Constructing a 'target population': A critical analysis of public health discourse on substance use among gay and bisexual men, 2000-2020.

BACKGROUND: Gay and bisexual men (GBM) have higher substance use prevalences than general population samples - often attributed to stigmatisation of sexual minority identities. We examined how influential public health research on substance use among GBM interprets this behaviour and what GBM-specific identities emerge through the discourses employed. METHODS: We searched Web of Science for publications on substance use among GBM, selecting 60 of the most cited papers published during 2000-2020. We studied the language used to describe and interpret drug-using behaviour using critical discourse analysis, focusing on interpretive repertoires and subject positions. RESULTS: Three distinct discursive tendencies were identified. First, in constructing a target population, GBM who use illicit drugs are positioned as deficient, socially irresponsible, and maladapted to dealing with stigmatisation and HIV risks. Second, in shifting the focus beyond the individual, the gay community is conceptualised as offering a safe space for socialisation. Nonetheless, gay community spaces are problematised as promoting substance use among vulnerable GBM through aggravating loneliness and normalising drug use as a form of maladaptive (avoidance) coping. Third, counterdiscursive movements add nuance, context, and comparisons that relativise rather than generalise substance use and focus on pleasure and self-determination. Such discourses centre the need for interventions that disrupt homophobic socio-structures instead of individualising approaches to limit non-conformity. CONCLUSION: 'Expert' assessments of substance use among GBM perpetuate pathologising understandings of this behaviour and promote abject subject positions, contributing to perpetuations of intergroup stigma and social exclusion based on drug and sexual practices. Our findings highlight the need for deliberate and critical engagement with prior research and a conscious effort to disrupt dominant discourses on GBM's substance use.

Community-based provision of direct-acting antiviral therapy for hepatitis C: study protocol and challenges of a randomized controlled trial.

BACKGROUND: To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to treatment. Direct-acting antiviral (DAA) treatment can be provided in primary healthcare services (PHCS), improving accessibility, and, potentially, retention in care. Here, we describe our protocol for assessing the effectiveness of providing DAAs in PHCS, and the impact on the HCV care cascade. In addition, we reflect on the challenges of conducting a model of care study during a period of unprecedented change in HCV care and treatment. METHODS: Consenting patients with HCV infection attending 13 PHCS in Australia or New Zealand are randomized to receive DAA treatment at the local tertiary institution (standard care arm), or their PHCS (intervention arm). The primary endpoint is the proportion commenced on DAAs and cured. Treatment providers at the PHCS include: hepatology nurses, primary care practitioners, or, in two sites, a specialist physician. All PHCS offer opioid substitution therapy. DISCUSSION: The Prime Study is the first real-world, randomized, model of care study exploring the impact of community provision of DAA therapy on HCV-treatment uptake and cure. Although the study has faced challenges unique to this period of time characterized by changing treatment and service delivery, the data gained will be of critical importance in shaping health service policy that enables the elimination of HCV. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT02555475 . Registered on 15 September 2015.

Aiming for elimination: Outcomes of a consultation pathway supporting regional general practitioners to prescribe direct-acting antiviral therapy for hepatitis C.

To increase access to treatment, the Australian government enabled general practitioners (GPs) to prescribe direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV)-in consultation with a specialist if inexperienced in HCV management. This study describes the establishment and outcomes of a remote consultation pathway supporting GPs to treat HCV. Key stakeholders from primary and tertiary healthcare services in the Barwon South Western region developed and implemented an HCV remote consultation pathway. Pharmaceutical Benefits Schedule prescription data were used to evaluate GP DAA prescription 12 months pre-and post- pathway implementation. A retrospective review of patients referred for remote consultation for 12 months post- pathway inception was undertaken to determine the care cascade. HCV treatment initiation by GPs increased after implementation of the remote consultation pathway. In the 12-month study period, 74 GPs referred 169 people for remote consultation; 114 (67%) were approved for GP DAA treatment; 48 (28%) were referred for specialist assessment. In total, 119 (71%) patients commenced DAA; 69 were eligible for SVR12 assessment. Post-treatment HCV RNA data were available for 52 (75%) people; 37 achieved SVR12; 15 achieved SVR ranging from week 5 to 11 post-treatment. No treatment failure was detected. Collaborative development and implementation of a remote consultation pathway has engaged regional GPs in managing HCV. Follow-up post-treatment could be improved; however, no treatment failure has been documented. To eliminate HCV as a public health threat, it is vital that specialists support GPs to prescribe DAA.

