Is Truvada (PrEP) the game-changer that will end new HIV transmissions in Australia?

Source: The Conversation— 29 March 2018

On Sunday, April 1, Australia will join only a handful of other countries in the world whose governments have made HIV pre-exposure prophylaxis (PrEP) readily available to populations at risk of HIV infection.

This step forward takes Australia much closer to achieving its pledge, made in 2014, to end new HIV transmissions by 2020.

What is prep and how does it work?

PrEP is the most powerful prevention tool currently available for people at risk of HIV infection. In people with high adherence to PrEP medication, it reduces the risk of acquiring HIV by 99%.

This compares to an HIV risk reduction of 70% for men who have sex with men (MSM) and 80% for heterosexuals who choose consistent condom use alone to prevent HIV infection. In 2015 the World Health Organisation declared that PrEP should be offered as an additional HIV prevention option to all populations at substantial risk of acquiring HIV.

In its current form, PrEP involves combining two antiretroviral drugs, tenofovir and emtricitabine, into a single tablet. PrEP is usually taken daily, but may be used just as effectively by MSM in an “on demand” fashion, taking tablets before and after sex.

What about side effects?

PrEP is generally well tolerated; in one study approximately 17% of people experienced mild side effects. These included headache, fatigue and gastro-intestinal upset within the first few weeks of starting PrEP.

These side effects mostly resolved over a few months. Only 5% of people ceased PrEP because of adverse effects. PrEP does cause a small decline in the health of the kidneys and bones, but these changes are reversible when PrEP is ceased.

People receiving PrEP see their clinician every three months to test for HIV and other sexually transmitted infections (STIs) and to monitor their overall health.

Early PREP study results in Australia

In Australia’s first PrEP study, VicPrEP, we observed a decline in condom use and a rise in sexually transmitted infections (STIs), which has been reported in other PrEP studies.

There are several reasons why STIs may rise in populations using PrEP. These include less condom use, but also simply that STIs are diagnosed more frequently because people on PrEP get tested for these every three months. More research and collaboration with the community are needed to better understand the relationship between PrEP and the incidence of STIs.

Despite PrEP only arriving on the PBS from April this year, Australia is already leading the world in its PrEP use. In Australia, 31,000 MSM are estimated to be eligible for PrEP.

Thanks to strong partnerships between community activists, peak Australian HIV organisations, doctors, researchers and state and territory health departments, approximately 16,000 MSM receive PrEP through state-funded PrEP trials. Several thousand more people are thought to be personally importing PrEP online thanks to dedicated community activists.

Early signs of success in PrEP’s ability to reduce HIV infections at a population level have come from New South Wales where, remarkably, about 9,000 people have enrolled in the PrEP implementation study, EPIC.

Recently, NSW reported a 32% decline in new HIV infections and a 25% overall statewide decline in new HIV diagnoses following the rollout of EPIC in 2016.

This remarkable progress should energise and provide impetus to other jurisdictions and countries, including Asia and the Pacific and particularly Eastern Europe and Central Asia where there is a dearth of PrEP use and the incidence of HIV has risen by 60% over recent years.

Getting PrEP through the PBS

From April 1 2018, people with a Medicare card who are at risk of HIV will be able to receive a script from their general practitioner or medical specialist for a three-month supply of PrEP.

The Pharmaceutical Benefits Advisory Committee approved PrEP in December 2017, which means the Pharmaceutical Benefits Scheme will subsidise its cost. People taking PrEP will pay up to $39.50, or $6.40 per month for concession cardholders.

The Commonwealth has provided funding to peak national HIV organisations to educate healthcare providers and the community about PrEP. This education must address and prevent the risk of people seeking PrEP - that is, people seeking a key preventive health measure - from being shamed and stigmatised in any healthcare setting. Hence a transgender man should be able to request and receive a vaginal swab to test for STIs in a pathology clinic in any Australian jurisdiction with impunity.

Broader PrEP awareness needed

To date, most people enrolled in Australia’s PrEP studies have been MSM. The immediate challenge is to make sure all populations at risk of HIV in Australia are appropriately engaged with, educated about and have access to PrEP.

