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There is increasing emphasis on involving the private sector in public health to harness the considerable resources and skills of the business world to address significant health issues. While such collaboration should be encouraged, the involvement of business in public health campaigns can raise unexpected challenges when the approaches and priorities of the public and private sectors clash. We report our experience in developing a public-private partnership to deliver a health promotion intervention using mobile phone text messages in Victoria, Australia. Although the partnership enabled the delivery of text messages on a far wider scale than previously possible, difficulties were experienced during implementation which are likely to have negatively impacted on project outcomes. Our experience has implications for any public health practitioner considering involving a private sector partner in program delivery.

Mobile phone text messages (SMS) are a promising method of health promotion, but a simple and low cost way to obtain phone numbers is required to reach a wide population. We conducted a randomised controlled trial with simultaneous brief interventions to (i) evaluate effectiveness of messages related to safer sex and sun safety and (ii) pilot the use of mobile advertising for health promotion. Mobile advertising subscribers aged 16-29 years residing in Victoria, Australia (n = 7606) were randomised to the "sex" or "sun" group and received eight messages during the 2008-2009 summer period. Changes in sex- and sun-related knowledge and behaviour were measured by questionnaires completed on mobile phones. At follow-up, the sex group had significantly higher sexual health knowledge and fewer sexual partners than the sun group. The sun group had no change in hat-wearing frequency compared with a significant decline in hat-wearing frequency in the sex group. This is the first study of mobile advertising for health promotion, which can successfully reach most young people. Challenges experienced with project implementation and evaluation should be considered as new technological approaches to health promotion continue to be expanded.

Background: Multiple PrEP studies suggest incidence of bacteria STIs among gay and bisexual men (GBM) increases following PrEP initiation, possibly due to changes in behaviour, sexual networks or testing. Regular, asymptomatic STI testing of PrEP users (Australian guidelines recommend three-monthly) may also help suppress incidence longer-term. Using national sentinel surveillance data, we report trends in STI incidence among GBM PrEP-users. Methods: Retrospective patient data were extracted from 35 clinics, with individuals' records linked between clinics. HIV-negative GBM with evidence of TDF/FTC prescription (excluding PEP) contributed person-time from their first subsequent STI test and were censored at their last test or six months after their last PrEP script. Censored participants could re-enter at PrEP re-initiation. Infection date was imputed as a random date between diagnosis and previous negative test. Using Poisson regression, we estimated half-yearly incidence and assessed trends (July 2016-December 2019) for syphilis, chlamydia and gonorrhoea, overall and stratified by anatomical site and age (35 years). To account for selection bias associated with differences in characteristics of GBM initiating PrEP over time, a closed-cohort analysis was conducted among GBM continuously using PrEP across the study period. Results: Among 17,250 PrEP-users contributing 24,823 person-years (median time between tests = 84 days) chlamydia (51.3/100 py to 39.1/100 py; p < 0.001) and gonorrhoea (43.1/100 py to 32.8/100 py; p < 0.001) incidence declined, whereas syphilis incidence increased (6.4/100 py to 9.9/100 py; p > 0.001). Among 3498 continuous-PrEP-users (10,538 person-years), declines were observed for overall chlamydia (54.0/100 py to 42.3/100 py; p < 0.001) and gonorrhoea (43.8/100 py to 34.9/100 py; p < 0.001) incidence; pharyngea chlamydia (p = 0.116) and urogenital gonorrhoea (p = 0.973) were stable, and syphilis incidence increased (6.8/100 py to 11.8/100 py; p < 0.001). For both cohorts, gonorrhoea and chlamydia incidence were greater among GBM < 35 years, with declines most prominent among those [greater than or equal to] 35 years. Syphilis rates and trends did not differ by age. Conclusions: Representing the largest cohort analysis of STI incidence among PrEP-users reported internationally, these data suggest that initial increases in incidence of some STIs following PrEP initiation may be attenuated over time. Frequent testing or changes in the risk profile of PrEP initiates over time may explain some reductions. Risk-mitigation strategies may be needed for younger GBM and to curtail syphilis incidence., OA16.01 M. Traeger (1); J. Asselin (1); C. El-Hayek (1); J. Dittmer (1); E.Wright (2); A. Carter (3); T. Vickers (3); P. Patel (3); C. Fairley (4); B. Donovan (3); [...]