Anorectal swabs as a marker of male-to-male sexual exposure in STI surveillance systems.

Identification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007-2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

Resumption of injecting drug use following release from prison in Australia.

INTRODUCTION: Ex-prisoners with a history of injecting drug use (IDU) experience disproportionate drug-related harm. Rapid resumption of substance use following prison release is common and evidenced in high rates of overdose mortality. However, few studies have documented the rate of IDU resumption following prison release or identified risk factors for relapse. METHODS: Structured interviews were conducted with 533 adults with a history of IDU in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Incidence of self-reported IDU resumption was calculated overall and for each follow-up interval. Risk factors associated with time to resumption of IDU were estimated using discrete-time survival analysis. RESULTS: IDU resumption was reported by 41% of participants during a median of 98days of follow-up (IQR=94-121), an overall crude incidence of 1.06 per person-year. The highest rate was observed in the first month (23%; crude incidence 2.24 per person-year). In adjusted discrete-time survival analyses, being unemployed at the previous interview (AHR=1.59; 95%CI:1.10-2.30), shorter incarceration (≤90days vs. >365days; AHR=2.20; 95%CI:1.33-3.65), and IDU during the index incarceration (AHR=2.80; 95%CI:1.92-4.09) were significantly associated with time to IDU resumption; parole was protective (AHR=0.66; 95%CI:0.47-0.92). CONCLUSIONS: Evidence-based efforts to prevent IDU in prison and IDU resumption after release are important for both prisoner and public health. Enhancing opportunities for employment and capitalising on the short-term benefits of parole for ex-prisoners may delay resumption of IDU after release from prison. These strategies should complement rather than replace harm reduction efforts for this high-risk population.

Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia.

INTRODUCTION: Release from prison is a period of elevated risk for drug-related harms, particularly among people who inject drugs (PWID). Non-fatal overdose can cause serious morbidity and predicts future fatal overdose, however neither the incidence nor the risk factors for non-fatal overdose following release from prison are well understood. METHODS: Structured health-related interviews were conducted with 1051 adult prisoners in Queensland, Australia prior to release and approximately 1, 3 and 6 months post-release. Incidence of self-reported overdose in the community was calculated for PWID and all prisoners for three discrete time periods. Negative binomial regression with robust error variance was used to identify pre-release predictors of overdose among PWID. RESULTS: The incidence of reported overdose was highest between 1 and 3 months post-release (37.8 per 100 person-years (PY) among PWID; 24.5/100 PY among all ex-prisoners). In adjusted analyses, the risk of post-release non-fatal overdose was higher for PWID who reported: being unemployed for >6 months before prison, having been removed from family as a child, at least weekly use of benzodiazepines and/or pharmaceutical opiates in the 3 months prior to prison, and ever receiving opioid substitution therapy (OST). Pre-release psychological distress and a lifetime history of mental disorder also predicted overdose, whereas risky alcohol use in the year before prison was protective. CONCLUSIONS: PWID have a high risk of overdose following release from prison. Imprisonment is an opportunity to initiate targeted preventive interventions such as OST, overdose prevention training and peer-delivered naloxone for those with a high risk profile.

Response to treatment following recently acquired hepatitis C virus infection in a multicentre collaborative cohort.

