NSW HIV STRATEGY 2021-2025 - END STIGMA - NSW Government
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NSW
HIV STRATEGY
2021–2025
END STIGMANSW Ministry of Health
1 Reserve Road
St Leonards NSW 2065
Tel. (02) 9391 9000
Fax. (02) 9391 9900
TTY. (02) 9391 9900
www.health.nsw.gov.au
This work is copyright. It may be reproduced in whole or part for study or training purposes
subject to the inclusion of an acknowledgement of the source. It may not be reproduced for
commercial usage or sale. Reproduction for the purposes other than those indicated above
requires written permission from the NSW Ministry of Health.
© NSW Ministry of Health 2020
SHPN (CPH) 200788
ISBN 978-1-76081-536-3 (print) and 978-1-76081-537-0 (online)
HIV Strategy 2021-2025
Further copies of this document can be downloaded from the NSW Health website
www.health.nsw.gov.au
NSW HIV STRATEGY 2021–2025 2MINISTER’S FOREWORD
New South Wales is recognised as a world But not every at-risk population has
leader in responding to HIV. Beginning with experienced the same level of success.
our swift response to HIV/AIDS in the 1980s, Stigma and discrimination also continue to
we have worked with people living with create barriers to accessing PrEP, testing and
and affected by HIV to innovate, to prevent treatment.
infections and to care for those living with HIV.
The new Strategy builds on the momentum
New ways to prevent, test and treat HIV have of the previous two strategies, while
led to dramatic reductions in transmission, introducing a renewed focus on working with
and notifications are now the lowest since sub-populations where change has not been
surveillance began in 1985. Pre-exposure as substantial, reducing stigma as a barrier
prophylaxis, or PrEP, has played a pivotal to prevention, testing and treatment, and
role in preventing new infections since we encouraging ongoing innovation.
implemented EPIC-NSW, one of the world’s
I am pleased to present the NSW HIV Strategy
largest implementation trials, for rapid roll-out
2021–2025, which will guide our response
across the state.
to achieving the virtual elimination of HIV
These innovations mean that the virtual transmission in NSW and support everyone
elimination of HIV transmission in NSW, once living with HIV.
inconceivable, is now a realistic and achievable
goal.
The partnership between the community,
government, researchers and clinicians has
been critical to our success. Working together,
we have:
Hon. Brad Hazzard, MP
• met
two of the UNAIDS targets, with 95% Minister for Health and Medical Research
of people living with diagnosed HIV on
treatment, and 95% of those diagnosed on
treatment with a suppressed viral load
• seen
a 19% reduction in new HIV notifications
in NSW residents over the past five years
• sustained
the virtual elimination of HIV
transmission between mother and child,
among people who inject drugs, and among
female sex workers.
NSW HIV STRATEGY 2021–2025 3NSW HIV STRATEGY 2021 – 2025
Aim
Vision
The virtual elimination of HIV transmission in NSW for all
A NSW where HIV transmission is virtually eliminated. Everyone is free from the risk of contracting
Headline target
HIV. Everyone can access HIV prevention, testing, treatment and care, and can do this without fear of
90% reduction in the rate of preventable HIV infection stigma or discrimination. Treatment begins early to improve health and prevent transmission.
Goals
1. Prevent 2. Test 3. Treat 4. Stigma
Prevent HIV transmission by promoting safe Normalise HIV testing for people at risk. Start and maintain treatment soon after diagnosis to Reduce stigma and discrimination as a barrier to prevention,
behaviours and by expanding access to condoms, maximise health outcomes and prevent transmission. testing and treatment.
PrEP, PEP, and sterile injecting equipment.
Targets 1.i 90% of men who have sex with male casual 2.i 95% of people living with HIV in NSW have 3.i 90% of people newly diagnosed with HIV initiate 4.i 75% reduction in reported experience of stigma or
partners report at least one form of HIV been diagnosed. treatment within 2 weeks discrimination by people at risk of and living with HIV in
prevention. NSW healthcare settings.
2.ii Reduce the time between arrival in Australia 3.ii 95% of all people diagnosed with HIV are on treatment
1.ii 90% of HIV-negative men who have sex with and the first HIV test for all at-risk overseas- and 95% of people on treatment have an undetectable 4.ii 75% reduction in discriminatory attitudes held towards
male casual partners without a condom take born people. viral load. people at risk of and living with HIV.
PrEP.
