STI Impacts on Indigenous Populations
SPEECH TO NATIONAL PRIMARY HEALTH NETWORKS CONFERENCE
SYDNEY, 16 NOVEMBER 2018
In the language of my people, the Western Australian Nyungar people, I say, kaya wanju – hello and welcome. I acknowledge the traditional custodians of the land in which we are meeting, the Cadigal people of the Eora nation, and pay my respects to elders past and present. I also want to acknowledge Tom, the conference convenor from Pens, representatives of PHNs and Aboriginal Community Controlled Health Services from across Australia, and to all Indigenous Australians in here.
Closing the Gap is important to the government which is why Aboriginal and Torres Strait Islander health is one of the seven agreed priority areas for all PHNs. At the beginning of my appointment, I’d wrote to PHNs, asking what was the focus of their work and how are they including Indigenous Australians in their planning and in the construct of their thinking. It’s a complex solution that we are seeking but we have to tackle it at multiple levels if we're going to make a difference and make inroads. The diversity in culture, language and geographic and socioeconomic influences on our people adds to the challenge. We are making headway on some indicators such as child mortality, early detection and management of chronic diseases and smoking rates. Other areas remain problematic and some such as sexually transmitted infections have become a growing concern in recent years. Chlamydia, gonorrhoea, and infectious syphilis are at unacceptable levels in our Aboriginal and Torres Strait Islander population.
I was at the 2017 G20 Health Ministers Meeting and we had a discussion around the STI prevalence rates around the globe. The most curious comment that the president then of the World Health Organization made was we’ve now reached a point in the world in which gonorrhoea can no longer be treated by any of the current antibiotics and she then went on to say that at some point, every country will face that issue unless they start processes that inform people; and look at the regimes and treatment that they're providing because she said part of the challenge is the investment in antibiotics and new antibiotics by pharmaceutical companies is not as prevalent as it once was. So it becomes a concern, particularly when you look at the rates within Australia at the moment.
On the latest information, rates of infection with these diseases are between three and six times higher for our people than other Australians, with even higher rates in remote communities. HIV and Human T-lymphotropic virus Type 1 or HTLV-1 are also overrepresented in Aboriginal and Torres Strait Islander people. It's something that we need to tackle as a society and as a nation. All Australians need to practice safe sex but this message does not seem to be getting through to many young First Australian men and women who are at risk. Well, they’ll be getting better information through projects like the Commonwealth-funded Goanna Survey. It's not easy to change behaviour in this area. There are complex social and cultural factors influencing attitudes on STIs and other barriers to them seeking medical assistance for prevention, testing or treatment, Sam, given your talk it’s become blatantly obvious that we've got this incredible gap and we're going to have to really turn our minds to how we deal with that.
But it’s been proven that true and lasting gains are made when Aboriginal and Torres Strait families and individuals are fully involved in making decisions and choices about their health care. This, in turn, results on improved education, awareness, of our sexual health and trust in health services. There are signs that we are making headway assisted by scientific advances. For example, the Commonwealth has provided more than $2.5 million over five years to the Kirby Institute to expand its Test, Treat and Go program or TTANGO. This is improving same-day testing and treatment for chlamydia, gonorrhoea, trichomonas, in remote communities using innovative and rapid appointive care testing technology. TTANGO is due to run until June 2020 and is currently operating from a network of Aboriginal Community Controlled Health Services in Western Australia, Queensland, and South Australia. This sort of program has the potential to greatly reduce the rates of gonorrhoea and chlamydia when coupled with more effective primary health care and stronger families and communities. On the other hand, we have no time to waste. We are seeing cases of antibiotic-resistant gonorrhoea so it’s vital that we take action now to reduce the transmission of all STIs. While all of these infections- [indistinct] but today I want to focus on the recent action by government to combat three of them – syphilis, HIV, HTLV-1.
Firstly, syphilis because it is curable of penicillin, this STI was virtually wiped out as a major public health issue in Australia, but between 2014 and ’17, the rates of syphilis notifications in Australia more than doubled from 10 to 26 notifications per 100,000 people. Our people have been particularly hard hit. An outbreak of infectious syphilis was identified in North Queensland in January 2011. By late 2016, it extended across the Northern Territory to the Kimberley in Western Australia then to the west of Eyre and far north regions of South Australia; and only last week, I was informed Adelaide itself. In August this year, the Pilbara was also declared an outbreak region. Syphilis is preventable and a treatable disease. In this day and age, it’s a tragedy and unacceptable it’s so present in some of our communities; and it does demand urgent action because if left untreated, infectious syphilis can cause heart and brain damage. In pregnant women, it can lead to miscarriage and stillbirth, birth complications, and congenital syphilis. Very sadly, pregnant women have been among those affected by the outbreak amongst our people. Since it started in 2011, there have been just under 2300 cases, mainly 15 to 29 year olds, and just 15 babies have been born with congenital syphilis. Seven of these precious babies have died, particularly in Queensland and then two other jurisdictions. Babies should not be dying of syphilis in our wealthy, developed country in the 21st century.