Pegylated interferon therapy is highly effective in recently acquired HCV. The optimal timing of treatment, regimen and influence of host factors remains unclear. We aimed to measure sustained virological response (SVR) during recent HCV infection and identify predictors of response. Data were from five prospective cohorts of high-risk individuals in Australia, Canada, Germany and the United States. Individuals with acute or early chronic HCV who commenced pegylated interferon therapy were included. The main outcome was SVR, and predictors were assessed using logistic regression. Among 516 with documented recent HCV infection, 237 were treated (pegylated interferon n = 161; pegylated interferon/ribavirin n = 76) (30% female, median age 35 years, 56% ever injected drugs, median duration of infection 6.2 months). Sixteen per cent (n = 38) were HIV/HCV co-infected. SVR among those with HCV mono-infection was 64% by intention to treat; SVR was 68% among HCV/HIV co-infection. Independent predictors of SVR in HCV mono-infection were duration of HCV infection (the odds of SVR declined by 8% per month of infection, aOR 0.92, 95% CI 0.85-0.99, P = 0.033), IFNL4 genotype (adjusted OR 2.27, 95% CI 1.13-4.56, P = 0.021), baseline HCV RNA <400 000 IU/mL (aOR 2.06, 95% CI 1.03-4.12, P = 0.041) and age ≥40 years (vs <30: aOR 2.92, 95% CI 1.31-6.49, P = 0.009), with no difference by drug regimen, HCV genotype, symptomatic infection or gender. The effect of infection duration on odds of SVR was greater among genotype-1 infection. Interferon-based HCV treatment is highly effective in recent HCV infection. Duration of infection, IFNL4 genotype and baseline HCV RNA levels can predict virological response and may inform clinical decision-making.

Does informing people who inject drugs of their hepatitis C status influence their injecting behaviour? Analysis of the Networks II study.

BACKGROUND: People who inject drugs (PWID) are at risk of hepatitis C virus (HCV). It is plausible that PWID who receive a diagnosis of HCV will reduce their injecting risk out of concern for their injecting partners, although evidence for this is currently limited. The aim of this study was to investigate whether informing PWID of their HCV diagnosis was associated with a change in injecting behaviour. METHODS: Prospective, longitudinal study of PWID recruited from street drug markets across Melbourne, Australia. Interviews and HCV testing were conducted at 3-monthly intervals. The association between receiving a diagnosis of HCV and (i) injecting frequency and (ii) injecting equipment borrowing, was examined using generalized estimating equations (GEE) analysis. RESULTS: Thirty-five individuals received a diagnosis of HCV during the study period. Receiving a diagnosis of HCV was associated with a decrease of 0.35 injections per month (p=0.046) but there was no change in injecting equipment borrowing (p=0.750). CONCLUSIONS: A small reduction in injecting frequency was observed in PWID who received a diagnosis of HCV. This finding should be investigated further in larger studies examining a wider range of injecting risk behaviours.

A randomised controlled trial using mobile advertising to promote safer sex and sun safety to young people.

Mobile phone text messages (SMS) are a promising method of health promotion, but a simple and low cost way to obtain phone numbers is required to reach a wide population. We conducted a randomised controlled trial with simultaneous brief interventions to (i) evaluate effectiveness of messages related to safer sex and sun safety and (ii) pilot the use of mobile advertising for health promotion. Mobile advertising subscribers aged 16-29 years residing in Victoria, Australia (n = 7606) were randomised to the 'sex' or 'sun' group and received eight messages during the 2008-2009 summer period. Changes in sex- and sun-related knowledge and behaviour were measured by questionnaires completed on mobile phones. At follow-up, the sex group had significantly higher sexual health knowledge and fewer sexual partners than the sun group. The sun group had no change in hat-wearing frequency compared with a significant decline in hat-wearing frequency in the sex group. This is the first study of mobile advertising for health promotion, which can successfully reach most young people. Challenges experienced with project implementation and evaluation should be considered as new technological approaches to health promotion continue to be expanded.