Greater HIV prevention efforts, including PrEP, must occur urgently with Indigenous Australians. The rate of HIV transmissions among Indigenous Australians increased by 33% in 2016; the rate among non-indigenous Australians declined by 22% in the same period.

People who inject drugs, transgender people, heterosexuals and people who are ineligible for Medicare are other key populations who will benefit from PrEP.

The world does not yet have a vaccine for HIV, but Australia now has the other two pillars of biomedical prevention that are necessary to end HIV: HIV treatment, which renders an HIV-positive person’s risk of transmitting HIV to “effectively zero”, and PrEP.

Let’s work towards a “Vale HIV” for 2020.

This article was written by Edwina Wright, Associate Professor, Monash University and originally published in The Conversation.

Syphilis Outbreak Evolving

The syphilis outbreak occurring in remote areas of Australia continues to evolve.  

Data released by the Multijurisdictional Outbreak Group  shows that since the outbreak was declared in January 2011 over 1850 cases of infectious syphilis have been reported among Aboriginal & Torres Strait Islander people in affected regions of Queensland, the Northern Territory, Western Australia and South Australia. These cases are predominantly among young people aged 15-29 years, and equally among women and men.

So far there have been 5 congenital deaths, including last month where we learnt of a congenital death in Far North Queensland. 

"This data makes it clear that we need to ramp up efforts to increase syphilis testing for young people in the regions affected by the outbreak", said A/Prof James Ward, from the South Australian Health and Medical Research Institute. "In these regions it's crucial that all pregnant women and anyone who has had a recent partner change are made aware of the risk, and encouraged to test", he said.

Read more about the syphilis epidemic and the multi-jurisdictional response here.



Syphilis out of control in the north

SourceNational Indigenous Times - 7 February 2018

Wendy Caccetta:

Northern Australia is in the middle of the worst outbreak of syphilis in three decades and it’s having tragic consequences, with the recent death of another baby whose mother was infected with the sexually transmitted bacterial infection.

Even if extra medical support crews were placed on the ground now, experts say it would still be a decade before the outbreak was under control in remote communities in Northern Queensland, the Northern Territory, Western Australia’s Kimberley and South Australia.

The Royal Australasian College of Physicians said another baby was last month confirmed as having died of congenital syphilis, where the disease is spread from an infected mother to her unborn baby via the placenta.

The death was the sixth infant death from the disease in Northern Australia since the outbreak began in 2011.

RACP spokesman Professor Basil Donovan said syphilis had been on the verge of being eliminated from Australia eight years ago, but the Queensland Government – under former Premier Campbell Newman – cut health services to remote areas.

He said without adequate health services for the remote areas in the state and experts to intervene, syphilis had returned.

“Essentially we’re riding through the worst outbreak we’ve had in 30 years,” Prof Donovan said.

He said the sexual behaviour of people in the communities was not very different to non-Indigenous communities; the problem lay in not having enough health and medical staff to screen for the disease and provide treatment.

“We need more boots on the ground,” he said. “More sexual health staff, particularly based out of remote health services.

“Probably more importantly, these are very sensitive issues … issues like confidentiality are magnified in remote settings. That makes people wary of health services.

“We need a discreet health service model, but also staff who know the communities well.”

Prof Donovan said the Federal Government had promised funding to fight the outbreak, but so far it hadn’t been delivered.

“They keep saying there is a national strategy about to be launched and we’re saying where’s the funding and the plan – what are you going to do?

“The strategy tells us what you want to achieve, but not how you are going to do it. It’s a mystery.”

He said members of communities could help protect themselves by asking for a syphilis test even if they were going to the doctor or health service for something different.

He said it was important for pregnant women to turn up for their first antenatal screen on time.

“Probably the most common outcome of untreated syphilis in pregnancy is what is regrettably called foetal wastage,” he said.

“Which means the baby dies in the womb. We don’t know how much of that is going on.

