Do death certificates accurately record deaths due to bloodstream infection?

To the Editor: Sepsis and bloodstream infection (BSI) are associated with significant morbidity and mortality although they are amenable to targeted intervention in the hospital setting. The Australian Bureau of Statistics (ABS) reported 1463 deaths due to septicaemia in Australia in 20121 — a number that is likely an underestimate.2

These statistics are based on reporting of cause of death on death certificates by medical practitioners. However, previous studies in Australia have found inaccuracies in reporting, with major revision of cause of death required in half of cases referred for coronial review.3 The need for education of reporting doctors and supervision by senior clinicians has been highlighted.4

A review of BSI at our institution during 2012 identified 571 patient episodes of BSI. We were able to analyse death certificates for 65 of 73 patients who died within 30 days of a clinically significant blood culture. The mortality from BSI reported in the literature is high, with a 30-day mortality rate of up to 23% for BSI with any organism, and up to 43.9% for BSI involving methicillin-resistant Staphylococcus aureus.5,6We thus assumed that BSI was likely to have contributed to mortality in deaths where there was evidence of BSI within 30 days of death. Our observed mortality rate of 13% was lower than reported figures, suggesting that BSI was likely contributory in these deaths.

In our series, BSI was reported as an underlying cause of death in 15 of 65 cases (23%), while only 39 death certificates (60%) identified the presence of BSI in any field. Seventeen death certificates (26%) did not reflect the presence of BSI at all. The BSI events not recorded as the underlying cause of death may not have been captured in ABS statistics as contributing to cause of death. Trends in the incidence of and mortality from BSI may therefore not be detected. This is a particular concern in an era of increasing global antibiotic resistance, when rising mortality due to BSI may signal increasing antibiotic resistance in the community.

Several systemic deficiencies likely contribute to underreporting. Events leading to death, but reported as following from the recorded underlying cause of death, are not reflected in cause of death data collected by the current system, which focuses on reporting the underlying cause of death. This approach fails to identify potentially preventable or reversible intermediary events, such as BSI, during complex and advanced medical care. Inaccuracies may be compounded by lack of training and experience and poor supervision of junior doctors who complete death certificates.7 As a result, it is likely that national death statistics are heavily biased towards single events such as road traffic accidents, or “upstream” diagnoses, like malignancy. We agree that increased and structured supervision and training of medical students and junior doctors in this area appears to be required. However, it may also be necessary to revise the reporting process itself to identify potentially preventable intermediary causes of death, that may then be more effectively targeted with research funding, awareness campaigns and clinical care bundles.

Lung transplant recipients receiving voriconazole and skin squamous cell carcinoma risk in Australia

Clinical record

In April 2002, 3 months after her second bilateral lung transplantation, a 45-year-old female patient commenced treatment for necrotising Aspergillus tracheobronchitis with liposomal amphotericin B followed by voriconazole 200 mg twice daily for 13.2 months. In January 2003, mild erythema was noted on her forehead and cheeks, accompanied by dryness and scaling of her forearms and dorsa of her hands. A photosensitive drug reaction was suspected. Two months later, several skin squamous cell carcinoma (SCC) lesions and solar keratoses were noted on the dorsa of her hands. In May 2003, voriconazole administration was ceased because the fungal infection had resolved.

In November 2004, the patient commenced a second course of voriconazole 200 mg twice daily — again, to treat tracheobronchitis — which was continued for 10.6 months. Three months after she started treatment, a photosensitive rash was noted on her lower legs and forearms. In September 2005, six skin SCC lesions were excised from her forehead and left hand, and actinic keratosis lesions were noted on her right forehead, the backs of her hands and on her chest and ankles. In January 2006, a third course of voriconazole 200 mg twice daily was administered for 7.2 months to manage Aspergillus airways colonisation. Two months after initiation of voriconazole prophylaxis, three small unspecified skin lesions were observed on her right temple, nose and anterior chest.

The patient underwent a third bilateral lung transplantation in September 2006 and received posaconazole prophylaxis for nearly 2 years. Multiple actinic keratosis lesions were again observed on her forehead, chest and hands. Twelve months later, she was diagnosed with a parotid gland metastasis from an SCC. She also developed subcutaneous nodules on the forehead, consistent with in-transit metastatic SCC. Radiotherapy was initiated to treat locally invasive skin SCC. In January 2008, a dermal lesion just to the left of the central forehead scar appeared as a new dermal metastasis. Skin SCC lesions were also noted on both of her lips, her left index and right little finger, and there were multiple actinic keratosis lesions on her hands, chest and neck.

In April 2008, the patient underwent right parotidectomy. The histopathology report showed residual microscopic skin SCC deep in the intratemporal fossa region, indicating a high risk of tumour recurrence. Oral capecitabine was given in conjunction with radiotherapy. In October 2008 (2 months after treatment with posaconazole was ceased), she again developed several actinic keratosis lesions scattered on her hand and forehead. She started a second course of posaconazole in December 2008. The patient experienced ongoing facial pain with recurrent tumour in and around the trigeminal nerve. She received stereotactic radiotherapy for meningioma involving the right middle cranial fossa in March 2009. The patient died, owing to metastatic SCC, in October 2009.