Summary: To increase access to treatment, the Australian government enabled general practitioners (GPs) to prescribe direct‐acting antivirals (DAAs) to treat hepatitis C virus (HCV)—in consultation with a specialist if inexperienced in HCV management. This study describes the establishment and outcomes of a remote consultation pathway supporting GPs to treat HCV. Key stakeholders from primary and tertiary healthcare services in the Barwon South Western region developed and implemented an HCV remote consultation pathway. Pharmaceutical Benefits Schedule prescription data were used to evaluate GP DAA prescription 12 months pre‐and post‐ pathway implementation. A retrospective review of patients referred for remote consultation for 12 months post‐ pathway inception was undertaken to determine the care cascade. HCV treatment initiation by GPs increased after implementation of the remote consultation pathway. In the 12‐month study period, 74 GPs referred 169 people for remote consultation; 114 (67%) were approved for GP DAA treatment; 48 (28%) were referred for specialist assessment. In total, 119 (71%) patients commenced DAA; 69 were eligible for SVR12 assessment. Post‐treatment HCV RNA data were available for 52 (75%) people; 37 achieved SVR12; 15 achieved SVR ranging from week 5 to 11 post‐treatment. No treatment failure was detected. Collaborative development and implementation of a remote consultation pathway has engaged regional GPs in managing HCV. Follow‐up post‐treatment could be improved; however, no treatment failure has been documented. To eliminate HCV as a public health threat, it is vital that specialists support GPs to prescribe DAA. [ABSTRACT FROM AUTHOR]

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct-acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016-2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale-up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879. [ABSTRACT FROM AUTHOR]

Inadequate response to injecting drug use ( IDU) is a significant problem the world over. Low levels of funding, political inaction, poor levels of health service coverage, high prevalence and incidence of IDU-related blood-borne viruses ( BBVs) and ongoing stigmatization/marginalization affect people who inject drugs ( PWID) regardless of the income status of the country they reside in. These barriers and system failings are, however, exacerbated in low and middle-income countries ( LMICs), meaning that the potential consequences of inaction are more pressing. In this narrative review, we describe the levels of IDU and IDU-specific BBV prevalence in LMICs; levels of harm reduction implementation; the consequences of late or insufficient response, the shortcomings of data collection and dissemination; and the barriers to effective LMIC harm reduction implementation. We also exemplify cases where IDU-related harms and BBV epidemics have been successfully curtailed in LMICs, showing that effective response, despite the barriers, is possible. In conclusion, we suggest four key priorities on the basis of the review: confirming the presence or absence of IDU in LMICs, improving the collection and dissemination of national IDU-specific data, increasing the level of harm reduction programme implementation in LMICs, and increasing both national and international advocacy for PWID and attendant public health interventions. [ABSTRACT FROM AUTHOR]

One challenge to HCV elimination through therapeutic intervention is reinfection. The aim of this analysis was to calculate the incidence of HCV reinfection among both HIV-positive and HIV-negative individuals treated for recent HCV infection (estimated infection duration <18 months). Individuals with recent HCV infection who achieved an end-of-treatment response in four open-label studies between 2004 and 2015 in Australia and New Zealand were assessed for HCV reinfection, confirmed by sequencing of the Core-E2 and/or NS5B regions. Reinfection incidence was calculated using person-time of observation. Exact Poisson regression analysis was used to assess factors associated with HCV reinfection. The cohort at risk for reinfection ( n=120; 83% male; median age 36 years) was composed of HIV-positive men-who-have-sex-with-men (53%) and people who inject drugs (current 49%, ever 69%). Total follow-up time at risk was 135 person-years (median 1.08 years, range 0.17, 2.53). Ten cases of HCV reinfection were identified, for an incidence of 7.4 per 100 py (95% CI 4.0, 13.8). Reinfection incidence was significantly higher among participants who reported injection drug use at end of or post-treatment, irrespective of HIV status (15.5 per 100 py, 95% CI 7.8, 31.1). In adjusted analysis, factors associated with reinfection were older age ( aIRR 5.3, 95% CI 1.15, 51.5, P=.042) and injection drug use at end of or post-treatment ( aIRR 7.9, 95% CI 1.6, 77.2, P=.008). High reinfection incidence following treatment for recent HCV infection in individuals with ongoing risk behaviour emphasizes the need for post-treatment surveillance, harm reduction strategies and education in at-risk populations. [ABSTRACT FROM AUTHOR]

