In the inner-city area of Sydney where HIV was once most prevalent, new HIV acquisition has dropped by 88% since 2010, through community outreach and prevention efforts, including widespread availability and use of pre-exposure prophylaxis (PrEP).
It’s an example that highlights both progress and potential — while HIV remains a global health challenge, it is more treatable and more preventable than ever before, and GPs play a pivotal role in further reducing transmission and improving quality of life.
Associate Professor and sexual health physician, Jason Ong, from Monash University and the Melbourne Sexual Health Centre, says diagnosing people living with HIV earlier and immediately linking them to ongoing care and treatment is crucial to this.
“Sexual transmission is still the predominant route of transmission for HIV in Australia. Less than 2% of new infections are people who inject drugs. The latest figures show that male to male sex is about 68% of new HIV infections. But while HIV is often said to be gay man’s disease, it is important to note that 27% of new infections are amongst heterosexuals. This undiagnosed cohort of patients need to be tested,” Dr Ong says.
A concerning trend is the rise in HIV transmission in overseas-born gay and bisexual men, predominantly from south-east Asia followed by South America and Africa. “About half of this population acquires the infection while travelling to their home countries, but we have also found that some have acquired HIV in Australia. It may be because they’re not accessing PrEP or they’re not testing frequently enough. In Victoria, the number of overseas-born patients with new HIV infections is twice that of Australian-born patients,” he adds.
Half of the new patients diagnosed in Australia are what is termed as `late diagnosis.’ That is when the patient’s CD4 count is already below 350. “This means that they’ve been living with HIV in the community for many years, but undiagnosed. GPs, who treat 80% of the population annually, are in a perfect place to increase testing, especially in this large pool of undiagnosed people who pose a greater risk of transmission than those diagnosed,” Dr Ong says.
Dr Ong underlines several key areas where GPs can play a vital role in HIV detection and transmission.
He recommends making HIV testing a part of the sexual health care package. For example, when a patient asks for a chlamydia test, GPs can suggest that they also test for HIV, syphilis and gonorrhea.
Congenital syphilis is another preventable disease that is rising in Australia and GPs can play a critical role in identifying undiagnosed syphilis.
There are many ways to test for HIV now. The venipuncture test is covered by Medicare (or most private health insurance plans for those without Medicare). Alternatively, the Atomo HIV Self-Test kit, available from pharmacies or online, provides results within 15 minutes and retails between $25-30; and Rapid HIV tests are done in some GP surgeries, but mostly in peer-based testing organisations such as the Victorian Pride Centre (PRONTO!).
Some general practices are also trialling ‘Opt-out’ HIV testing. This means that any patient is automatically tested for HIV in their annual blood test for cholesterol and glucose levels, unless they explicitly tell the GP not to test for HIV.
“As part of a sexual health check, I always offer comprehensive testing that includes chlamydia, gonorrhoea, syphilis and HIV,” Dr Ong says.
“Patients should feel comfortable and safe to discuss their sexual orientation or any risky sexual behaviours with their GPs. There’s a lot of evidence to show that patients do want to talk to their GPs, but they sometimes feel unsafe or uncertain. We see patients, who come to a sexual health clinic for anonymity. An open dialogue could help foster trust and encourage patients to undergo HIV testing with their GP without feeling that they are being judged,” Dr Ong says.
The Australian STI Management Guidelines offer examples of how to start the conversation around sexual history in primary care. Assuring privacy and confidentiality is key, Dr Ong adds.
GPs can also help address misconceptions and provide accurate information to their patients.
“HIV is no longer a death sentence, but we still see patients, especially the overseas born, who have this myth that HIV is a killer disease. GPs can help dispel this myth by explaining that HIV is a chronic disease, like diabetes and hypertension, and people living with HIV can live long and productive lives up to their normal life expectancy by taking a daily pill,” Dr Ong says.
Since mid-2023, everyone with HIV has access to free or affordable antiretroviral therapy (ART), regardless of their Medicare status. “However, some GPs remain unaware that these drugs, that cost between $10,000 to $15,000 annually, are now fully funded by the government. GPs need to convey this important positive message to the patients, emphasising that HIV treatment comes at zero cost to them,” he adds.
Dr Ong highlights another major gap in knowledge around PrEP, a highly effective HIV prevention strategy. “Since 2018, every GP can prescribe PrEP, regardless of the S100 accreditation. PrEP is now available on the Pharmaceutical Benefits Scheme (PBS) for people at substantial risk of contracting the disease. Some GPs, who may not feel comfortable with starting a patient on PrEP, can use the ASHM decision making tool,” he says.
The fight against HIV is far from over and if Australia is to achieve international targets, Dr Ong says, it will need to scale up efforts to diagnose people living with HIV earlier, and support people to protect themselves from getting HIV, through PrEP, condoms or lifestyle choices.
Key points
- More than one quarter of new infections are occurring in heterosexuals
- HIV is rising in overseas born gay and bisexual men
- Regular testing of at-risk groups is crucial to diagnose earlier and reduce transmission
- Offer HIV testing alongside tests for other sexually transmitted diseases
- Antiretroviral therapy is now subsidised on the PBS for everyone with HIV, regardless of Medicare status
- All GPs can now prescribe PrEP, which is on the PBS for high risk patients
- The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) has developed this tool to help with prescribing decisions around PrEP.
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