Emerging evidence for causal associations between prolonged voriconazole exposure and skin SCC1–6 is of concern, given the frequent use of voriconazole prophylaxis, administered for months in patients after lung transplantation (LTx).7 In our institution, 13.7% of patients (14/102) receiving voriconazole after LTx between July 2003 and June 2010 had at least one episode of skin SCC. Drug-related photosensitivity is the most common cutaneous reaction that has been reported with voriconazole use.8 It has been postulated that long-term voriconazole therapy results in chronic phototoxicity, which, in turn, contributes to the development of skin SCC in transplant recipients.1

A study in the United States from 2003–20083 reported that a high cumulative voriconazole dose was not an independent risk factor for skin SCC in patients who have undergone LTx, in contrast to other findings.4 However, this same study reported that the occurrence of skin SCC among LTx patients was related to the duration of voriconazole therapy,3 which is supported by more recent findings.5,6 The inconsistencies between studies are likely to be related to differences in the methods employed to evaluate predictors and in study design, which may not have adequately controlled for potential confounding factors, such as patient sex, age, sun exposure, history of chronic obstructive pulmonary disease (which could be a proxy variable for smoking status) and level of immunosuppression. Longer and more intensive immunosuppressive regimens have been associated with a higher risk of developing skin SCC.9 Indeed, prolonged duration of voriconazole prophylaxis may have been a surrogate marker for a more compromised immune system or opportunistic infections that could, in turn, influence a patient’s risk of developing skin SCC.

Residing in geographical locations with high levels of sun exposure has also been identified as an independent risk factor for LTx patients developing skin SCC.3 Higher rates of skin SCC have been reported in areas of significant sun exposure, with increased exposure to ultraviolet (UV) radiation being a significant risk factor.3 Importantly, UV radiation is a known distinct mutagen of keratinocytes and induces an immunosuppressed condition that prevents tumour rejection.10 In our patient, multiple skin SCC lesions were noted on photoexposed areas, as has been reported in other patients given prolonged voriconazole therapy.1,2 Our patient reported a history of extensive sun exposure and sunburn and was aged 45 years when her first skin SCC was diagnosed. This is consistent with evidence of a higher incidence of skin SCC in older populations,5 which could be explained by accumulation of high-dose UV radiation over a prolonged period of time.

It is worth noting that aggressive skin SCC lesions and the parotid gland metastasis in this patient occurred during posaconazole prophylaxis (after discontinuation of voriconazole). While studies have reported regression or fading of skin SCC after switching from voriconazole to posaconazole or itraconazole,2 this was not observed in our patient. Her skin SCC could have continued to develop spontaneously despite cessation of voriconazole or could have been due to prolonged posaconazole exposure. Clearly, we need to institute surveillance programs to ascertain whether posaconazole confers a similar level of risk to voriconazole with respect to the development of skin SCC.

In summary, long-term administration of voriconazole demands caution, especially in patients with a risk of high-level sun exposure. Routine prospective dermatological examination should be performed, particularly in patients at high risk as defined by the intensity and duration of immunosuppressive therapy, history of prior skin SCC and geographical location.

Lessons from practice

Before commencing voriconazole therapy, obtain the patient’s history of sun exposure and conduct a baseline skin review, with particular vigilance for patients with light skin, patients who have a high level of sun exposure and those with a previous history of skin SCC.
Give the patient appropriate advice regarding sun protection (eg, wear sunscreen, hats and protective clothing).
Monitor the patient for a photosensitivity reaction while they are receiving voriconazole therapy. If a reaction is noted, consider switching to an appropriate alternative.
After voriconazole has been discontinued, conduct dermatological examinations at 3- to 6-month intervals, particularly for patients with previous skin SCC.
The overall risks versus benefits of using voriconazole should be considered in patients with previous skin SCC and those who had a recurrence or worsening SCC lesions subsequent to voriconazole administration.

Standing at the crossroads in HIV management: implications for primary care practice from the AIDS 2014 conference

Increase testing, increase treatment, consider prophylaxis, search for a cure and try to eradicate HIV

There has recently been renewed interest in HIV management in Australia. Studies have contributed evidence that effective HIV antiretroviral treatment (ART)1,2 and chemoprophylaxis3 prevent HIV transmission. There is a push to identify people with chronic HIV infection who have not been tested4 and to identify people during the acute phase of infection,5,6 when they are most infectious and most likely to transmit disease7 but unlikely to know they are infected.8 HIV treatment is more effective than it was previously; lower pill burdens cause fewer side effects and less toxicity and are less prone to the development of resistance. When combined with traditional HIV prevention measures, the use of antiretroviral agents as pre-exposure prophylaxis (PrEP) by HIV-negative people at high risk of HIV infection reduces transmission by about 75%. The World Health Organization recently recommended PrEP be integrated into prevention programs.9

The 20th International AIDS Conference was held in Melbourne in July, attracting about 14 000 delegates. The theme, “Stepping up the pace”, characterised the meeting’s aim, which was to explore how all these resources and initiatives can be harnessed to have the greatest effect in the global control and ultimate eradication of HIV. There is rekindled interest in HIV cure research, including the continuing pursuit of a vaccine. Speaking at the opening ceremony, UNAIDS Executive Officer Michel Sidibé espoused 2020 targets of 90–90–90: 90% of people living with HIV knowing their status, 90% of people with HIV receiving ART, and 90% of people receiving ART having an undetectable viral load. The Australasian Society for HIV Medicine (ASHM) held a special session to look at Australia’s past role and its new strategic directions nationally (Baggoley, TUSS04) and internationally (McDonald, TUSS04) in relation to HIV. (All proceedings cited here can be accessed by name or session number at the conference website.10) While attendees were upbeat about the potential for ending HIV, the disparity in opportunities between developed and developing countries was an ever-present reality. How does Australia stack up, and what are the challenges for primary care?

