NACCHO Members' conference 2019.

1. Indigenising interventions to impact STI and BBV
inequality among First Peoples of Australia
A/Prof James Ward
South Australian Health and Medical Research Institute
Adelaide
Twitter: @researchjames

2. Acknowledgements and Overview
Acknowledgements
• Traditional owners
Overview
• The research pathway
• What have we learnt
• Ways forward

3. The current situation
• Many efforts to reduce STI and HIV
• Few areas nationally that are doing well
• STIs and HIV still not easy to discuss
• Remote and regional areas particularly impacted by STIs

4. The Northern Territory Youth Health
Summit Declaration
• Sexual and reproductive health concerns all people. Historically the issue
has not been discussed openly and honestly. We need to change this. To do
this there must be current and relevant education, which fosters healthy
expectations and relationships. This should be encouraged through candid
discussion at all level of society and with all ages.

5. Four major issues impacting STI and BBVs
and our peoples
1. Ongoing high rates of STIs in many communities
2. Syphilis outbreak northern and central Australia
3. HIV is increasing
4. Hepatitis C associated with injection drug use

6. NT Notification Rates per 100,000 Chlamydia,
Gonorrhoea and Syphilis 1996-2017
0
100
200
300
400
500
600
700
800
900
1000
1100
1200
CT NG Syphilis

7. STIs prevalence among young people
Guy et al STI 2015

8. Consequences of STIs
• PID
• Ectopic pregnancies
• Miscarriages
• Disseminated gonococcal infections

9. The majority of women positive for gonorrhoea were
Aboriginal (78%) and almost all ectopic pregnancies
(81%; 43/53) and all the tubal infertility cases (100%;
8/8) were among Aboriginal women.

10. Characteristics and Impact of Disseminated Gonococcal
Infection in the “Top End” of Australia The American Journal of
Tropical Medicine and Hygiene
Johanna M. Birrell1, Manoji Gunathilake1, Sally
Singleton1, Shellee Williams1, Vicki Krause1
• 2010-2018
• 94 cases of DGI among Aboriginal people
• Highest incidence in 15-19 year age group
• Ninety-four patients (88.7%) presented with purulent arthritis.
• Disseminated gonococcal infection was estimated to cause at least
10.0% of nonpenetrating septic arthritis in the Top End and 1,234
days of hospitalization during the study period.

11. Syphilis Outbreak
• >3000 cases since outbreak
started
• North QLD- 1412
• NT -1157
• WA -394
• SA -80
• Around 60% in 15-29 year age
group

12. Syphilis Point of Care Testing
Patient Testing
• 50µL of finger prick (or venous) blood added to sample pad
• Wait 1 minute, add 1 drop of Chase Buffer to sample pad
• Wait 15 minutes, read result
1 Min 15 Min

13. 4 December, 2019
ACCHS sites
Puntukurnu
Aboriginal
Medical
Service
OVAHS
Phase 1 ACCHS
Phase 2 ACCHS
Wuchopperen Health Service
Townsville Aboriginal
and Islander Health
Service
Danila Dilba Health Service
Kimberley Aboriginal
Medical Services
Yura Yungi
Kutjungka
Katherine West Health Board
Wurli-Wurlinjang Aboriginal Health Service
Sunrise Health
Derby
Mala’la Health Service
Wirraka Maya
Health Service
Phase 3 ACCHS
Tullawon Health Service
Ceduna Kooniba Health Service
Port Lincoln Aboriginal Health Service
Nunyara Aboriginal Health Service
Pika Wiya Health Service
Umoona Tjutagku Health Service
AHCSA/Nunkuwarrin Yunti
Stage 2 – Proposed POCT sites
Miwatj Aboriginal Health Service

14. 4 December, 2019 14

15. HIV is increasing
3.5 3.3 3.2
3.5 3.7
3.4
3.7
3.1
3.0
2.8
3.4
4.6
3.8 3.9
5.0
4.6
5.4
6.2
6.5
4.6
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Agestandardisedrateper100000
Year
41% increase over 5 years vs 12% decrease
Rate of HIV diagnosis by Aboriginal Status

17. What are we doing about all this?

18. Young Deadly Free Campaign
• A multifaceted program of research to improve knowledge and testing of STIs and
BBVs among young Aboriginal and Torres Strait Islander People living in remote
communities
• Consortium of partners ACCHS sector –AMSANT, QAIHC, KAMSC, AHCWA, AHCSA
• Regional Coordinators employed in each jurisdiction
• Peer Education
• Health Promotion
• Outcomes- Increases in knowledge and testing for STIs
• Health Promotion component Led by Amanda Sibosado

19. Health Promotion
• Social media
• Animations
• Videos
• Website
• Posters
• TV and Radio
• Fact sheets

20. Young Deadly Free
www.youngdeadlyfree.org.au

21. Translation activities-Social Media
• www.youngdeadlyfree.org.au
• Facebook
• Instagram
• You Tube
• Twitter

22. ATLAS – national sentinel surveillance
network
• Working with 52 Aboriginal Health
Services
• Focus is clinical activity -attendance,
testing, retesting, treatment outcomes
for all STI/BBVs
• 12 performance measures to drive
continuous quality improvement