Can data from HIV voluntary counselling and testing be used to assess the impact of public health interventions? A literature review.

Routinely collected data from clinical sites offering voluntary counselling and testing (VCT) for HIV diagnosis have been used to evaluate the impact of public health interventions; however, there has been considerable diversity in strategies. To gain an understanding of the outcome of these evaluations and provide the basis for considering methodological issues, we reviewed published studies. Search criteria were met by 20 papers that described 38 interventions, of which 29 were media-related and nine were policy changes. Most (25 of 38) were based on comparisons between two time periods, before and during the intervention, while 13 used multiple time points, including nine that adopted regression methods. About a third (13 out of 38) of the evaluations monitored HIV positivity rates and a small number investigated impact according to sex (six), age (five) and whether clients were new or repeat (three). For the 29 media-related interventions, there was an average 53% increase in the number of HIV tests performed during the intervention compared with beforehand. For policy change interventions, a 35% increase was found. Routinely collected data from VCT sites can be used to evaluate the impact of public health interventions, but attention to methodological issues will maximize their value for evaluation purposes.

Markers and risk factors for HCV, HBV and HIV in a network of injecting drug users in Melbourne, Australia.

BACKGROUND AND AIMS: Current injecting drug users (IDU) in major street drug markets within greater Melbourne were recruited to a longitudinal study on blood borne viruses. Here we investigated risk factors for hepatitis C virus (HCV), hepatitis B virus (HBV) and HIV infection in these IDU at the time of their recruitment. METHODS: Three hundred and eighty-two IDU completed detailed questionnaires on their drug use and risk behaviours, and provided blood samples for serology testing. These data were analysed using univariate and multivariate techniques. RESULTS: The overall prevalence of exposure to HCV, HBV and HIV was estimated at 70%, 34% and <1%, respectively. Independent predictors of HCV exposure were history of imprisonment (RR 1.34, 95% CI 1.19-1.52), use of someone else's needle or syringe (RR 1.23, 95% CI 1.07-1.42), >7.6years length of time injecting (RR 1.21, 95% CI 1.07-1.37), and originating from Vietnam (RR 1.12, 95% CI 1.07-1.18). Independent predictors of HBV exposure were HCV exposure (RR 2.15, 95% CI 1.35-3.43), >7.6years length of time injecting (RR 1.57, 95% CI 1.17-2.13) and originating from outside Australia (RR 1.60, 95% CI 1.22-2.10). Neither prison- nor community-applied tattoos predicted HCV or HBV exposure. Up to 31% of IDU who injected for 1year or less were HCV antibody positive, as were 53% of those who injected for 2years or less. CONCLUSIONS: Ongoing engagement with young IDU, through the provision of harm reduction education and resources, is critical if we are to address blood borne viral infections and other health and social harms associated with injecting drug use.

Dietary intake and domestic food preparation and handling as risk factors for gastroenteritis: a case-control study.

Cases of gastroenteritis were examined to identify if dietary intake prior to an episode and food-handling and storage practices in the home were risk factors for illness. Cases and controls completed a dietary questionnaire after an event or when well, and questionnaires concerning food-handling, storage and general food-hygiene practices. Comparing cases to themselves when well. subjects were more likely to have eaten cold sliced salami, fried rice and foods cooked elsewhere, and to have had a baby in nappies in the house (OR 1.52-6.24, P< or =0.01). Cases compared to non-cases were more likely to have bought frozen poultry, have eaten foods cooked elsewhere and to have had a baby in nappies in the house (OR 1.44-2.05, P< or = 001). Although food-handling and storage practices are considered important, we were unable to detect an association in this study.

The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities.