Chronicity and cure

In the developed world, HIV is now a long-term, manageable chronic condition. This is the case in Australia for people who are diagnosed and are eligible for Medicare, but the drugs remain expensive and current treatment needs to be taken for life. Cure research suggests that it might be possible to flush HIV from the system if treated early enough (TUAA01). While this remains an aim, follow-up of the Mississippi baby thought to have been cured of HIV infection found that HIV again became detectable after an extended period of no treatment.11 Nevertheless, cure researchers were excited that HIV viral replication was held at bay as long as it was, and see this as a line of investigation. However, a cure is still elusive. While vaccines may be a long way off, primary care remains the ideal setting for long-term chronic disease management and a central point for identifying HIV infection.

Control

The conference began with an overview of the tools we now have to control HIV and how a combination of treatment and prevention can have a synergistic effect in reducing infections (Abdool Karim, MOPL01). Key in demonstrating the prevention benefits of treatment are PrEP trials, which are beginning to report findings. When taken regularly, ART prevents HIV acquisition, and this protective benefit appears to be holding when condom use is not universal (TUAC01). A combination of PrEP and condom use remains recommended (Bavinton, WEAC01). Challenges and obstacles to PrEP for health care providers were explored (Wright, WESY04) and deserve continued discussion. PrEP is often misunderstood as being “a morning-after pill”, flexible or a short-term commitment, but these studies indicate the need for regular dosing to sustain drug levels sufficient to confer prevention. PrEP works, but it needs to be taken rigorously. The Centers for Disease Control and Prevention in the United States have produced comprehensive guidelines,12 and demonstration studies are currently underway in Australia.

Discussion of the role of HIV testing has become increasingly nuanced. It is not simply about laboratory performance, but also about clinical strategies that identify those living with chronic infection. These strategies include indicator-triggered testing, where the presence of diseases that are common in HIV trigger HIV testing, irrespective of other risk factors;13 normalising voluntary HIV testing, where there is no longer a requirement for detailed pretest counselling, simply a requirement for informed consent;14 making testing available in more settings;15 and simplifying the return of test results.

Simplification of treatment

HIV treatment is much simpler than it used to be. The recommended first-line ART in Australia is a once-daily regimen combining three drugs.16 This commonly results in a rapid decline in HIV viral load to an undetectable level (viral suppression) and a steady increase in CD4+ T cells, indicating restoration of a damaged immune system (Cooper, FRPL01). Monitoring viral suppression and treatment tolerance can then be done routinely in general practice, with intermittent specialist review, and many people can keep taking first-line therapy for years. This makes HIV truly a disease that should be managed as a chronic illness in primary care. Previously, treatment regimens were more prone to failure and the development of resistance. While initiation of HIV therapy is restricted to accredited prescribers, all primary care clinicians can participate in the shared care of patients living with HIV.

Complex management

Management of HIV in the older patient is something of particular interest in Australia, as many of our HIV patients have been living with HIV for decades and, as a consequence, are experiencing illnesses associated with ageing. It appears that HIV directly, or possibly indirectly through the drugs used to treat it, accelerates the ageing process (THBS01). It is hypothesised that this effect may be reduced if treatment is initiated earlier, before inflammation associated with HIV has an impact (Deleage, WEAA01). Preventing the damage caused by inflammation associated with early HIV disease is one of the key principles driving earlier treatment initiation (WEAA01). The pragmatic argument is often put that treatment is not delayed in other diseases, yet in HIV, which is clearly communicable, considerable debate has centred on when to start treatment. Historically, this has been a function of wanting to delay the toxicity and difficulties associated with treatment so as to maximise the duration of impact. However, with safer, easier treatment options, this argument holds less weight. We were reminded at the conference that long-term studies are still needed and that there is variation between guideline approaches and recommendations (Cooper, FRPL01).

Domestic and regional responses

The Australian response to HIV was described in the ASHM special session (Wright, TUSS04) and a satellite symposium held by the New South Wales Ministry of Health (SUSA30). Jurisdictional and national strategies are urging greater testing and greater treatment. Barriers to testing are being removed and access to treatment is being expanded, but many social barriers remain (Altice, FRPL02). Australia reaffirmed its commitment to a regional HIV response through supporting regional capacity development. This stands as a reminder that much of the region is experiencing a significant HIV epidemic (McDonald, TUSS04), which has implications for Australians who travel for work and recreation. Global mobility means that we are seeing a change in the characteristics of HIV presentation in Australia, and while 70% of infections are among men who have sex with men, 30% of infections are not, making the question “Could it be HIV?” all the more important. We are at a crossroads — we have the tools, we have the commitment; now we need to harness these to achieve the aim of ending HIV.

The cost-effectiveness of primary care for Indigenous Australians with diabetes living in remote Northern Territory communities

In reply: I acknowledge that data from community controlled health services were not included in our study.1 The high mobility of this population is well recognised and is most common between related communities.2 The bulk of primary care services in remote Northern Territory communities are provided through the 54 government clinics, and we have captured the movement between those services in our dataset. The lesser degree of movement between government and community controlled clinics3 would not have substantively affected our results or our conclusions.

We used propensity score matching4 to improve comparability of the low, medium or high primary care use groups. As shown in the Box, we adjusted for key confounders (age, sex, number of chronic diseases) and found no statistically significant differences between groups. All communities in this study were geographically classified as remote or very remote5 and were similar in terms of their SEIFA (Socio-Economic Indexes for Areas) score.6 Other factors raised by Whyatt and colleagues, including social acceptability and the behaviour of health care providers, may well have significant influence on decisions to use primary care services and, in part, explain the poorer outcomes among the low primary care users.