“They could also be stillborn … or they might be so severely macerated by the infection that they die in the first few weeks of life or they may look quite normal at birth and over the next year or two they may start manifesting some nasty signs, mainly affecting the brain.”

Associate Professor James Ward is a Pitjantjatjara Nurrunga man, head of the Infectious Diseases Program — Aboriginal Health at the South Australian Health and Medical Research Institute and a member of the national Multi-jurisdictional Syphilis Outbreak Group, which was set up in response to the outbreak.

He agreed the outbreak would “take a while to turn around”.

“There’s been a constant call for additional resources to one, inform communities about syphilis and the importance of testing and two, to have increased resources on the ground to build the capacity of current health service staff to bring the outbreak under control,” he said.

Assoc Prof Ward said communities could help by learning more about the disease.

“What communities can do is know about it and have testing among the affected population, which are predominantly 15-35-year-old people who live in communities and are not in monogamous relationships,” he said.

Federal Indigenous Health Minister Ken Wyatt said curbing the syphilis outbreak was a top priority.

He said the government’s Strategic Approach and Action Plan endorsed in December was currently being rolled out. The action plan included workforce strategies and intensive work to reduce infection, such as point-of-care testing.

Mr Wyatt said the Turnbull Government had committed $8.8 million over three years to implementing the action plan.

More information on syphilis is available here.






Commitment and investment needed to address syphilis epidemic

Source: RACGP Media Release  31 January 2018

ctors are urging the Federal Government to make a long-term investment in sexual health programs and services, including prevention, testing and treatment initiatives, to address the ongoing syphilis outbreak affecting northern parts of Australia. This follows confirmation earlier this month of another congenital syphilis death in Far North Queensland, the sixth fatality from congenital syphilis that has occurred in Northern Australia since 2011.

“We are extremely concerned about the growing number of Aboriginal and Torres Strait Islander people who are contracting these infections,” Royal Australasian College of Physicians (RACP) President, Dr Catherine Yelland said.

"The prevalence of syphilis is highest in rural Indigenous populations and in some parts of Australia, the disease is now endemic.

“Pregnant women are particularly at risk because if they contract syphilis it can result in serious and sometimes fatal complications for their baby. It shouldn’t be this way, we can prevent and treat these infections through routine screening and treatment programs.

“We understand that the Commonwealth has developed an Action Plan to deliver short term responses to high rates of syphilis, with a focus on increasing testing, treatment, education, antenatal care and supporting an appropriately trained workforce.

“The recent death from congenital syphilis underlies the need to fund and implement this Action Plan without further delay.”

As detailed in its pre-budget submission, the RACP is recommending long-term investment in sexual health programs to accompany the Action Plan. It also wants to see a funded implementation plan for the Fifth National Aboriginal and Torres Strait Islander Blood-Borne Viruses and Sexually Transmitted Infections Strategy.

Dr Yelland said there needs to be a greater investment in Aboriginal and Torres Strait Islander sexual health services to improve people’s sexual health in the long-term.

“Aboriginal and Torres Strait Islander people must be pivotal in the development and implementation of these strategies. They are the ones who understand the health issues impacting their communities and can help ensure the services delivered are culturally safe.”

There were 28 new notifications of syphilis in North Queensland during October 2017, up from 12 notifications in the same period last year.


Syphilis 'should never happen in a developed nation'

Extract from report by: Meredith Griffiths, ABC National Reporting Team          Source: ABC News online

Associate Professor James Ward from the South Australian Health and Medical Research Institute says that cases of syphilis increased by about 200 per cent among young heterosexual Indigenous people living in remote areas of Queensland, the NT, the north-west of WA and SA over the past five years.

He said that it all started from one outbreak in 2011.

"There was a lack of a rapid response to that outbreak," he said. "The response was delayed even further because at the time public health services in remote and regional Queensland were being dismantled by the government in Queensland at the time, the Campbell Newman government."

He said health departments were trying to keep track of the disease, that a major awareness campaign was underway, and clinicians were being urged to test people — but there was a long way to go.

