Treatment and Care, and Clinical Research

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Treatment and Care, and Clinical Research
Basil Donovan National Centre in HIV Epidemiology
and Clinical Research, University of New South
Wales and Sydney Sexual Health Centre, Sydney
Hospital
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Treatment and care of HIVwhats different about
Australia?

• Medicare (since 1984/5)
• Previously, cash or private insurance required to
  pay for GPs, specialists, and pathology tests
• Skeletal public sector in sexual health/HIV
• Inner city pharmacists treated many STIs
• MSM encouraged to use Blood Bank for syphilis and
  hepatitis screening

3
Treatment and care of HIVwhats different about
Australia?

• Medicare (since 1984/5)
• Previously, cash or private insurance required to
  pay for GPs, specialists, and pathology tests
• Skeletal public sector in sexual health/HIV
• Inner city pharmacists treated many STIs
• MSM encouraged to use Blood Bank for syphilis and
  hepatitis screening
• Fee-for-service structure of Medicare permitted
  rapid growth in primary care for HIV/AIDS
• Strategic (proactive) growth in public sector

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Education of the Australian public 1987

• Indicated that there was a serious problem
• Addressed basic misconceptions
• Referral for information
• Probably little direct effect on behaviour. Bell
  RA et al AIDS 1990 2 71-84
• Fuelled Australian appetite for HIV testing

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c.1983/4 Pre-ACON
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ACON, mid 80s
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Sydneys network of clinical care for people with
or at risk of HIV

• Anyone with a Medicare Card anywhere

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Sydneys network of clinical care for people with
or at risk of HIV

• Anyone with a Medicare Card anywhere
• Travelers, migrants, sex workers sexual health
  clinics (SHCs) and Kirketon Road Centre (KRC)
• Street youth/IDUs - KRC
• People with STIs GPs, SHCs, KRC

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Sydneys network of clinical care for people with
or at risk of HIV

• Anyone with a Medicare Card anywhere
• Travelers, migrants, sex workers sexual health
  clinics (SHCs) and Kirketon Road Centre (KRC)
• Street youth/IDUs - KRC
• People with STIs GPs, SHCs, KRC
• People with HIV/ADS anywhere, especially GPs,
  as well as dedicated services

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Sydneys network of clinical care for people with
or at risk of HIV

• Anyone with a Medicare Card anywhere
• Travelers, migrants, sex workers sexual health
  clinics (SHCs) and Kirketon Road Centre (KRC)
• Street youth/IDUs - KRC
• People with STIs GPs, SHCs, KRC
• People with HIV/ADS anywhere, especially GPs,
  as well as dedicated services
• Complex clinical care tertiary hospitals and
  dementia service
• Respite/palliative care Sacred Heart Hospice
• In summary, a very heterogeneous system

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Implications of a heterogeneous system

• A degree of duplication (often over-estimated),
  iniquitous funding structures, communication gaps

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Implications of a heterogeneous system

• A degree of duplication (often over-estimated),
  iniquitous funding structures, communication gaps
• The drift between services raises standards
• Capacity for growth and better targeting
• Clinical safety net

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Implications of a heterogeneous system

• A degree of duplication (often over-estimated),
  iniquitous funding structures, communication gaps
• The drift between services raises standards
• Capacity for growth and better targeting
• Clinical safety net
• Professional education and accreditation (ASHM)
• Research has to be collaborative

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Evolution of medical specialties

• Increasing overlap between infectious disease
  physicians and immunologists
• Special-interest GPs have become the new general
  physicians in private practice
• Sexual health physicians more population-focused
• HIV and sexual health services have become models
  of multi-disciplinary client-focused care within
  hospitals with nurses, counselors, researchers,
  and health promoters all seen as essential

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Clinical research
St Vincents Hospital 1985/6
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Australias HIV/AIDS research response

• Initially small, but timely natural history
  cohorts in Sydney and Melbourne

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Australias HIV/AIDS research response

• Initially small, but timely natural history
  cohorts in Sydney and Melbourne
• National Centres in Epidemiology and Clinical
  Research, Social Research, and Virology (tall
  poppy syndrome)

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Australias HIV/AIDS research response

• Initially small, but timely natural history
  cohorts in Sydney and Melbourne
• National Centres in Epidemiology and Clinical
  Research, Social Research, and Virology (tall
  poppy syndrome)
• Commonwealth AIDS Research Grants scheme

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Australias HIV/AIDS research response

• Initially small, but timely natural history
  cohorts in Sydney and Melbourne
• National Centres in Epidemiology and Clinical
  Research, Social Research, and Virology (tall
  poppy syndrome)
• Commonwealth AIDS Research Grants scheme
• Now, mainstream NHMRC and other sources

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Some research landmarks

• Primary HIV
• Novel modes of transmission for example,
  artificial insemination and breast feeding
• Community involvement leading to rapid
  implementation of findings
• Immunological mechanisms, inc. reconstitution
• Intricacies and trends in MSM behaviour
• Role of non-nucleoside reverse transcriptase
  inhibitors
• Metabolic complications of anti-viral drugs
• Pharmacogenomics (HLA-B5701)

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Current research status

• Diversified funding base, including NHMRC
• Community involvement now seen as an asset
• All HIV clinicians value and are involved in
  research, including enhanced surveillance
• Substantial body of expertise and infrastructure
  now involved in other infectious diseases and
  other countries

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1992