We are confident that the evidence generated by this study is of use to policymakers and health planners in their efforts to strengthen primary care in remote areas of Australia.

Proportion of patients in each primary care use group before and after propensity score matching, by age, sex and number of chronic diseases

	Low-use (n = 6987)		Medium-use (n = 5926)		High-use (n = 1271)		χ2 significance (P)
	Before	After	Before	After	Before	After	Before	After

Age (years)
15–29	48%	20%	47%	19%	20%	20%	523.3*	2.04†
30–39	24%	23%	25%	25%	23%	23%
40–49	14%	26%	15%	27%	27%	27%
50–59	7%	18%	8%	17%	17%	17%
60–69	7%	13%	5%	12%	13%	13%
Sex
Male	50%	35%	39%	35%	33%	33%	523.3*	2.07†
Female	50%	65%	61%	65%	67%	67%
Number of chronic diseases
0	63%	10%	43%	10%	10%	10%	2004.8*	11.12†
1	17%	16%	22%	16%	16%	16%
2	9%	22%	17%	23%	23%	23%
3	7%	28%	13%	30%	31%	31%
4	4%	20%	5%	17%	16%	16%
5	1%	4%	1%	5%	5%	5%

* P < 0.01. † P > 0.05.

Age: HIV knows no boundary

Clinical record

A 66-year-old retired man was referred to a regional hospital for investigation of a prolonged illness characterised by a 9-month history of profound lethargy, loss of appetite, episodic explosive watery diarrhoea without blood or mucus, and weight loss of 45 kg, resulting in a body mass index of 19 kg/m2. His functional status had deteriorated such that he was mostly bed-bound and required a walking stick to mobilise. The patient’s syndrome had been extensively investigated in the outpatient setting by other clinicians in the region without any causative abnormality identified.

The patient described intermittent fevers and sweats and reported a propensity to pick up “every common infection going around”. He had a background of two coronary angioplasties, mild depression, hypertension and dyslipidaemia, for which he was receiving appropriate treatment. His regular medications included citalopram, aspirin, simvastatin and metoprolol, and he had no history of medication allergies. He was married and had adult children from a previous marriage. He denied a history of smoking or use of recreational drugs, and reported drinking alcohol on social occasions.

On physical examination, he was cachectic and afebrile, with normal vital signs and mildly dry mucous membranes. Results of a clinical examination were otherwise unremarkable, with no organomegaly, lymphadenopathy or rashes evident.

The patient had been extensively investigated over the preceding 9 months by three specialist clinicians. These investigations included upper and lower gastrointestinal endoscopies, which were unremarkable, and chest and abdominal computed tomography scans, which showed only mild non-specific intra-abdominal lymphadenopathy. Blood tests had shown a mild normocytic anaemia (haemoglobin level, 121 g/L [reference interval (RI), 128–175 g/L]), ferritin level of 2400 µg/L (RI, 30–600 µg/L), erythrocyte sedimentation rate of 53 mm/h (RI, 1–10 mm/h), C-reactive protein level of 4.5 mg/L (RI, 0–5 mg/L), normal white blood cell count and no evidence of lymphopenia. Serum electrolyte levels and results of liver function and renal function tests were also within reference intervals. Serological test results confirmed past exposure to cytomegalovirus, Epstein–Barr virus and toxoplasmosis and were negative for hepatitis A, B and C. Levels of tumour markers including carcinoembryonic antigen, CA-125, CA19-9 and prostate-specific antigen were within reference intervals, as were serum cortisol and plasma copper levels. Three stool specimens collected on consecutive days tested negative for white blood cells, red blood cells, pathogenic cysts, ova and parasites.

Given the clinical syndrome, occult malignancy was considered and peripheral lymphocyte flow cytometric analysis was performed, which showed a total CD4+ count of 66 cells/µL (RI, 410–1545 cells/µL). The patient denied risk factors for HIV acquisition and reported having a negative HIV test result 10 years earlier. He denied any intravenous drug use or unprotected sexual intercourse outside his marriage. On subsequent questioning, he did not report an illness consistent with seroconversion illness.

HIV testing was conducted after counselling and consent and gave a positive result, with a viral load of > 1 000 000 copies/mL. The patient was subsequently screened for opportunistic infections, including tuberculosis and sexually transmitted infections. HIV genotyping identified no resistance mutations and he commenced daily treatment with a combined tablet (Atripla; Gilead) containing efavirenz 600 mg, emtricitabine 200 mg and tenofovir 300 mg. He was discharged home after 3 weeks without emergence of immune reconstitution inflammatory syndrome. On follow-up 6 weeks later, the patient had gained 6 kg in weight, diarrhoea had ceased and he was able to ambulate independently without gait aids over 100 m. His partner subsequently tested negative to HIV.

Despite better awareness of HIV, late diagnoses — defined as a CD4+ count of < 350 cells/µL on testing, or presentation with an AIDS-defining illness — continue to occur, even in wealthy countries. The rate of new HIV diagnosis in Australia has begun to rise in recent years, and older people are increasingly represented.1–3 Multiple studies have demonstrated that a diagnosis of HIV over the age of 50 years is associated with more advanced disease at the time of diagnosis, and that age is an independent predictor of clinical progression to AIDS or death.2,3 Therefore, while older people with HIV are few in absolute numbers, they experience significant HIV-associated morbidity and mortality.