23. Five Clinical Hubs and >40 Aboriginal health
services
• Apunipima Cape York Health Council: Cairns and Cape York
• Institute for Urban Indigenous Health: Brisbane metropolitan area
• Aboriginal Health Council of South Australia: South Australia
• Aboriginal Health & Medical Research Council of New South Wales: NSW
• Kimberley Aboriginal Medical Service: East and west Kimberley
• Other remote sites

25. Summary Reports sent to all ACCHS
• Summary and longer
reports sent to each
participating ACCHS in
YDF PE Program

26. GOANNA - National survey of young
Aboriginal and Torres Strait Islander people
• Cross sectional surveys of Aboriginal and Torres Strait Islander people
aged 16-29 years
Methods
• 40 community events; surveyed n=2,877
• Assessed knowledge, risk factors and health service access
• GOANNA 2 underway n=985
• Assessing online survey collection n= 2200 in SA
Publications arising from study Ward STD 2017
Ward ANZJPH 2016 Bryant DAR 2016
Wand BMC Public Health 2017

27. Some new approaches

28. Precision Public Health for STIs
Health Service Data- Access, Testing coverage, retesting,
incidence, prevalence, management of STI and BBV, elimination
of HCV
Understanding issues on ground- mobility, concurrency, what
works for young people
Pathogen genomics - transmission networks, clusters - early
detection of outbreaks- precise treatment
Linking data esp SDOH using Indigenous data sovereignty
principles e.g. by clan SDOH granular level
Trials of interventions

29. Can Meningococcal vaccination impact on Gonorrhoea
B Part of it NT
• Neisseria meningitidis (Nm) and Neisseria
gonorrhoeae (Ng) - same bacterial genus and
share large proportion of primary genetic
sequences
• Suggestive evidence of protective effect from
4CMenB vaccine for Neisseria gonorrhoea
• Studies from NZ and Canada show 31% (1) &
59% (2) RR of NG
• World first and opportunity to conduct a sufficiently
powered study to generate evidence1. Petousis-Harris H, Paynter J, Morgan J, et al 2017
2. Longtin J, Dion R, Simard M, et al 2017

30. Epidemiology of
meningococcal
disease in
Australia
30
Department of Health. Australian Government. Invasive meningococcal disease national surveillance report.
#4 2018

31. Epidemiology of meningococcal disease in
the NT
31
1.Disease Control Bulletin Centre for disease control, NT Government. June 2019;26(2). www.nt.gov.au/health/cdc/cdc.shtml
Incidence Men B in NT 1.9/100,000
in 2017, 1.3/100,000 in 2018
Incidence meningococcal disease
nationally 1.5/100,000
2 deaths in 6 cases of meningococcal
B disease in the NT (2017 - 2019)

32. Gonorrhoea in 15-19 year olds, NT (2018)
Aboriginal Non-Aboriginal
NT Health
District
Notificati
ons
Population Rate Notificatio
ns
Populatio
n
Rate
Alice Springs
Rural
154 869 17722 0 50 0
Alice Springs
Urban
92 548 16788 2 988 202
Barkly 46 363 12672 0 72 0
Darwin Rural 15 1141 1315 0 70 0
Darwin Urban 26 1624 1601 7 6519 107
East Arnhem 62 1247 4972 1 148 676
Katherine 100 1102 9074 0 388 0

33. Impact of 4CMenB vaccine on gonorrhoea
• Impact on gonorrhoea; observational data
• VE=31% (21, 39; p=<0.001) [MeNZB; New
Zealand] ³
• VE= 59% (- 22.0, 84; p=0.1) [4CMenB; Quebec]
• 80-90% genetic homology between Neisseria
meningitidis and Neisseria gonorrhoeae
3. Lancet Petousis-Harris H. et al Lancet 2017;390:1603-1610. 4. Longtin J et al. Advancing Science, Improving Care; 2017 Oct 4-8; San Diego,
CA: Infectious Diseases Society of America.
Low genetic diversity of gonococcus in remote areas, key proteins eg. porB expressed by the
gonococcal strains in the NT show very close homology to meningococcal strains causing
disease in the NT (personal communication D Whiley)

34. Overview of Eliminate Hepatitis C (EC) Australia
• EC Australia -funded by the Paul Ramsay Foundation
• Aim: To support and facilitate a national coordinated response to
ensure we meet our elimination targets.
• This work will focus on:
• People who inject drugs, Aboriginal and Torres Strait Islander Peoples, people
in prison and men who have sex with men co-infected with HIV
• People living with hepatitis C that are at risk of progressing to severe liver
disease and HCC
• Ensure at least 15,000 Australians with chronic hepatitis C are
treated and cured of their infection annually

35. EC Australia Components
• Aboriginal and TI Leadership
Group to be formed
• To guide direction of EC
• To provide insight into
achieving EC goals

36. HIV
• Achieving equity
• Aboriginal and Torres Strait
Islander HIV Awareness Week
• www.atsihiv.org.au
• TASP
• PrEP
• Other prevention methods

37. In summary
• STIs/BBVs remain a wicked issue that prevalence has been hard to
shift
• Approaching STI control with a syndemics lens – Understanding how
STIs are exacerbated by the social, economic, environmental and
political milieu in which a population is immersed
• Language in STI control is important
• Centering communities has to be done better to enable strength based
approaches to be implemented
• Reforms are required as is a long term vision

38. Acknowledge Infectious Diseases
Group
Collaborators +++++
NHMRC
Commonwealth Department of
Health