"The really big problem with infectious syphilis is that since this outbreak began in 2011 there've been five babies lost to congenital syphilis and that should never happen in a developed nation like Australia," Dr Ward said.

New STI and BBV data for 2016 released today: alarming trends for Aboriginal people

The Kirby Institute (UNSW) 2017 surveillance reports for STIs and blood borne viruses, released today, again show alarming concerns for Aboriginal and Torres Strait Islander people.

The new data for STIs among Aboriginal and Torres Strait Islander people show no abatement in alarming rates of STIs – with data extremely high for chlamydia, gonorrhoea and syphilis in regional and remote areas.

Rates of hepatitis C continue to climb for Aboriginal and Torres Strait Islander people – especially among younger people aged less than 25 years.

Leading researchers* wrote in an article for The Conversation  today that the HIV data is cause for particular concern. Over the last 5 years there has been a 33% increase in the rate of new HIV diagnoses in the Aboriginal and Torres Strait Islander community, and at the same time a 22% decrease among Australian born non-Indigenous people.  This has created another gap in health outcomes between Aboriginal and Torres Strait Islander people and non-Indigenous Australians. The rate of diagnosis is now more than double that of non-Indigenous Australians.

A/Prof James Ward, Head of infectious Diseases Research – Aboriginal Health, at the South Australian Health and Medical Research Institute (SAHMRI) says:

‘This should not be happening in 2017 when we have all the answers at hand to prevent HIV  – including PrEP (pre-exposure prophylaxis) and strategies such as Treatment as Prevention, which aims to prevent HIV at a population level by reducing transmissions.

‘It is likely that the different exposure categories are contributing to the divergence in rates, because health promotion efforts are concentrated toward the main population group affected by HIV in Australia, gay men and other men who have sex with men. This health promotion misses women.

'This data highlights the need for culturally relevant HIV prevention programs for Aboriginal people. We need enhanced community education, targeted testing and treatment initiatives – including access to PrEP, and greater access to sterile needle and syringes, and drug dependence treatment for people who inject drugs', says A/Prof Ward.

The new data serve to emphasise the importance of Commonwealth funded SAHMRI projects that aim to increase STI and blood-borne virus testing and treatment rates for people among Aboriginal and Torres Strait communities, including:

Access the Aboriginal and Torres Strait Islander STI and BBV data  here.

Access the Kirby Institute media release here.

* Conversation article authors

  1. Research Fellow, UNSW

  2. Professor of Medicine, Clinical Researcher and Epidemiologist, UNSW

  3. Associate Professor, Infectious Diseases Research Aboriginal and Torres Strait Islander Health, South Australian Health & Medical Research Institute

  4. Research Officer, UNSW

  5. Associate Professor of Epidemiology & Program Head of Surveillance Evaluation and Research, UNSW

Sexual health crisis: Syphilis epidemic rages as doctors sound alarm on rising HIV rates

EXCLUSIVE: Since 2011 a syphilis epidemic has swept across northern Australia, spreading across multiple states and hitting Indigenous communities hard. Figures obtained by NITV News show the rate of infections is rising fast. Now, stretched health services are warning a rise in HIV cases could be the next epidemic to hit the region.

By Robert Burton-Bradley  Source: NITV News. 20 Oct 2017

Indigenous Australia is in the grip of a serious health crisis as skyrocketing rates of syphilis have seen five babies die and hundreds of new cases appear. Now, rates of HIV are on the rise too. Doctors and health professionals working on the frontline have said more resources are urgently needed to stop the outbreak which is now in its seventh year.

Professor James Ward from the South Australian Health and Medical Research Institute told NITV News the situation was all the more concerning because it was preventable.

“We had a very good opportunity to eliminate it, we missed it, and now we're in this situation,” he said. “It is unacceptable in this day and age to have any congenital death related to an STI in a country like Australia, where we’ve got very good testing and very good treatment for these STIs.”

“If this had occurred in non-Aboriginal communities there would have been a national outcry.”

