When size really does matter - providing PrEP across Queensland

Background: Providing universal access to PrEP across Queensland, the 2nd largest and 3rd most populous state in Australia has provided unique challenges. Queensland has 22.5% of Australia’s total land area, compared to the 14.4% of New South Wales, Victoria and Tasmania combined. Queensland is also less centralised with 50% of the population living outside the state capital and 25% outside of the south eastern region. Notably, this population distribution is reflected in HIV diagnoses with 24% of new diagnoses in 2015 coming from Health Service Areas outside of the south east. Method: The unique service models, buildings, personalities, communities and clinical capacity of regional services has required bespoke solutions to implement QPrEPd in these sites. Many sites have not taken part in clinical trials before and required additional support. Additionally, the barriers to access found in more conservative services and communities has required the implementation team to advocate and educate for universal PrEP provision. Protocol modification has enabled nurses to manage ongoing PrEP provision in services with limited medical officer support. Results: Eleven study sites are outside of the south east corner; 7 public sexual health services, 3 general practices in Cairns and one Aboriginal Medical Service in Toowoomba. These sites have enrolled 18.5% of the all participants. The remaining 11 sites in the south east corner are include 5 general practices, including one run through a community based organisation, 5 public sexual health clinics and one private hospital. Overall, nearly 63% of the participants have enrolled at general practice sites. Conclusions: While this project has provided access to PrEP throughout much of Queensland, gaps remain. The key limitation in regional areas where there is no public sexual health service is the lack of S100 prescribing general practitioners. In order to expand access other service delivery models are being explored

PrEP, sweat and tears: challenges for the Queensland QPrEPd Operation Team

Background: In 2015 cairns Sexual Health Services (CSHS) successfully implemented QPrEP across 6 sites providing 50 participants PrEP for a 12 month period. In April 2016 the Queensland Minister for Health, and Ambulance Services, instructed the CSHS to expand this project to 2000 participants with the explicit expectation of commencement within 6 months

"From Top to Bottom" – Queensland Pre-Exposure Prophylaxis (QPrEPd) demonstration trial and sexually transmitted infections

Background: In the eighth month since the QPrEPd project rolled out across Queensland, 22 clinical sites have recruited 1695 participants. This paper describes the prevalence of sexually transmitted infections (STIs) in QPrEPd participants at three monthly time points. Methods: At each time point participants undergo blood testing for HIV and syphilis, urine PCR and pharyngeal swabs and where indicated, anal swabs, for chlamydia and gonorrhoea. Results: Five participants tested positive for HIV at the screening visit and were all tested at south east Queensland sites. Of the 1,394 participants who completed the entry survey, a third identified that they had not had an HIV screening test within the past 3 months. Of greater concern is the 2.4% who had not been screened within the past 2 years and the 1% who had never been screened in this high risk for HIV population. At screening 12.8% of participants had one or more STIs with little difference at three months (11.3%), however almost half of the three month results are yet to be reported. Interestingly at six months the anal chlamydia prevalence at 9.1% is almost double the 4.5% at screening but this trend may reflect a higher risk of early enrolees and could change once all results have been received. 15% of STI tests conducted at the 11 sites outside of the Queensland south east corner were positive compared to 8.6% in the 11 south east sites. Conclusion: The preliminary results reveal that a substantial proportion of the population at high risk of HIV acquisition are not following the Australian recommendation of 3 monthly screening. Over time we will explore the regional differences in HIV and STI prevalence and the seeming increasing trend in anal chlamydia

How was it for you? The first three months on the Queensland Pre-Exposure Prophylaxis (QPrEPd) demonstration trial

Background: In the eighth month since the QPrEPd project rolled out across Queensland, 22 clinical sites have recruited 1695 participants. This paper describes the pattern of pill taking and experiences of participants from enrolment to month three. Methods: Surveys undertaken by participants were confidential. In order to encourage honesty, clinicians did not have access to their clients' responses. Data was analysed descriptively and results were compared between entry and 3 month visits. Results: 832 QPrEPd participants have completed the 3 month survey. 70% of participants felt more sexually empowered whilst taking PrEP. Patients preferred to take their PrEP medication in the morning, 87% found the pills "completely acceptable" and 81% of participants were completely comfortable taking pills. Interestingly, 69% of participants took their pills on a regular basis and 92% reported good compliance by taking their pills every day between study visits. Only 7.8% of participants preferred to take intermittent PrEP rather than continuous daily doses and 83% of these participants used condoms during the period they were intentionally not taking PrEP. 68% of participants surveyed never reported any side effects with their PrEP, whilst only 2.5% reported side-effects "most" or "all of the time". Surprisingly, 77% of participants did not increase their number of sexual partners, 31% reported that PrEP did not change their sex life and only 28.3% agreed that taking PrEP changed their sexual risk taking behaviour. 81% strongly agreed "STI checks are needed every 3 months while taking PrEP" and only 2.1% "strongly disagreed" with this statement. Conclusion: So far QPrEPd has found that participants are proactive in preventing HIV, whilst still enjoying their sexual freedom. It will be exciting to see how the result patterns unravel during the demonstration project over the next few years

Biomedical studies on temporal bones of the first multi-channel cochlear implant patient at the University of Melbourne

Objective: To analyse the temporal bones and implant of the first University of Melbourne’s (UOM) patient (MC-1) to receive the multi-channel cochlear prosthesis.Methods: The left cochlea was implanted with the prototype multi-channel cochlear prosthesis on 1 August 1978, and the Cochlear versions CI-22 and CI-24 on 22 June 1983 and 10 November 1998, respectively. MC-1 died in 2007.Results: Plain X-rays of the temporal bones showed that after the CI-22 had been explanted seven electrode bands remained in situ. Micro-CT scans also revealed a partially united fracture transecting the left implanted and right control cochleae. Histology indicated a total loss of the organ of Corti on both sides, and a tear of the left basilar membrane. In addition, there was a dense fibrous capsule with heterotopic bone surrounding one proximal band of the CI-22 array that restricted its removal. This pathology was associated with dark particulate material within macrophages, probably due to the release of platinum from the electrode bands. Scanning electron microscopy (SEM) showed possible corrosion of platinum and surface roughening. Three-dimensional reconstruction of the cochlear histology demonstrated the position of the electrode tracts (C1-22 and CI-24) in relation to the spiral ganglion, which showed 85–90% loss of ganglion cells.Discussion and conclusions: This study confirms our first histopathological findings that our first free-fitting banded electrode array produced moderate trauma to the cochlea when inserted around the scala tympani of the basal turn. The difficulty in extraction was most likely due to one band being surrounded by an unusually large amount of fibrous tissue and bone, with an electrode band caught due to surface irregularities. Some surface corrosion and a small degree of platinum deposition in the tissue may also help explain the outcome for this long-term cochlear implantation.</p