The clinical manifestations of HIV include an acute seroconversion illness, followed by a period of latency typically lasting 5–10 years, with later protean clinical manifestations occurring with declining immunological function. Patients often have multiple clinical encounters before the diagnosis is made, emphasising the importance of opportunistic testing even when risk factors are not reported.

Factors that are likely to contribute to low rates of testing and late or missed diagnosis of HIV include older age, poor awareness and misconceptions regarding HIV risk factors.3–5 In addition, older people are less likely to be screened for HIV.4 One study found that adults aged 65 years or older had the lowest HIV testing rate (11.4%) compared with other age groups, with the highest rate seen among adults aged 25–34 years (53.5%).5 Health care providers consistently under-recognise the possibility of HIV in older patients because specific HIV or opportunistic infection symptoms can mimic other diseases frequently associated with older age.3 The patient reported here presented with a syndrome compatible with stage IV HIV and was diagnosed late despite numerous clinical encounters; HIV testing was only initiated after a low CD4+ cell count was indirectly identified on peripheral lymphocyte flow cytometry as part of an investigation into suspected malignancy.

The Australian HIV epidemic is largely dominated by diagnoses associated with male-to-male sexual transmission in young men, with over 63% of all new diagnoses made in this cohort.1,6,7 The median age of Australian men diagnosed with HIV in 2011 was 37 years.1 Geographically, young to middle-aged male patients tend to be clustered in urban areas, with most diagnoses (> 88%) made in metropolitan centres.8,9 As these patients are subsequently treated in a few specialised clinics, rural and general practitioners are relatively underexposed to patients with HIV. It is important that members of the medical community outside specialised clinics remain vigilant for HIV in their patients.

This case highlights the importance of early consideration of HIV infection in all patients presenting with symptoms compatible with a diagnosis of HIV, not only those with traditionally recognised risk factors for infection. Given that the number of HIV infections in Australia is rising annually, and there are serious public health implications associated with missed or delayed diagnosis, it is important to heighten awareness of HIV across all medical specialties, including in rural and remote centres. In Australia, HIV testing is accessible and effective treatment available, and they should be readily offered to avoid the devastating consequences of advanced infection.

Lessons from practice

New diagnoses of HIV are continuing to rise in the Australian population, and older people are increasingly represented.
In older people, a diagnosis of HIV can be missed or delayed if clinicians do not consider the diagnosis.
Clinicians should consider HIV testing in any patient presenting with an HIV-compatible clinical syndrome, even when traditional risk factors are not reported.
Clinicians outside specialised clinics should have a low threshold for offering HIV testing, given the protean manifestations of the disease, especially in its advanced stage.

Splenic rupture: a rare complication of infectious mononucleosis

A 28-year-old man presented to the emergency department with acute left upper quadrant tenderness and postural hypotension. He reported having had fever and cervical tenderness for 1 week before his presentation.

Blood tests showed an elevated white cell count with reactive lymphocytosis. A test for infectious mononucleosis heterophile antibody was positive, consistent with recent infection.

A contrast scan of the abdomen showed splenomegaly with subcapsular haematoma.

Splenic rupture after infectious mononucleosis is rare (incidence, 0.1%–0.5%), but can have disastrous consequences if overlooked.1,2

A stitch (of primary care) in time

Management of a patient’s immediate problem has never been the only goal of a general practice consultation. It is good that each episode of primary care is increasingly recognised for its role in a patient’s health trajectory and in wider community-level health. Primary and community care are powerful means for preventing illness or complications and protecting those at risk.

Primary care is the main vehicle for the Healthy Kids Check (HKC), which may be having a positive impact on managing child health. Thomas and colleagues, in their audit of the medical records of two Queensland practices (doi: 10.5694/mja14.00637), show that the HKC assisted in identifying problems in 116 out of 557 children, 3%–11% of whom required a change in clinical management. The HKC also spurred general practitioners on to consider aspects of a child’s health that it did not cover. Oberklaid (doi: 10.5694/mja14.01200) says that although the concept of a general health screen is intuitively appealing, implementation is challenging in terms of population coverage, interpreting results against normal developmental variability, and getting timely intervention for detected problems. Responding to parents’ concerns is the cornerstone for early detection and prevention, and primary care plays an important role in increasing the emphasis in health care on prevention.

At the other end of the lifespan, GP consultations present the opportunity to reconsider older patients’ regular medicines. Reeve and colleagues (doi: 10.5694/mja13.00200) highlight the importance of deprescribing in resolving unwanted drug effects and increasing adherence to needed medicines. But they also emphasise caution so as to reduce adverse drug withdrawal reactions and disease re-emergence, and they point out the lack of evidence to construct optimal methods to deprescribe. Likewise, Scott et al (doi: 10.5694/mja14.00146) highlight the barriers to deprescribing and emphasise the need to have holistic discussions with patients of its risks and benefits so that deliberate and considered plans for withdrawing medications are formulated.

Reconsidering a patient’s medication burden naturally leads to a rethink of how underlying chronic conditions should be managed. This is particularly pertinent with regard to chronic pain. Although early intervention and referral to specialist services are common for other chronic conditions, Cousins and Brydon (doi: 10.5694/mja14.00572) emphasise that this is lacking for the one in five Australians in chronic pain. Given the current overreliance on opioids and the long waiting times to attend pain clinics, they welcome National Pain Strategy recommendations to provide resources and training for GPs, establish multidisciplinary regional pain centres and set levels of care based on case complexity.