Figures obtained by NITV News reveal that as of August this year, Queensland has had almost 1000 cases of syphilis among its Indigenous population since the outbreak began there in 2011. The Northern Territory has seen a dramatic rise in infections more than doubling from 229 cases last year to 588 cases since 2013. Western Australia has had 134 cases since 2014, mainly in the Kimberley region, and the now the epidemic has spread to South Australia, which has had 26 cases since late last year. In most cases, the victims are under 29-years-old. There have been five cases of babies dying after being born with congenital syphilis and an unknown number of babies born with congenital abnormalities.

Cairns is the epicentre of the epidemic with the highest number of cases. Cairns Sexual Health Service Director, Dr Darren Russell, said he has never seen a syphilis outbreak like this before.

“It is concerning. We don’t know where it will end up, but it’s worse than it ever has been and the rates around the country are increasing, not decreasing,” he told NITV News. "We’ve seen is this incredible resurgence of syphilis and now we are seeing HIV where we have never seen it before. There is real concern."

“Cairns and surrounds is really the main area of concern. In North Queensland itself, up to August 2017, there have been 941 cases and five deaths of babies from congenital syphilis.”

“There is a lot of work going on to try and prevent further deaths, but it is very difficult when you have so many cases and you tend to get syphilis in young sexually active people.”

map of syphilis outbreak in northern Australia

A map of the syphilis outbreak in northern Australia.

Dr Russell said part of the problem is that in some communities the outbreak has become firmly entrenched.

“Initially, you can talk about an epidemic where an infection gets into a community and then what happens after a time is the infection can become endemic, more established in that community – that’s probably what is going on now in the Cairns area and the top end of the Northern Territory, and possibly even Townsville too”," he said. He warns of rising HIV notifications in and around Cairns, which he says could be linked to the syphilis epidemic. Now, there has been a spike in HIV infections, particularly in the Indigenous population, says Dr Russell.

“The syphilis epidemic started in 2011 and there was always a concern that HIV could piggyback on that because HIV and syphilis tend to go together,” he said. “Around Australia, HIV notifications in Indigenous people used to be about the same as non-Indigenous people, but they are now twice the rate and it looks like they are continuing to increase."

In Cairns, it is up to 50 per cent of infections, said Russell. "I don’t think we know at this stage if it is too late"

A public health alert sent to Queensland health workers last month warned the rising rates of HIV are tied to the syphilis outbreak and that a majority of the cases are among younger Indigenous people, under 40 years of age.

It came after an emergency HIV roundtable of around 80 clinicians and community leaders to discuss the crisis in Cairns earlier this week.

Professor Ward, a sexual health expert, who attended the conference as a speaker said the number of Indigenous HIV infections is not huge, but warns that could change unless extra resources are brought in.

“It used to be relatively stable. We’d have say 20 (Indigenous) cases a year nationally, we’re almost double that now, perhaps, even more, when you look at the most recent data, and that’s very problematic because once it reaches a tipping point, it will move into an endemic state and I think now is the time to put lots of effort into preventing HIV."

The other issue, said Dr Russell, is that diseases like syphilis and HIV can be sleeper infections and people could be unaware for lengthy periods of time they have been exposed, and in turn, pass it on to others.

“One of the problems is we don’t know what we don’t know, there will be individuals who haven’t been diagnosed yet, and if they are not aware they have HIV, then onward transmissions will continue."

“I think we have always been concerned in Australia that there would be an epidemic of HIV in the Indigenous community and we’d almost eliminated infectious syphilis a few years ago – what we’ve seen is this incredible resurgence of syphilis and now we are seeing HIV where we have never seen it before. There is real concern at this stage and we don’t know where the HIV epidemic is going to go, whether it will continue or be brought under control."

How did this happen?

A decade ago, syphilis in Queensland was on track to being eradicated, but then in 2010, the number of cases diagnosed started drastically increasing. By 2011, it was being called an epidemic. By 2014 it had spread into the Northern Territory, before moving into the Kimberley region of WA and reaching South Australia last year. Many of the cases are in remote Indigenous communities.