So we’re working closely with states and territories for a national strategic approach to addressing the high rates of syphilis and other STIs among Aboriginal and Torres Strait Islander people. That strategic approach was endorsed by the Australian Health Ministers’ Advisory Council on 8 December last year. And what intrigued me was when my own agency came to me and said we needed $25 million to fund that NACCHOS to address the outbreak, and the comment I made was: where are the states and territories in this? They have an obligation under infectious disease controls to be equally involved in the treatment of Indigenous people and in addressing any infectious outbreak. And I met with the chief medical officer and asked why we have not invoked the AHMAC processes to ensure that we were starting to tackle what was becoming an alarming trend in the numbers then once you do the mathematical modelling, it doesn't take long for the infectious outbreaks to spread quite widely. The other concern I raised: what about all those people who are presenting at a health facility that are living with an STI? What have we done about that? Chief Medical Officer Brendan Murphy, to his credit, has worked very closely with NACCHO, the Aboriginal Community Controlled Health Organisations, and state and territory governments to address this issue on a national basis but to focus resources specifically within areas that we've identified. So we've got a lot more to do.
The education awareness program that James Ward has been providing through SAHMRI have also been effective.
Up to date, we’ve provided $8 million over three years to implement the action plan. We'll continue to provide, out of that funding, staff who will be trained to do point of care testing but also developing an awareness within our own communities. The trouble is we sometimes make assumptions about words and what they mean to people. I can say to you I have the colour- a blue object in my hand. Some of you all think of royal blue; some will think of aqua; but it doesn't mean the same is what I have in my hand. And in the work we do in communities, we need to explain far better than what we do; what the words syphilis, gonorrhoea, and any other STI means and what it does to the body. We have to tell the story far better than what we do because if we don't tell the story, then we're not going to make the impact on the rates. We cannot rely exclusively on treatments. We’ve found in the ‘60s and ‘70s is in the top end of our state, Western Australia, it was automatic to give anybody who showed with what was seen as a possible STI penicillin, then we wondered why we had MRSA prevalent in the top end because people ceased taking it halfway through a treatment.
So, there's much work that we have to focus on. And we also have to look at the feedback; what works, what isn't working. How effective are we on the ground in delivering the impact of services to our people and in reducing the prevalence rates? Because if we don’t, we’ll end up with significant problems. Test and treat kits have now been distributed to three other regions: East Arnhem Land, Katherine in the Northern Territory and the Kimberley region in Western Australia. I believe this is a critical breakthrough and we'll start to see the tide turning on this syphilis epidemic soon.
Now, we could go into figures and rates; I won't. Because I want to just touch on HIV. From 2010 to 2015, HIV rates amongst first Australians climbed alarmingly. In 2015, we saw the highest number of new cases diagnosed since 1992. The rates of notification in Aboriginal and Torres Strait Islander people was more than double the rate for non-Indigenous Australians.
Last year, the relentless increase came to a halt. In 2017, there were only 31 new HIV diagnosis in Aboriginal-Torres Strait Islander people; a 30 per cent drop from 2016. While this is good news, Aboriginal and Torres Islander people remain disproportionately affected by HIV. At 4.6 per cent per 100,000 their age standardised per capita rate of infection last year was 1.6 times the rate of non-Indigenous Australian born population. Compared to others, first Australians are six times more likely to contract HIV as a result of injecting drugs and more likely to get it from heterosexual sex. Aboriginal and Torres Strait Islander people are more likely to have undiagnosed HIV. It's estimated that in 2017, 40 per cent of first Australians who had HIV had not been diagnosed. I mentioned earlier the new medical science is helping the fight against STIs. In relation to HIV, the medicine known as PrEP is a breakthrough. And from April this year, it has been available through the Pharmaceutical Benefits Scheme. The PBS makes PrEP, or pre-exposure prophylaxis affordable to everyone who needs protection against HIV infection.