2.iii Reduce the time between arrival in Australia 3.iii 75% of people living with HIV in NSW report good
1.iii Reduce sharing of injecting equipment among and HIV diagnosis for overseas-born MSM, quality of life.
people who inject drugs. where infection was probably acquired
overseas
Initiatives 1.1 New models of care for PrEP 2.1 Innovative testing models 3.1 HIV Support Program 4.1 Media engagement
1.2 PrEP prescribers expansion 2.2 Dried blood spot (DBS) testing 3.2 Antiretroviral resistance surveillance 4.2 Healthcare worker training
1.3 PrEP Guidelines 2.3 GPs and primary care workforce 3.3 Shared care 4.3 Community primary care
1.4 GPs and primary care workforce 2.4 Community mobilisation and health promotion 3.4 Models of care 4.4 Health systems
1.5 Community mobilisation and health promotion 2.5 Statewide HIV testing campaign 3.5 Clinic audits 4.5 Peer support
1.6 Sex worker peer outreach
2.6 International students testing 3.6 Community mobilisation and health promotion 4.6 Stigma-aware campaigns
1.7 Needle and Syringe Program
2.7 People visiting high-prevalence countries
1.8 Information and referral campaign
1.9 Aboriginal services 2.8 HIV contact tracing
1.10 Research and surveillance 2.9 Antenatal screening
2.10 Research and surveillance
NSW HIV STRATEGY 2021–2025 4 NSW HIV STRATEGY 2021–2025 5CONTENTS
HIV IN NSW 7
A RENEWED FOCUS 10
THE PROPORTION OF GAY
IDENTIFIED MEN LIVING IN NSW 13
IMPACT OF COVID-19 IN 2020 14
PRIORITY POPULATIONS 15
PRIORITY SETTINGS 16
OUR VALUES 16
1. PREVENT 17
2. TEST 22
3. TREAT 27
4. STIGMA 31
MONITORING AND GOVERNANCE 34
ABBREVIATIONS 36
REFERENCES 37
NSW HIV STRATEGY 2021–2025 6HIV IN NSW
Considerable progress has been made towards the The proportion of at-risk MSM on PrEP increased
elimination of HIV transmission in NSW. HIV diagnoses between 2013 and 2019 (Figure 1, orange line).
decreased by 19% in NSW residents over the five PrEP roll-out initially occurred through EPIC-NSW,
years 2015–2019, and by 25% among men who have one of the world’s largest PrEP implementation
sex with men (MSM) (Figure 1, blue line). trials, between 2016 and 2018. The expansion of
PrEP availability has only been possible through
clinical service redesign and the responsiveness of
the NSW health system, nurse-led models, and the
partnership between general practitioners (GPs), the
HIV diagnoses 19% Kirby Institute and ACON peer support workers. Since
decreased by 19% in its listing on the Pharmaceutical Benefits Scheme in
April 2018, PrEP has been dispensed to over 15,000
NSW residents over the NSW residents.3
last five years HIV prevention coverage or safe sex is high in NSW,
with 79% of men who have sex with male casual
partners in 2020 reporting at least one form of
effective prevention (such as PrEP, condom use or
This is the lowest rate of HIV notifications in NSW treatment resulting in undetectable viral load).2
since surveillance began in 1985 and is the result of
investment in a number of effective interventions: There has been a dramatic reduction in the time from
access to PrEP, earlier treatment and high uptake diagnosis to treatment initiation between 2013 and
among people diagnosed with HIV (preventing 2019 (Figure 1, teal line). In 2019, 88% of people
onward transmission), promoting condoms, and diagnosed with HIV had started treatment within six
harm reduction strategies such as the Needle weeks, including 44% who started within two weeks
and Syringe Program and the Opioid Treatment of diagnosis.3
Program. This has only been possible through
strong partnerships between affected and at-risk
communities, government, clinicians, general practice
and researchers. The virtual elimination of HIV
Community-led ‘Ending HIV’ campaigns and the transmission between mother
redesign of public sexual health services to make and child, among people who
testing for HIV and sexually transmissible diseases
(STIs) more accessible have led to high testing
inject drugs, and among female
and treatment rates as well as early initiation of sex workers, has been sustained
treatment. General practice and primary care have
played a pivotal role in diagnoses and ongoing care.
The HIV Support Program has underpinned rapid
initiation of treatment by supporting doctors. A robust
data and surveillance system, with a focus on contact
tracing and partner notification, has built a foundation
for other interventions.