Early prevention and detection through primary care should also apply to mental health in people of all ages, as Reavley and Jorm argue (doi: 10.5694/mja13.00198). They welcome increases in mental health resourcing and service availability over the past two decades, and the reduction of some measures of mental illness. Yet population health-oriented strategies for early detection and support for people, starting early and continuing throughout the lifespan, are more likely to produce substantial improvement for less cost.

The health of vulnerable populations also falls within the purview of community care, and practitioners may feel hindered in their efforts to help. Corbett and colleagues (doi: 10.5694/mja14.00279) found responses by general and community paediatricians to a questionnaire assessing knowledge and attitudes to asylum seeker children revealed that most are strongly supportive of the Australian Medical Association’s position on children in immigration detention and strongly opposed to offshore detention. But notable gaps exist in knowledge of Medicare eligibility rules, hospital fee-waiver programs and screening tests conducted for visa applications. The paediatricians are well motivated to help these vulnerable children but would be aided by better knowledge of the administrative mechanics.

GPs and others working in community health care should be confident that their clinical practice for individual patients has positive lasting effects on their and their communities’ health. Patient-centred primary care that acts in a timely way and directs further care appropriately will continue to be effective in these respects.

The importance of effectively combating HIV/AIDS through tackling the social aspects of the pandemic post-2015.

An open letter to Ban Ki Moon

Mr Secretary General:

This letter starts with one patient.

I met her on my second day at Kenyatta National Hospital, on the paediatrics ward. I would like to tell you her name, but she had never been given one, so I called her “Beautiful”. She was 3 months old and had never left the hospital. Twenty-four hours after a traumatic birth to an HIV-positive mother who had not accessed the care freely available to all pregnant women for prevention of mother-to-child-transmission, she had been abandoned. Despite having no name, she already had a status: positive. When I met her she didn’t cry, because in her short life she had learnt that no one came when she did. She was developmentally delayed because, in such an underresourced department, caring for the well child was not the physician’s priority. “What makes a mother give up her child?” I asked one of the junior doctors. He responded: “It happens; there are usually more of them”. I explained that I didn’t understand, and the doctor’s response was as sharp as the answer was obvious — I was right. I didn’t understand. “Having HIV is more than just a disease here”, he said, “it is a lifetime of struggling against prejudice. It is a life sentence”.

I knew the proportion of AIDS-related fatalities had decreased dramatically with the upscaling of highly active antiretroviral therapy (HAART) availability.1 In Kenya, where 300 000 children are HIV positive,2 this little girl was my first insight into the social issues involved in the pandemic; unfortunately she wasn’t going to be my last. During my elective I was involved in the daily diagnosis and management of many HIV-positive children. I saw at first hand the reluctance of caregivers to permit HIV testing, diagnosis and treatment for their children, and there was a significant loss to follow-up. It is estimated that for each paediatric HIV/AIDS case reported in Kenya there are 3–4 other infected children undiagnosed.3 Beautiful’s situation forced me to confront the staggering social and cultural barriers to combating HIV/AIDS in some of the world’s worst-affected countries.

The fight to achieve Millenium Development Goal 6 with regard to HIV/AIDS (achieve universal access to treatment by 2010 and begin to reverse its spread by 2015) has champions from doctors to musicians and has achieved falling infection rates and increasing availability of HAART. However, given the plight of Beautiful, and countless children like her, I have come to believe that a paradigm shift in our approach to providing prophylaxis and treatment is desperately needed. In order to achieve the AIDS-free generation that UNICEF deems possible, the interplay of stigma, socioeconomic status and a distrust of health care professionals has to be better understood and addressed. As physicians and policymakers, to successfully tackle the epidemic affecting not only Kenya’s children, but the world’s, we need to see past the disease and consider the dramatic effect such a diagnosis can have on a patient and his or her family.

I spent 3 weeks in Kibera (Nairobi’s biggest slum), where it is estimated that between 10% and 25%4 of children are HIV positive. The poorest neighbourhoods lack the necessary infrastructure to combat the spread of HIV. I met young girls, orphans of the pandemic, who had dropped out of school and had no other means to survive but through transactional sex work, resulting in pregnancy, poor health and HIV infection.5 One 14-year-old girl said she didn’t see the point of condoms; she was going to die of AIDS anyway. The brutal truth is that statistics bear out this young girl’s dark prediction. In homeless youth, HIV infection progresses rapidly to disease, and mortality is greater than 50% by 15 years of age.6 I met this girl while I was working in a free clinic serving the slum. Clearly, access to health care wasn’t the issue.

During my time on the ward, Beautiful did not require anything more than her daily feed, something that the health care workers were only too ready to provide. But for the boy in the next cot it was different. He was also HIV positive and had been admitted for treatment of an AIDS-associated infection, which necessitated frequent blood tests. Not one of the ward staff were prepared to carry these out. So I did.

One study found 9% of doctors routinely refused treatment to HIV-positive patients or their children, considering it a waste of resources.7 When I read this statistic, I was ashamed to be part of the same profession that turned away people in so much need. I cannot imagine how devastating this must be for patients who simply have to live with the implications of their doctor’s prejudice.