Combining phylogenetic and network methodologies has the potential to better inform targeted interventions to prevent and treat infectious diseases. This study reconstructed a molecular transmission network for people with recent hepatitis C virus ( HCV) infection and modelled the impact of targeting directly acting antiviral ( DAA) treatment for HCV in the network. Participants were selected from three Australian studies of recent HCV from 2004 to 2014. HCV sequence data (Core-E2) from participants at the time of recent HCV detection were analysed to infer a network by connecting pairs of sequences whose divergence was ≤.03 substitutions/site. Logistic regression was used to identify factors associated with connectivity. Impact of targeting HCV DAAs at both HIV co-infected and random nodes was simulated (1 million replicates). Among 236 participants, 21% (n=49) were connected in the network. HCV/ HIV co-infected participants (47%) were more likely to be connected compared to HCV mono-infected participants (16%) ( OR 4.56; 95% CI; 2.13-9.74). Simulations targeting DAA HCV treatment to HCV/ HIV co-infected individuals prevented 2.5 times more onward infections than providing DAAs to randomly selected individuals. Results demonstrate that genetic distance-based network analyses can be used to identify characteristics associated with HCV transmission, informing targeted prevention and treatment strategies. [ABSTRACT FROM AUTHOR]

Cross-continental phylogenetic analysis is important to understand subtle molecular differences of currently circulating hepatitis C virus (HCV) subtypes. Existence of such differences can be crucial in pursuing a universal hepatitis C vaccine. We characterized molecular epidemiology of early HCV infections identified across nine cohorts [North America (n=4), Australia (n=4) and Europe (n=1)] in the International Collaborative of Incident HIV and Hepatitis C in Injecting Cohorts (InC3). One hundred and ninety-two full-length HCV genomes were amplified from plasma of incident infections and subjected to next generation sequencing to establish the largest cross-continental, full-length acute HCV genomic data set available to date. Genomes from the most common subtypes (1a: n=94, 2b: n=15 and 3a: n=68) were used in phylogenetic analysis. Using full genome trees, 78 sequences (44%) were found to lie within 29 phylogenetic clusters/pairs defined on the basis of molecular similarity of consensus sequences. Of these, 26 each had exclusively Australian or North American sequences indicating a strong geographical bias for molecular similarity. On further analysis of behavioural and demographic associations, binary logistic regression analysis showed that older age and non-Caucasian ethnicity were significantly associated with clustering. HCV probably evolves in micro-epidemics within geographically isolated communities. [ABSTRACT FROM AUTHOR]

Background: Australia has increased coverage of antiretroviral treatment (ART) over the past decade, reaching 73% uptake in 2014. While ART reduces AIDS-related deaths, accumulating evidence suggests that it could also bolster prevention efforts by reducing the risk of HIV transmission ('treatment as prevention'). While promising, evidence of community-level impact of treatment as prevention on reducing HIV incidence among gay and bisexual men is limited. We describe a study protocol that aims to determine if scale up of testing and treatment for HIV leads to a reduction in community viraemia and, in turn, if this reduction is temporally associated with a reduction in HIV incidence among gay and bisexual men in Australia's two most populous states. Methods: Over the period 2009 to 2017, we will establish two cohorts making use of clinical and laboratory data electronically extracted retrospectively and prospectively from 73 health services and laboratories in the states of New South Wales and Victoria. The 'positive cohort' will consist of approximately 13,000 gay and bisexual men (>90% of all people living with HIV). The 'negative cohort' will consist of at least 40,000 HIV-negative gay and bisexual men (approximately half of the total population). Within the negative cohort we will use standard repeat-testing methods to calculate annual HIV incidence. Community prevalence of viraemia will be defined as the proportion of men with a viral load ≥200RNA copies/mm3, which will combine viral load data from the positive cohort and viraemia estimates among those with an undiagnosed HIV infection. Using regression analyses and adjusting for behavioural and demographic factors associated with infection, we will assess the temporal association between the community prevalence of viraemia and the incidence of HIV infection. Further analyses will make use of these cohorts to assess incidence and predictors of treatment initiation, repeat HIV testing, and viral suppression. Discussion: This study will provide important information on whether 'treatment as prevention' is associated with a reduction in HIV incidence at a community level among gay and bisexual men. [ABSTRACT FROM AUTHOR]