By 2016, NSW had already met the UNAIDS 90–90–
90 targets for HIV diagnosis, treatment uptake and
viral suppression.1 That same year, NSW rapidly rolled
out PrEP (antiretroviral medication taken by HIV-
negative individuals to prevent HIV infection). PrEP is
now the most common HIV prevention method used
by HIV-negative MSM.2
NSW HIV STRATEGY 2021–2025 7The virtual elimination of HIV transmission between The Needle and Syringe Program (NSP) remains
mother and child,3,27 among people who inject drugs, a highly cost-effective public health program6 to
and among female sex workers, has been sustained.4 prevent the transmission of HIV among people who
The incidence of HIV (new cases) among women in inject drugs and the wider community. The expansion
sex work in NSW is among the lowest in the world of the NSW Opioid Treatment Program into the
due to highly successful HIV prevention initiatives. primary care sector, and the increased involvement of
Among gay and bisexual men who attend sexual GPs, non-government organisations and community
health clinics, HIV prevalence among male sex pharmacies, have also played a substantial role in
workers is no different to HIV prevalence among gay harm minimisation and HIV prevention among people
and bisexual men who report no recent history of sex who inject drugs.
work.5
Figure 1: HIV in NSW, 2012 to 2019
Source: Adapted from a figure produced for AVAC Global Advocacy for HIV Prevention and the Friends of the Global Fight
against AIDS, Tuberculosis and Malaria for the 10th IAS Conference on HIV Science, 2019, Mexico City.
Outcomes: Rate of HIV diagnoses in MSM
Interventions: Percentage of at-risk MSM on PrEP
Percent of HIV-positive patients on treatment by 6 weeks
15 100
Crude rate of HIV diagnoses in NSW per 100,000 males
80
10
60
Percentage %
40
5
20
0 0
2012 2013 2014 2015 2016 2017 2018 2019
New South Wales ‘Treat all’
‘Virtual elimination’ guidelines
strategy launched
‘Ending HIV’
campaign launched; NSW second HIV
Rapid HIV testing launched Strategy launched
UNAIDS 90–90–90
targets reached;
PrEP roll out
NSW HIV STRATEGY 2021–2025 8In 2019, NSW achieved two of the UNAIDS Fast-
track 95–95–95 targets for HIV diagnosis, treatment
and viral suppression.1, 7 However, data modelling by
the Kirby Institute estimates that only 91% of people
living with HIV in NSW have been diagnosed; in other
words, 9% of people with HIV do not know they have
it (Figure 2).
Figure 2: The NSW HIV diagnosis and care cascade, 2019
Source: Unpublished analysis using data to December 2019 by the Kirby Institute, UNSW
95% of people living 95% of people on
91% of people living with with diagnosed HIV treatment had a
HIV had been diagnosed were on treatment suppressed viral load
12,000
10,000
Number of people in NSW
8,000
6,000
4,000
2,000
0
Living Diagnosed Retained Receiving Suppressed
with HIV with HIV in care treatment virus
NSW HIV STRATEGY 2021–2025 9A RENEWED FOCUS
Substantial improvements have been made in This Strategy builds on the momentum of the
HIV prevention, testing and treatment in NSW. previous two by adding to current activities, with new
Unfortunately not all groups have benefited equally initiatives focusing on:
from these successes. To make new gains the
• stigma and discrimination
Strategy must:
• MSM living in areas of outer Sydney and regional
• address the barriers created by stigma NSW with low concentrations of gay-identified men
• adapt, pilot and implement new technologies • culturally and linguistically diverse (CALD) and
• engage sub-populations who have not experienced recently arrived overseas-born MSM
the same level of recent success, including a • heterosexuals at risk, including CALD people, MSM
renewed focus on: and women who are sexual partners of MSM
– preventable infections acquired in NSW and by • young MSM aged under 25 years
residents travelling overseas
• Aboriginal people.
– connecting overseas-born people who acquired
HIV abroad with testing and care soon after their The Strategy also introduces a new headline target,
arrival in Australia. to achieve a 90% reduction in the rate of preventable
HIV infection as an ambitious target of ‘virtual
elimination’ (Figure 3).
Figure 3: Rate of new HIV diagnoses per 100,000 people, 2008 to 2019
All diagnoses
Preventable diagnoses
6
Crude rate of HIV infections per 100,000 people
5
4
3
90% reduction in
preventable diagnoses
2
1
0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
NSW HIV STRATEGY 2021–2025 10Stigma and discrimination CALD and recently arrived overseas-
Stigma and discrimination are barriers to prevention, born MSM
testing, treatment initiation and adherence, and An emerging priority population identified in this
retention in healthcare settings.8, 9 Healthcare Strategy is overseas-born MSM, particularly CALD
workers who bring stigmatising assumptions to residents and MSM who have lived in Australia for
their work miss opportunities to offer testing for four years or less. When people are diagnosed with
HIV or suggest prevention options including PrEP. HIV, test results can indicate roughly how long they
Negative perceptions and experiences of stigma and have been living with HIV.