This study measured the prevalence and the risk factors associated with HCV antibody-positive prisoners. A total of 630 prisoners completed a questionnaire about risk behaviours associated with HCV transmission and were tested for HCV antibody from a blood test. Of these 362 (57.5%) prisoners were HCV antibody positive. A total of 436 (68.8%) prisoners reported ever injecting drugs and 332 reported injecting drugs in prison. HCV-positive prisoners were more likely to have injected drugs (OR 29.9) and to have injected drugs in prison during their current incarceration (OR 3.0). Tattooing was an independent risk factor for being HCV positive (OR 2.7). This is the first study conducted on prisoners that has identified having a tattoo in prison as a risk factor for HCV. Injecting drugs whilst in prison during this incarceration was also a risk factor for HCV. Our results show prisoners who injected drugs outside of prison continue to inject in prison but in a less safe manner.

Failure to detect norovirus in a large group of asymptomatic individuals.

Noroviruses are a major cause of both sporadic and epidemic gastroenteritis in humans, but the mechanisms by which norovirus circulates within the community are poorly understood. In this study, we examined the hypothesis that asymptomatic people act as a reservoir for norovirus. Faecal specimens from 399 asymptomatic individuals were tested for norovirus by reverse transcription polymerase chain reaction (RT-PCR) methodology, and no norovirus was detected. The failure to detect norovirus was not apparently due to the test sample being resistant to norovirus infection, nor to the presence of PCR inhibitors in the test sample. The findings suggest that, if norovirus is carried by asymptomatic people, the carriage rate is very low; the upper bound (95% confidence interval, binomial distribution) of the carriage rate was only 0.8%. Thus, it is unlikely that asymptomatic people are an important reservoir for norovirus.

HIV in prison: what are the risks and what can be done?

Prisons are recognised worldwide as important sites for transmission of blood-borne viruses (BBVs). There are two reasons why transmission risks in prison are higher than in the community. First, in most western countries, many prison entrants have histories of injecting drug use, and thus already have high prevalences of BBVs. Second, the lack or under-supply of preventive measures (such as clean needle and syringes or condoms) in most prisons, combined with extreme social conditions, creates extra opportunities for BBV transmission. HIV prevalence in prisoners in more developed countries ranges from 0.2% in Australia to over 10% in some European nations. There are case reports of HIV being transmitted by sharing injecting equipment and sexual activity. Tattooing has been reported as a risk factor for the transmission of BBVs in prison. Access to condoms and needle and syringe programmes in prisons is extremely limited, despite success when they have been introduced. The vast majority of prison inmates are incarcerated for only a few months before returning to the community--thus they are, over the long term, more appropriately regarded as 'citizens' than 'prisoners'. Public health policy must involve all sections of the community, including prison inmates, if we are to reduce transmission of HIV and other BBVs.

The rate of gastroenteritis in a large city before and after chlorination.

There is conflicting evidence about the contribution of drinking water to endemic community gastroenteritis in water supplies which meet conventional microbiological standards with some studies reporting associations between drinking water and endemic disease and others finding no evidence that water is implicated in disease. This study reports the results of an ecological study investigating the effect on community gastroenteritis of chlorinating a city of over 3 million people in the mid 1970s. Prior to chlorination faecal coliforms were regularly identified in the water. Admissions for gastroenteritis and attendances to the Emergency Department of the Royal Children's Hospital, Melbourne's major children's hospital, were measured between 1974 and 1980 inclusive and the influence of chlorination on rates of gastroenteritis was examined. No statistically significant difference was found in the number of admissions or emergency department visits before and after chlorination of the water supply. The study highlights the need for caution when interpreting the relationships between drinking water and gastroenteritis. The result suggests that water was not a dominant contributor to the burden of gastrointestinal disease in the community despite faecal coliforms being present in the water supply. It indicates the need for caution when attributing significant illness to drinking water when there have been only small changes in water quality without first stringently reviewing the studies methodology and understanding their limitations.

A randomized, blinded, controlled trial investigating the gastrointestinal health effects of drinking water quality.