Indigenous Australians are six times more likely to catch syphilis than the non-Indigenous population. Staggeringly, this increases to 132 times higher in remote areas. Rates of HIV infection are twice as high for Indigenous people than the rest of the population.

“These things take you by surprise, there is no way of pre-empting some of this kind of outbreaks but a fast response is really necessary.”

Dr Russell warns that HIV is now looming as a follow up threat. He points to Canada’s experience, where Indigenous people account for as much as 11 per cent of new HIV infections, despite making up just 4.3 per cent of the total population.

“We appear to be heading in that direction,” he warned.

Dr Mark Wenitong, Public Health Medical Advisor at the Apunipima Cape York Health Council, said a large part of the blame resides with the drastic cuts to public health spending made by the incoming government of former Queensland Premier Campbell Newman in early 2012, and a failure by health services to recognise the threat early on.

"Very unfortunate that five women have lost their babies but there have been a number of other babies born with congenital syphilis abnormalities which is problematic and why we are desperate to get message out there for that target age group." said Professor James Ward.

“The thing is there were resources going into North Queensland through the health department, but after the election, that got cut a fair bit, and from the perspective of primary health care, that really did leave a hole in education. Screening and particularly sexual health teams, that has definitely had an impact,” he said.

Dr Wenitong said this compounded the already large challenges health providers face in the Indigenous community in an area like Cape York.

“There are limited resources because everything is a priority in Aboriginal communities because of the prevalence of a lot of different illnesses,” he said.

Dr Russell said previous outbreaks of STI’s like HIV had largely bypassed these communities, meaning that some were caught off guard.

“It’s a whole range of things. You have a population that is quite marginalized and disadvantaged, has poor access to health care, you’ve also got a group in whom traditionally there hasn’t been a lot of HIV, so the health services aren’t really geared up for thinking about HIV and testing for it.”

Dr Wenitong conceded the outbreak had now spread beyond the control of some health providers.

“These things take you by surprise, there is no way of pre-empting some of this kind of outbreaks but a fast response is really necessary.”

“I think one of the things we feel is a bit of a sense of failure in a way, that things like syphilis which is preventable and controllable, that that got away from us across the Top End of Australia.

What is being done

In response to growing calls for action, the Government has committed more resources, says Liberal senator Dean Smith, who is chair of the Chair of the Parliamentary Liaison Group for HIV/AIDS, Blood Borne Viruses and Sexually Transmitted Infections.

“The evidence of the alarming disparity in the rates of STIs between Indigenous and non-Indigenous Australians is very credible.

“I am aware that over the last four years, $15 million has been spent on a variety of specific STI and BBV prevention and education activities across northern Australia, including  trialling “point-of-care” testing for certain diseases and surveying the sexual health and lifestyle behaviours of Aboriginal and Torres Islander communities,” he tells NITV News.

He said everyone needs to be worried by the current crisis and urged his own Government to do more.

“As an immediate action, I firmly believe there must be a stronger response from the Federal Government and that it must take a more proactive leadership role in coordinating the activities of State and Territory Governments on the issue."

Indigenous Health Minister Ken Wyatt said the government was aware of the problem and is taking steps to combat the spread of syphilis and HIV.

“In August, I raised the syphilis issue with the Australian Health Ministers’ Advisory Council’s (AHMAC) Australian Health Protection Principal Committee (AHPPC), which is currently intensifying the national response to the current outbreak, including short-term actions to reduce infection,” Minister Wyatt told NITV News in a statement.

“A governance group has been established and will report on the proposed action plan to the Health Minister and myself in December 2017. The response will also focus on a long-term and sustainable response to combating other blood-borne viruses and sexually transmitted infections.

“The Commonwealth continues to fund targeted activities and a national network of approximately 140 Aboriginal Community Controlled Health Services (ACCHSs) and around 40 other providers to deliver comprehensive, culturally appropriate primary health care services, including sexual health and maternal health services."

A new awareness campaign called Young Deadly and Syphilis Free has been rolled out over the last few months targeting Indigenous communities and urging regular resting and treatment of infections.