discrimination may result in reductions in testing,
treatment engagement and retention in treatment. Between 2015 and 2019, there was a substantial
47% decline in late diagnoses (having a CD4+ cell
This Strategy introduces a new group of initiatives
count ofYoung MSM aged under 25 years Aboriginal people
Over the last five years, young MSM aged under 25 HIV diagnoses among Aboriginal people remained
years have not benefited from the same reduction low in NSW between 2015 and 2019,4 but greater
in HIV notifications as older MSM. Young MSM are recognition of diverse social and cultural factors
less likely to live in inner Sydney suburbs, which have which can influence the health and wellness of
high concentrations of gay-identified men; they are Aboriginal people is required to maintain these low
also less likely to be highly socially engaged with gay rates.11 While HIV diagnoses are low in NSW, the rates
community.10 This is likely to mean that they are less of gonorrhoea and chlamydia infections are higher
connected to innovations in prevention. Young MSM in Aboriginal people (compared to non-Aboriginal
have lower PrEP use than older MSM, particularly people),7 highlighting the need for increased HIV and
those living in suburbs with low concentrations of STI prevention efforts.
gay-identified men. This Strategy renews a focus on
Aboriginal people who inject drugs, including those
campaigns with messaging about condom use, PrEP
who are incarcerated, are at greater risk for acquiring
and testing for HIV and STIs that resonates with
blood-borne viruses. In 2020, one in five attendees at
young MSM. The Strategy also extends targeting to
NSPs identified as Aboriginal.13 This Strategy aims to
those living in outer suburbs and other regions of
improve the availability of sterile injecting equipment
NSW.
in areas where a high number of Aboriginal people
who inject drugs live, and to increase the uptake of
PrEP among Aboriginal people at risk.
In 2020, the new National Agreement on Closing
the Gap to reduce disparities in health and social
outcomes was released. This Strategy will ensure
that all NSW health services, including sexual
health clinics and general practice, are focused on
improving the health outcomes of Aboriginal people
by providing culturally appropriate services.
NSW HIV STRATEGY 2021–2025 12THE PROPORTION OF GAY IDENTIFIED MEN LIVING IN NSW Figure 4: Outer suburban MSM Note: In 2019 a method for estimating the number and proportion of adult males who are gay in each postcode was developed.14 Postcodes were categorised into three groups (
IMPACT OF COVID-19 IN 2020
The COVID-19 pandemic has had significant impacts The number of units of injecting equipment
on how people interact with the healthcare system. distributed in April–June 2020 remained stable
It has also amplified issues like mental health, drug- compared to the same period the year before. NSP
use, isolation and homelessness. services remained open and outreach was enhanced
to ensure people could access sterile injecting
The number of HIV tests conducted was 24% lower
equipment during the pandemic. The NSW Users
in April–June 2020 than during the same period
and AIDS Association (NUAA) expanded their NSP
in 2019. This was due to reduced service capacity,
postal service, which included the addition of online
restricted movement and resulting changes to sexual
ordering.
behaviour, and altered healthcare-seeking behaviour
due to COVID-19. As restrictions eased throughout COVID-19 did not have an effect on HIV treatment
late May and June, overall testing numbers began to coverage, with 99% of HIV-positive patients seen in
increase and return to the five-year average.3 public sexual health clinics on treatment in the April–
June quarter.3
The number of community-based rapid HIV tests
and HIV dried blood spot (DBS) self-sampling tests The NSW Government and community partners
also fell during 2020 but remained targeted to MSM, rapidly re-oriented services and programs in response
people from CALD backgrounds and people who to COVID-19, to ensure the ongoing availability
inject drugs who test infrequently or have never of HIV prevention, testing and treatment with a
tested previously.3 focus on innovative online services and telehealth.
Communication messaging promotes HIV testing and
PrEP use declined by 21% in April–June 2020
recommencement of PrEP to priority populations.
compared to the previous quarter.3 This was probably
due to lower levels of casual sex activity. Sexual This Strategy will explore opportunities to increase
activity changed significantly among gay and bisexual HIV awareness, testing, treatment and care among
men in response to COVID-19 as reported by self- international travellers, particularly students who
assessment in the Flux cohort study. Among gay and are in mandatory hotel quarantine after arrival in
bisexual men in Flux, the proportion reporting any sex Australia.
with casual partners dropped dramatically from 79%
in 2019, to 9% in early 2020 during the initial period
of lockdown in NSW.15
During the COVID-19 pandemic,
the number of HIV tests
conducted was 24% lower
in April-June 2020 compared to the
same period in 2019
NSW HIV STRATEGY 2021–2025 14PRIORITY POPULATIONS
This Strategy prioritises meaningful participation of people living with HIV along with
other priority populations as essential to its development, implementation, monitoring
and evaluation.