We performed a systematic review to estimate the proportion of men who have sex with men (MSM) in Asia who are bisexual and compare prevalence of HIV and sexual risk between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). Forty-eight articles based on 55 unique samples were identified from nine countries in Asia. Bisexual behaviour was common among MSM (pooled prevalence 32.8 %). Prevalence of HIV (pooled OR 0.90; 95 % CI 0.77-1.05), recent syphilis infection (pooled OR 0.99; 95 % CI 0.93-1.06) and unprotected anal intercourse (pooled OR 0.80; 95 % CI 0.57-1.11) were similar between MSMW and MSMO, but heterogeneity was high. MSMW had lower odds of reporting a prior HIV test than MSMO (OR 0.82; 95 % CI 0.70-0.95; p = 0.01, I = 0 %). Targeted interventions are needed to increase uptake of HIV testing among MSMW. Increased reporting of disaggregated data in surveillance and research will help improve understanding of risk in MSMW and inform targeted interventions. [ABSTRACT FROM AUTHOR]

Improved understanding of natural history of hepatitis C virus (HCV) RNA levels in chronic infection provides enhanced insights into immunopathogenesis of HCV and has implications for the clinical management of chronic HCV infection. This study assessed factors associated with HCV RNA levels during early chronic infection in a population with well-defined early chronic HCV infection. Data were from an international collaboration of nine prospective cohorts studying acute HCV infection (InC3 study). Individuals with persistent HCV and detectable HCV RNA during early chronic infection (one year [±4 months] postinfection) were included. Distribution of HCV RNA levels during early chronic infection was compared by selected host and virological factors. A total of 308 individuals were included. Median HCV RNA levels were significantly higher among males ( vs females; 5.15 vs 4.74 log IU/mL; P < 0.01) and among individuals with HIV co-infection ( vs no HIV; 5.89 vs 4.86; P = 0.02). In adjusted logistic regression, male sex ( vs female, adjusted odds ratio [AOR]: 1.93; 95%CI: 1.01, 3.69), interferon lambda 4 ( IFNL4) rs12979860 CC genotype ( vs TT/CT; AOR: 2.48; 95%CI: 1.42, 4.35), HIV co-infection ( vs no HIV; AOR: 3.27; 95%CI: 1.35, 7.93) and HCV genotype G2 ( vs G3; AOR: 5.40; 95%CI: 1.63, 17.84) were independently associated with high HCV RNA levels (>5.6 log IU/mL = 400 000 IU/mL). In conclusion, this study demonstrated that IFNL4 rs12979860 CC genotype, male sex, HIV co-infection and HCV genotype G2 are associated with high HCV RNA levels in early chronic infection. These factors exert their role as early as one year following infection. [ABSTRACT FROM AUTHOR]

Men who have sex with men are a priority population for HIV control in Laos, but encompass men diverse in sexual orientation, gender identification, and behavior. Behaviorally bisexual men and their sexual partners were recruited in Vientiane, Laos, in 2010 using modified snowball sampling. Heterosexual-identifying bisexual men identified as exclusively/predominantly heterosexual and other bisexual men identified as bisexual or predominantly/exclusively homosexual. Sixty (68%) heterosexual-identifying and 38 (32%) other bisexual men were recruited; the median number of sex partners in the past year was eight and seven, respectively. Consistent condom use was low with regular (7%) and casual (35%) partners and did not differ by identity. More heterosexual-identifying (53%) than other bisexual (29%) men reported weekly alcohol consumption. Twelve (20%) heterosexual-identifying and 15 (54%) other bisexual men correctly answered all HIV-knowledge questions. High-risk behaviors for STI and HIV transmission were common. Targeted HIV prevention initiatives are needed, particularly to reach heterosexual-identifying bisexual men. [ABSTRACT FROM AUTHOR]