This week, the Queensland Government announced an expansion of the number of places for people to PrEP (Pre-Exposure Prophylaxis) a medication that can dramatically reduce the risk of HIV transmission in HIV negative people.

Queensland Health Minister, Cameron Dick, acknowledged working with communities would be crucial in combating the further spread of the outbreak.

“If we are to achieve our shared goal of the virtual elimination of HIV in Queensland by 2020, we must reach out to Aboriginal and Torres Strait Islander people in every community.”

A spokesman for Queensland Health said the government was committing $15.8 million over three years to support the actions of the North Queensland Aboriginal and Torres Strait Islander Sexually Transmissible Infections Action Plan 2016-2021, in addition to millions being spent more broadly on sexual health.

Despite the promises of increased resourcing, the problem, more than seven years after the first outbreak in Queensland, remains for the time being.

Professor Ward said he believed the slow response was in part because the affected population was Indigenous.

“If this had occurred in non-Aboriginal communities there would have been a national outcry.”

Dr Russell from Cairns Sexual Health says it may already be too late to resolve the outbreak anytime soon.

“That’s the million dollar question. I don’t think we know at this stage if it is too late, but clearly, there are worrying signs and it is certainly not controlled at this stage."

Dr G. Yunupingu’s legacy: it’s time to get rid of chronic hepatitis B in Indigenous Australia

News of the tragic death of Dr G. Yunupingu last week in Darwin at only 46 years of age has again highlighted the unacceptable gap in life expectancy between Aboriginal and Torres Strait Islanders and other Australians. Yunupingu had been living with chronic hepatitis B since early in life, and experienced complications of this condition including liver and kidney disease.

Hepatitis B infections, which can lead to liver disease and cancer, are unacceptably high in Indigenous Australians. In Northern Australia, 10-20% of the Indigenous population is infected with the virus. Eliminating the impact of this infection in Indigenous Australians would make a substantial contribution to closing the gap in life expectancy.

Hepatitis B in Indigenous Australia

Hepatitis B is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. Interestingly, hepatitis B used to be known as the “Australia Antigen” as it was first discovered in Australian Aboriginal people in the 1960s.

Hepatitis B is around ten times more prevalent in Indigenous communities than in the rest of Australia. Of the nearly 240,000 Australians estimated to be living with chronic hepatitis B, over 20,000 are thought to be Indigenous people. New infections with hepatitis B remain three times as common in Indigenous people as in non-Indigenous Australians.

The chance of developing chronic hepatitis B depends on an individual’s age at the time of infection. Around 90% of those who were exposed as infants develop chronic hepatitis B, but only 5% of those who were exposed as adults will develop chronic infection. Most people living with chronic hepatitis B were infected as young children – often, through mother-to-child transmission at the time of birth. This is why vaccination during infancy is particularly important.

The prevalence of chronic (long-term) hepatitis B in Indigenous Australians varies significantly between regions. It is most prevalent in remote areas of Australia, with the Northern Territory having the highest prevalence of any Australian jurisdiction. Around 1.8% of the NT population live with the disease.

The prevalence of hepatitis B and other communicable diseases such as skin infections and influenza in Indigenous communities is intensified by the social, economic, environmental and political situation in which Indigenous Australians find themselves.

Liver disease

In some people, chronic hepatitis B can cause severe liver scarring (cirrhosis) or liver cancer. Less commonly, hepatitis B can damage other parts of the body, including the kidneys and blood vessels.

Chronic liver disease contributes significantly to the Indigenous life expectancy gap. Liver cancer is the fastest-increasing cause of cancer deaths in Australia. In 2016, it was the sixth-most-common cause of cancer deaths. However, for Indigenous people it is the second-most-common cause of cancer-related death after lung cancer.

Compared to non-Indigenous Australians living in the NT, the rate of death due to liver cancer is six times greater in Indigenous Australians.

Cure is rare with liver cancer, and most Indigenous Australians die within a few months of being diagnosed. In the NT, a range of factors contribute to the unequal burden of liver cancer in Indigenous Australians, but hepatitis B is the most important cause.