I was shocked that prejudice against those with HIV was reflected in health policy. Comprehensive Care Clinics (CCC) seemed like an unnecessary segregation of HIV sufferers. In Kenya the CCC’s only function is to maintain the care of HIV-positive patients, and they are held in specific locations at specific times for only this purpose.8,9 Consequently, mothers do not bring their children, since their HIV status would be disclosed by simply attending.10 One mother told me “I am so afraid my neighbours will see me and they will know”, such is the stigma surrounding HIV. This fear translates to antenatal clinics, where up to 16% of women refuse HIV testing11 and 36% do not return for the results.12 Likewise, 30% of HIV-positive breastfeeding mothers go against medical breastfeeding advice so as not to disclose their HIV status.1 3,14

Yet, pioneering initiatives are breaking down these barriers. For instance, the results of a study being conducted at Kenyatta, centred around encouraging parents to disclose their own status and that of their child to trusted friends and family members, thus far indicate a positive correlation between disclosure and compliance with medical advice and treatment. In debunking this culture of secrecy, investigators are seeking to promote family-centred HIV care.15 The international community should look to these examples, building on their founding principles; to beat AIDS we must do more than diagnose and treat. This is what effective global health should look like post-2015.

I left Kenya and Beautiful in August, having contacted a charity-run orphanage and asked them to give her a home. When I had first arrived at the Kenyatta National Hospital I saw a straightforward choice for patients when given access to free medical treatment: say yes. What I learned was to see the devastation of the disease from the patients’ perspective. To me the devastation was in high viral load, but to them it meant ostracism, poverty and prejudice. Their diagnosis meant no quality of life. And there is no point in having a treatment if those who need it don’t access it. What I learnt is not only applicable in Kenya: the time I spent there opened my eyes to the challenging and unyielding nature of practising medicine in resource-poor settings.

Global health as a discipline has something to heed from this lesson as well. HIV treatment services fall short in the provision of care, not because of resources, but because they only focus on the biological aspects of HIV and not the impact such a diagnosis has upon the lives of the patients and their families. The post-2015 agenda should build on the valuable foundations of Millenium Development Goal 6 — the aspiration to reverse the spread of HIV/AIDS and provide universal treatment. However, in seeking to improve the lives of affected populations and countries we must be sure to consider HIV holistically rather than just biologically.

Mr Secretary General, I implore you, renew your commitment to the fight against HIV/AIDS, but this time deal with the social and cultural barriers to accessing treatment. In this way we must work together to ensure that no more children, like Beautiful, are left nameless.

Sincerely,

Heather Kitt

Eliminating HIV transmission in New South Wales: the critical role of testing

The “ending HIV” movement calls for new and innovative approaches to testing

In Australia, about 1000 new HIV diagnoses are notified annually. In 2012, after 10 years of relative stability, the number of HIV notifications in New South Wales sharply increased. Most other states and territories have experienced a similar trend. There were 409 new notifications of HIV reported in NSW in 2012; a 24% increase compared with 2011.1 In 2013, there were 357 notifications; a fall of 13% from 2012 but still higher than any year since 2007. Men who have sex with men (MSM) accounted for 78% of all notifications.2

In the 30 years since the first Australian HIV case was recorded in Sydney, approaches to HIV diagnosis, treatment and prevention have evolved in response to emerging scientific evidence. Thanks to the availability of effective antiretroviral treatment, receiving a diagnosis of HIV in Australia is no longer the death sentence it once was. Instead, living with HIV today carries with it the lifelong health and social consequences of a unique chronic disease.

A new era

In 2011, a large clinical trial demonstrated that antiretroviral treatment not only effectively treats HIV but also prevents HIV transmission within serodiscordant heterosexual couples.3 The results were heralded as the scientific breakthrough of 20114 and revolutionised HIV prevention by placing treatment-based approaches alongside traditional behavioural interventions. However, the study was not able to assess HIV transmission between MSM owing to insufficient numbers.

In 2014, interim results were released from the second large study to look at the impact of antiretroviral treatment on HIV transmission,5 which included a significant cohort of serodiscordant male couples. The results show that treatment also prevents HIV transmission between MSM, with a maximum 1% per year chance of transmission from any anal sex from someone on successful HIV treatment. Final results from the study will be available in 2017.

The concept of treatment as prevention is not unique to HIV, having long been the keystone in the control of communicable diseases such as tuberculosis and syphilis. However, HIV poses particular challenges to the traditional model of communicable disease control, because the phase of greatest infectiousness is usually soon after infection and is often asymptomatic, contact tracing is frequently complex, and treatment is not yet a cure and therefore must be lifelong.

In this new era, where antiretroviral treatment has not only redefined HIV as a chronic disease but is also a powerful addition to the HIV prevention armamentarium, the elimination of HIV transmission can for the first time be considered a potentially achievable goal. In December 2012, the NSW Minister for Health launched the NSW HIV Strategy 2012–2015,6 which has the overarching goal of working towards the elimination of HIV transmission by 2020. The strategy sets treatment and prevention targets for NSW that align with those defined in the landmark 2011 United Nations political declaration on HIV and AIDS,7 to which Australia committed.

Test more, test often

In this new scientific and political framework, successfully implementing an HIV testing strategy that reduces the pool of undiagnosed HIV infection, detects new infections early and facilitates linkage to care is a key component of HIV prevention.8 Modelling of the Australian HIV epidemic in MSM suggests that transmission from people with undiagnosed infection could account for more than 30% of all new infections.9

Free HIV testing targeting the high-risk populations of MSM, injecting drug users and sex workers has long been accessible in clinical settings in NSW. Despite the relative ease of access to clinical services, there remain at-risk individuals who do not engage with the health system and are therefore not tested, or who do engage but are not tested at all or frequently enough. This is especially relevant for MSM, for whom testing up to four times a year may be recommended, depending on individual factors.10 Achieving substantial increases in testing rates and changing the pattern of testing among segments of the population of MSM in NSW is essential if the goal of the HIV strategy is to be achieved.