A double-blinded, randomized, controlled trial was carried out in in Melbourne, Australia, to determine the contribution of drinking water to gastroenteritis. Melbourne is one of the few major cities in the world that draws drinking water from a protected forest catchment with minimal water treatment (chlorination only). Six hundred families were randomly allocated to receive either real or sham water treatment units (WTUs) installed in their kitchen. Real units were designed to remove viruses, bacteria, and protozoa. Study participants completed a weekly health diary reporting gastrointestinal symptoms during the 68-week observation period. There were 2,669 cases of highly credible gastroenteritis (HCG) during the study (0.80 cases/person/year). The ratio of HCG episode rates for the real WTU group compared to the sham WTU group was 0.99 (95% confidence interval, 0.85-1.15, p = 0.85). We collected 795 fecal specimens from participants with gastroenteritis, and pathogens were not more significantly common in the sham WTU group. We found no evidence of waterborne disease in Melbourne. The application of this methodology to other water supplies will provide a better understanding of the relationship between human health and water quality.

Methods used to maintain a high level of participant involvement in a clinical trial.

OBJECTIVES: To describe the strategies adopted to maintain high level participation throughout a community based clinical trial, and the reasons given by participants for why they participated in the study. DESIGN: Observational study. SETTING: Community based clinical trial in Melbourne, Australia that ran for 68 weeks and involved 2811 community based individuals from 600 families. A high level of commitment was required of the families; each participant completed a Health Diary each week of the 68 week study, as well as answering numerous other questionnaires, and providing faecal and blood samples. MAIN RESULTS: Only 41 of the 600 families withdrew from the study; the majority of these families withdrew because they sold their home and moved from the study area. The completion rate of Health Diaries averaged 90.7% over the 68 weeks of data collection. Of the 559 families who completed the study, 524 (93.7%) completed the Participation Questionnaire. The statement that received the highest rating for why families enrolled in the study was they thought the study was researching an important community issue. The statements that received the highest ratings for why families continued to participate in the study was the family being kept well informed about the study's progress and that the study was well run. CONCLUSIONS: The low numbers of withdrawals and the high level of participation throughout the study suggests the strategies of (a) having a non-aggressive recruitment method, (b) maintaining regular contact with the participants and (c) ensuring participants were kept well informed of the study's progress and constantly encouraged to continue participation were successful. The results also suggest people involve themselves in research because they perceive it to be of value to the community, not simply for personal gain. They indicated that they maintained their participation because it was a well run study and they were kept well informed throughout the study.

An outbreak of cryptosporidiosis in an urban swimming pool: why are such outbreaks difficult to detect?

OBJECTIVE: To describe an outbreak of Cryptosporidium gastroenteritis in a swimming pool in Melbourne in early 1998 that was not detected through routine surveillance, and discuss difficulties in identifying such outbreaks. METHODS: The Water Quality Study (WQS) was a large community-based study of gastroenteritis. Following suspicion of an outbreak of cryptosporidiosis within the study group, due to pool "X", a nested case control study was performed. Each case of Cryptosporidium gastroenteritis was matched with six controls and data from weekly Health Diaries from the WQS were reviewed. The Department of Human Services also instigated active surveillance among patrons at pool "X" using a systematic sample of 50 people from the pool's swim-school enrollment list. RESULTS: There were seven cases of Cryptosporidium gastroenteritis in the case control study. Five cases and eight controls swam at pool "X" during the outbreak period. The adjusted odds of developing cryptosporidial diarrhoea if an individual swam at pool "X" was 34.5 (CI 2.3-2548). DHS identified another 11 laboratory confirmed cases associated with pool "X" as well as cases not linked to pool "X". 125 cases were identified throughout Melbourne with the suspected involvement of seven swimming pools. CONCLUSIONS: Despite a high odds ratio of developing cryptosporidiosis this outbreak was not detected by routine surveillance methods. Current outbreak detection methods lack sensitivity, specificity or timeliness. IMPLICATIONS: Improved surveillance systems are required if outbreaks of gastroenteritis are to be detected early so an intervention can be instigated to reduce the amount of subsequent illness.