Hepatitis B vaccine is one way

A safe, effective vaccine for hepatitis B has been provided for all infants in Australia since 2000 – and in the Northern Territory since 1990. As a result, new hepatitis B infections in children born since 2000, as well as those who received adolescent catch-up vaccination from 1998 onwards, have fallen markedly.

However, funded hepatitis B vaccine for Indigenous adults is available only in some states and territories. This limits access for Indigenous people who remain at much higher risk of infection. A recent study suggested a funded catch-up vaccination program for Indigenous adults could rapidly eliminate disparity in hepatitis B incidence.

Vaccination has no effect for those who already have chronic hepatitis B. It is believed over 90,000 Australians living with hepatitis B have never been diagnosed and are unaware of their infection. Only 15% of those infected are receiving treatment or monitoring for their condition.

Unlike hepatitis C, hepatitis B is not yet curable, but current treatments are very well tolerated and effective at preventing liver disease and liver cancer. The profound lack of access to treatment and care among Indigenous people contributes to the disproportionate impact of hepatitis B on this population.

Other ways to reduce infections

An example of innovative care has been operating in Dr G. Yunupingu’s home community of Galiwin’ku for over five years. Under the management of Miwatj Health, an Aboriginal community-controlled health organisation, a hepatitis specialist visits regularly three to four times per year.

The specialist brings necessary diagnostic equipment and effectively provides a “one-stop shop” for individuals living with hepatitis B in Galiwin’ku. Just as importantly, a local healthcare practitioner champions the cause of hepatitis B treatment and elimination. Those infected are contacted and encouraged to see the specialist team.

Several other regions in the world with large Indigenous populations and high hepatitis B prevalence, such as Alaska and New Zealand, have developed programs to test most of the population and identify those with hepatitis B infections. Affected individuals are offered regular follow-up and care to prevent cirrhosis and liver cancer.

When delivering such care to Indigenous communities, it’s essential to develop trust and ensure culturally appropriate approaches. Also important is partnering with communities and their health workers to develop new ways of building awareness of hepatitis B as an important health issue.

With comprehensive public health initiatives, long-term commitment to funding and policy – including significant workforce development to ensure as many people as possible are tested and appropriately followed up – the impact of hepatitis B on Indigenous communities can be eliminated.

This article was written by Benjamin Cowie, James Ward and Steven Tong and originally published in The Conversation.

Hepatitis C - PBS listing: 'Medical miracles welcome, but barriers to elimination remain'

Federal Government funding of a breakthrough antiviral medicine that can cure all forms of hepatitis C must be matched by a concerted effort to reconnect people living with the liver-destroying virus with clinical care.

Speaking on World Hepatitis Day (28 July), CEO of Hepatitis Australia Helen Tyrrell welcomed the Federal Health Minister’s announcement that the first pan-genotypic antiviral, Epclusa® would be PBS listed from 1 August. The new therapy is more than 90 per cent effective in achieving a cure within 12 weeks, regardless of hepatitis C genotype.

“Australians living with hepatitis C now have unprecedented access to curative therapies; however this is only the first step to eliminating hepatitis C as a public health threat in Australia,” Ms Tyrrell warned.

“Equipping health care professionals to feel confident engaging their patients in conversations about hepatitis C and the availability of cures must now become a focus,” she said.

“We must also communicate to those living with the condition that a life free from hepatitis C can be a reality.”

Epclusa (sofosbuvir 400 mg/velpatasvir 100 mg) is a pan-genotypic regimen for the treatment of adults with genotype 1-6 chronic hepatitis C virus infection. The therapy is used in combination with ribavirin in patients with cirrhosis.

New campaign to prevent syphilis in remote Indigenous communities

A new radio, television and social media campaign has been launched to help prevent the spread of syphilis in remote Indigenous communities.

There are now 1,400 diagnosed cases among young people across four states, after an outbreak six years ago.

The South Australian Health and Medical Research Institute hopes its community education and awareness program about the Sexually Transmitted Infection, will cut through.

Featured: Professor James Ward, SA Health and Medical Research Institute