Previously, PrEP could only be obtained at full cost of free of charge through state government clinical trials. But of almost all of the 17,000 participants in PrEP trials, only 200 were identified as Aboriginal and Torres Strait Islander people. So, I hope that we enrol more of our people who have HIV into the PrEP program. Part of the $1.2 million the Government has allocated to educate consumers and health professionals about PrEP will be directed to our people. There are potential barriers; there is cultural factors, inadequate knowledge, shame and fear of stigma. To benefit from PrEP, men and women must accept they are at risk of catching HIV, they need to see a doctor and get a script and fill it, and take the medicine as required. As with syphilis, communities and health services, as well as health professionals can play a significant role in promoting, educating, and developing an awareness of the risk of HIV and the availability of PrEP. HTLV1 – it’s fascinating in that I recall and I was in the Health Department in WA in 1990, there was a research started in the Fitzroy Valley of which The Sunday Times ran this article about HTLV1 being a major issue in Aboriginal communities; and then it disappeared. And when I took over the role of the responsibility for Indigenous Health, I had my first meeting with the group who told me it was quite advanced and significant throughout parts of the Territory, South Australia, WA.
And so what I have done with the Chief Medical Officer and the NACCHO and care organisation is to bring them together to say: let’s first of all, identify the extent. Let’s look at what is required and then let’s put into place the interventions that we need to address the issue and the challenges, particularly the health issues that I have become aware of. And based on research out of Japan and a couple of other countries, what they were saying was this will become more of an issue as the problem is identified and people are identified with it. They even suggested to me that it was passed through breast milk but I’ve said that we need the evidence on that first before we make any major statement. So that we don’t, inadvertently, cause a change in practice that we’re trying to encourage in terms of breastfeeding. So, we’ve set aside $12 million that will be managed through the AIMAC processes, that will be developed and implemented through this group that Brendan Murphy and Pat Turner are involved in; working with Congress, with other key players within the region. It’s a piece of work that will continue to evolve, but it is the important piece. And we do have to turn our minds, because it seems as though we've ignored it for some time.
The forum that they held recently have agreed to a process. They're developing clinical guidelines for doctors diagnosing and treating conditions associated with our HTLV1. They didn’t recommend widespread testing at this stage. More research needs to be done with the active leadership from affected communities to understand where the virus occurs, how it spreads, and how it's affecting people in Central Australia. We do know, like other STIs, it can be prevented by safe sex and not sharing needles. Once acquired, HTLV is present for life. But there are management options for most of the diseases that many will see arise from it. And further treatment options are being investigated. So, the Australian Government continue to work with other parties present at the forum to develop a coordinated approach to HTLV1 in Australia.
And before I finish, I really want to suggest that we pick up on the point of data. Data is absolutely critical in determining whether need is; the extent of need, but then the resources that we need to turn towards addressing the challenges of the issue. Often people come to tell you that there is evidence of an explosion or a challenge in the spread of a disease, but what we never know is the extent of that impact. I think if we take note of what Jane said, that there are many that are undiagnosed. And it means that the extent is not known by any of us. And it is important that we share data. I know there are ethical issues that NACCHOs have raised. But if we are to tackle the insidious set of diseases, then we need to look at how we collectively do it. If I give the funding totally and exclusively to NACCHOs, what I do with the people who do not use a community controlled health service who may have infections. What do we do if they only go to state systems that never come back to a NACCHO? Or the other point that people don't think about is people access an emergency department for treatments. And if they go to an ED – as I saw in Liverpool when I was the Director of Aboriginal Health in New South Wales – their next step of primary health care didn't occur until it became problematic and they would return back to the ED Department.
So, from a population health approach, it is absolutely critical that PHNs, the medical professions, the GPs and the ACCHOs work collectively together. Because if we take the modelling of the spread of the infectious diseases we now have in the top end of Australia, and if we had antibiotic resistant gonorrhoea in this nation, then we would have a significant population health issue. We would see untreatable disease. And if you don't think that will happen, think about tuberculosis coming out of Papua New Guinea. We are seeing antibiotic resistant, untreatable TB. What concerns me is our people are vulnerable. For a couple of reasons: one is if you don't fully understand what the illness is or the disease is, then you can sometimes become lackadaisical in the way in which you have it treated. If that occurs, and given the way some communities are challenged by dysfunction, the impact of drugs and alcohol, then we’ll see a generation of young people affected and infected in a way that we should not allow. So, I wish you well in your continuing deliberations and I thank you for the work that you're doing. But it is about every one of you, fundamentally holding hands together and working for a far better outcome that means we will see better solutions for our people. Set aside the differences of opinion, set aside the differences of boundaries of control. This is about how we collectively work for the Indigenous populations in each of our states and territories. Thank you.