with a high caseload of recent HIV diagnoses, as well as through more broad-based publicity. At the end of December 2012, 424 individuals who had recently seroconverted had participated in the survey and 72 had been interviewed. Two community reports have already been produced. Data collection and analysis is ongoing.

NSW HIV Modelling and Acceptability Study

Garrett Prestage, Ian Down, Richard Gray (Kirby Institute) and David Wilson (Kirby Institute)

This study assesses the potential impact of a range of interventions on the projected HIV epidemic among gay men in NSW and the feasibility of such interventions based on their acceptability among gay men. The project recruited over 300 men in NSW and a further 300 men from across Australia. In addition, five focus groups were conducted in Sydney. The qualitative and quantitative arms of the study included both HIV-positive and HIV-negative men. Participants were recruited using a variety of methods, both online and through community organisations, social groups and venues. Recruitment was focused on, but not restricted to, men at highest risk of HIV transmission. Data collection was completed in May 2010. Data analysis is ongoing and a community report has been published.

Sexually Adventurous Men Project – Documenting and Process Evaluation

Graham Brown, Kylie Johnson and Garrett Prestage

The Sexually Adventurous Men (SAM) Project is a joint partnership between the Victorian AIDS Council/Gay Men’s Health Centre (VAC/GMHC), People Living with HIV/AIDS Victoria (PLWHA), and ARCSHS.

ARCSHS has monitored and supported the project as it was developed and evolved since 2009. This study documents and analyses the SAM Project's process of community engagement and community development, resource development, and online initiatives within sexually adventurous networks. From its inception, the SAM project has worked to establish and maintain strategic alliances with party organisers, venue owners and social groups, as well as more generally with sexually adventurous men. Throughout the project’s development and implementation, the project staff have worked to facilitate opportunities for suggestions, feedback and direct involvement in the development of the sexual health initiatives by the project.

The documenting and analysis role by ARCSHS includes strategies such as project worker diaries, reports, and interviews as well as in-depth interviews with community stakeholders and partners. It documents the learning and experiences of this evolving initiative, supports the project's strategic planning, and contributes to a co-written evaluation report and recommendations with an external consultant (Aldo Spinner). The next phase will include developing approaches to survey members of the sexually adventurous men community in collaboration with community groups and online initiatives. Funding for this project comes from VAC/GMHC and PLWHA Vic.