Studies examining the effect of coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) on the HCV-specific immune response in acute HCV infection are limited. This study directly compared acute HCV-specific T-cell responses and cytokine profiles between 20 HIV/HCV-coinfected and 20 HCV-monoinfected subjects, enrolled in the Australian Trial in Acute Hepatitis C (ATAHC), using HCV peptide enzyme-linked immunospot (ELISPOT) and multiplex in vitro cytokine production assays. HIV/HCV coinfection had a detrimental effect on the HCV-specific cytokine production in acute HCV infection, particularly on HCV-specific interferon γ (IFN-γ) production (magnitude P = .004; breadth P = .046), which correlated with peripheral CD4(+) T-cell counts (ρ = 0.605; P = .005) but not with detectable HIV viremia (ρ = 0.152; P = .534). [ABSTRACT FROM AUTHOR]

HCV transmission networks within the Australian Trial in Acute Hepatitis C occurred predominantly in HIV positive populations and almost exclusively in men who have sex with men. Both sexual and injecting drug use risk were observed within the same clusters.Background. Injecting drug users remain the population at greatest risk of acquiring hepatitis C virus (HCV) infection, although a recent increase in cases of sexually transmitted HCV infection has been observed among human immunodeficiency virus (HIV)–infected individuals. The extent to which these separate epidemics overlap is unknown.Methods. The Australian Trial in Acute Hepatitis C (ATAHC) enrolled 163 individuals (29% of whom were HIV infected) with recent HCV infection. E1/HVR1 sequences were used to construct phylogenetic trees demonstrating monophyletic clusters or pairs, and viral epidemic history and phylogeography were assessed using molecular clock analysis. Individual clusters were characterized by clinical and demographic characteristics.Results. Transmission through injection drug use occurred for 73% of subjects, with sexual transmission occurring for 18% (92% of whom were HIV infected). Among 112 individuals with available E1/HVR1 sequences, 23 (20%) were infected with a strain of HCV identical to that of another subject, comprising 4 homologous clusters and 3 monophyletic pairs, the majority of which (78%) were HIV infected. Clusters contained individuals with both injection drug use–related and sex-related acquisition, and in all clusters (except for 1 female HIV-uninfected pair), individuals identified as men who have sex with men, irrespective of HIV status.Conclusions. This large unique study of HIV-infected and HIV-uninfected individuals with recently acquired HCV infection demonstrates that clustering is common in the HIV-infected population and that it occurred almost invariably among men who have sex with men, irrespective of the actual mode of acquisition. These findings suggest the coexistence of both injection drug use and sexual risk behaviors for individuals in the same social networks and have implications for the development of public health messages.Clinical trial registration. NCT00192569. [ABSTRACT FROM AUTHOR]

We explored the utility of routine HIV testing data from clinical services for estimating HIV prevalence. A systematic review identified 28 eligible publications, covering concentrated epidemics (16 of 28) and generalized epidemics (12). Of the 16 papers from concentrated epidemics, five presented estimates by risk group and four by testing history with a median HIV prevalence of 1.8% in first-time testers compared with 3% in repeat testers. Two reports from generalized epidemics restricted estimates to asymptomatic clients and three included breakdowns by reason-for-test, with the median HIV prevalence higher in symptomatic clients (62%) than others (24%). Two papers from generalized epidemics showed prevalence estimates based on routine HIV testing data were slightly higher than estimates derived from other surveillance methods, but did not restrict estimates to asymptomatic patients. We conclude that routine HIV testing data may be a supplementary data source for HIV surveillance provided careful analyses are conducted. [ABSTRACT FROM AUTHOR]