Getting high-risk populations to test frequently can be complex, and evidence for effective approaches is lacking. A qualitative study of MSM in NSW found that testing more frequently would be acceptable if more convenient testing and rapid result turnaround were made available.11 Developing new service models to make HIV testing easier, quicker and more accessible is a critical step towards achieving the high coverage and frequency of HIV testing needed.

A diversity of testing options is essential, recognising that the willingness and ability of at-risk people to test for HIV on a regular basis will be influenced by a range of factors including time constraints, geographical location and perception of risk. Different testing options may not only suit different individuals but also each individual differently depending on the occasion. For example, a gay man may find it most convenient to see his general practitioner once a year for a complete sexual health check including HIV testing, and then visit a community-based site every 3 months for HIV screening with a rapid test. Creating a variety of easy testing options is the task at hand for NSW Health and its health sector, community and academic partners.

Rapid HIV testing

Since October 2011, rapid HIV testing has become increasingly available in NSW via trials, demonstration projects and routine practice, and it is currently available at more than 19 sites, including three community sites. A range of rapid tests are on the market and allow results to be given to the patient within 30 minutes. The Therapeutic Goods Administration (TGA) has approved one of these tests, the Determine HIV-1/2 Ag/Ab Combo (Alere), for point-of-care use in Australia, and other tests are under review. The use of rapid tests to screen for HIV in novel settings, in conjunction with conventional testing in clinical settings, has the potential to significantly increase testing across the state.

To mark World AIDS Day 2013, NSW Health launched the first ever pop-up HIV testing site in Australia. A caravan, marked with NSW Health and ACON (AIDS Council of NSW) branding, provided a private and confidential space on Oxford Street, Darlinghurst, where clients could drop in for a test (Box). The 5-day site attracted media coverage that reached an estimated audience greater than 4 million people. Over 500 people engaged with the site and 195 opted to have a test, almost all of whom were MSM. No new HIV diagnoses were made. Feedback from clients showed that the model was highly valued (unpublished data). Since that initial experience, further pop-up sites have been established in NSW at the Tropical Fruits New Year’s Eve Festival in Lismore and on Oxford Street during the 2014 Sydney Gay and Lesbian Mardi Gras.

NSW local sexual health and laboratory services oversee pop-up sites to ensure compliance with TGA requirements for point-of-care HIV testing. For all rapid-testing sites, including pop-ups, the local service’s standard operating procedures ensure that any person with a reactive rapid test is offered prompt laboratory-based confirmatory testing and linkage to comprehensive clinical care and psychosocial support including early assessment for treatment initiation. If a person with a confirmed diagnosis has a regular GP, the sexual health service can inform that GP if the patient so wishes. Newly diagnosed patients can choose their preferred arrangements for ongoing HIV management. If the regular GP is not an accredited HIV section 100 prescriber, a shared-care model may be adopted.

Additionally, the NSW HIV Support Program helps diagnosing doctors ensure that all people who are newly diagnosed with HIV have timely access to appropriate clinical management, psychosocial support, counselling on HIV treatment and preventing transmission, assistance with contact tracing partners at risk, and linkage to relevant specialist and community services.12

Although making HIV testing facilities visible in public locations may be confronting for some, visibility is important in encouraging open conversation about HIV and normalising testing, especially in areas with high concentrations of at-risk people. Further exploration of pop-up rapid-testing models is needed to better understand their specific role in facilitating high testing rates among at-risk populations and in reaching individuals who are long-term non-testers. In addition, the cost-effectiveness of different testing models in NSW remains to be determined. New approaches to add to the current mix of testing options are anticipated and include innovations like self-testing and self-sample collection.

NSW Health and its partners are committed to escalating HIV testing, acknowledging that the elimination of HIV transmission will not be possible without it. Achieving this escalation means listening to affected communities and the health profession, and rethinking traditional approaches to testing in this new era of HIV.

Impact of pneumococcal polysaccharide vaccine in people aged 65 years or older

To the Editor: Menzies and colleagues promote the 23-valent polysaccharide pneumococcal vaccine (23vPPV) as effective in people aged 65 years or older.1 I believe their data show exactly the opposite. The vaccine appears to be ineffective.

In 2005, a nationally funded vaccination program began with 23vPPV for those aged ≥ 65 years and a 7-valent pneumococcal conjugate vaccine (7vPCV) for children. Subsequently, there was a rapid and dramatic drop in invasive pneumococcal disease in older people, but this was only for disease due to serotypes covered by the childhood 7vPCV. When the effects of the other components of the 23vPPV are examined, there is no fall but instead a statistically significant increase in invasive infections in older people.1

Vaccinating children with highly effective conjugated pneumococcal vaccines is associated with a dramatic decrease in invasive pneumococcal disease not only in children but also in older people. Older people benefit because vaccinated children carry fewer pneumococcal strains and thus pass on fewer invasive strains to parents and grandparents.2–4

I think that the only reasonable conclusion from the study by Menzies et al is that the non-conjugated vaccine is ineffective in those aged ≥ 65 years. Its use may perversely have even been associated with an increase in invasive disease.

This clearly shows the superiority and easily measured benefits of conjugated pneumococcal vaccines. Why persevere with the unconjugated 23vPPV in older people given its poor or potentially non-existent efficacy? We need to ensure that we have effective pneumococcal vaccines available for older people. This means conjugated pneumococcal vaccines.