People including those with diverse cultural, sexual and gender identities may belong to
more than one priority population.
People living with HIV Men who have sex with
men (MSM), including:
· c ulturally and linguistically
diverse (CALD)
· r ecently arrived (four years
or less) overseas-born
· u nder 25 years old
People from or who travel Aboriginal people
to countries with high HIV
prevalence
People who inject drugs Sex workers
and their clients
People who are in Sexual partners of
or have recently members of priority
been in custodial populations
settings
NSW HIV STRATEGY 2021–2025 15PRIORITY SETTINGS
General practices and
other primary care
services including
Publicly funded HIV and Community and Aboriginal Community Needle and Syringe
sexual health services online services Controlled Health Services Program outlets
Antenatal care Drug and alcohol services Mental health services Emergency departments
Tertiary education
institutions including
Technical and Further
Education (TAFE),
universities and language
Custodial settings schools
OUR VALUES
Equality and equity Efficiency and value for money
Diversity Self-determination
Harm reduction Gender-affirming healthcare
Person-centred care Innovation
Respect Research and development
Collaboration and partnership Empowerment
NSW HIV STRATEGY 2021–2025 161. PREVENT
Prevent HIV transmission by promoting This Strategy prioritises the availability of condoms
safe behaviours and by expanding access and supports this choice for priority populations
to condoms, PrEP, PEP and sterile and communities, including young MSM and
injecting equipment heterosexuals.
The availability of new prevention strategies means
that virtual elimination of HIV transmission is now
feasible. The elimination of HIV transmission can be of HIV negative gay
achieved through a combination of evidence-based
prevention options, which include: 60% and bisexual men
who had condomless
• using condoms
• if HIV-negative, using HIV pre-exposure
sex with a male casual
prophylaxis (PrEP) partner take PrEP
• if HIV-positive, taking HIV treatment effectively to
achieve undetectable viral load
• using sterile injecting equipment every time and HIV pre-exposure prophylaxis (PrEP)
never sharing PrEP is now the most commonly used HIV risk
• if exposed to HIV, using post-exposure prophylaxis reduction strategy among gay and bisexual men
(PEP) within 72 hours of exposure with their casual male partners in Sydney. In 2020,
60% of HIV-negative gay and bisexual men who
This Strategy will include a focus on ensuring there
had condomless sex with a casual male partner
are high levels of prevention and extending it to
take PrEP.2 PrEP does not protect against other
emerging populations at risk of HIV transmission.
STIs, meaning that condom promotion, behavioural
prevention, testing and treatment strategies are still
Condoms
required.
While PrEP is the most common HIV prevention
method, condoms are the preferred choice for Barriers to PrEP use are associated with individual
a significant number of MSM. Condoms are and social factors including not being willing
very effective at preventing HIV and sexually to take medication to prevent HIV, fear of side
transmissible infections (STIs). In 2020, 22% of gay effects, having a lower education or income, lack
and bisexual men who had sex with a casual male of perceived risk, not being engaged with the gay
partner reported consistent condom use, down from community, low health literacy, difficulties with
44% in 2016; this is likely attributed to the rapid navigating online ordering, and difficulties finding
uptake of PrEP.2 non-judgemental clinical care.16–18 Asian-born men
without Medicare access are over-represented
among men who are willing to use PrEP but are not
doing so.19, 20 People from minority populations and
of gay and bisexual marginalised groups are also less likely to initiate
PrEP.21 Peer-based and community-led services can
men use condoms be more attractive to some than traditional clinic-
every time they have based services to members of marginalised groups
22% sex with a casual such as gay and bisexual men, Asian-born MSM, and
transgender and gender-diverse people.22–24
partner
NSW HIV STRATEGY 2021–2025 17There are opportunities to expand access and Sterile injecting equipment
encourage use of prevention methods including PrEP. The NSW NSP provides people who inject drugs with
Tailored marketing, promotion and peer-led initiatives sterile injecting equipment. The NSP is an evidence-
have resulted in high uptake of PrEP among gay men based, cost-effective public health program to prevent
and other MSM in inner Sydney,25 which is a focus in the transmission of HIV and hepatitis C virus among
this Strategy. PrEP use can be expanded to emerging people who inject drugs and the wider community.6
sub-populations including at-risk heterosexuals, young This Strategy will prioritise continuous improvement
MSM, CALD and overseas-born MSM, and MSM living in the delivery of NSPs to increase access to sterile
in areas with lower concentrations of gay-identified needles and syringes and to monitor reach and
men. coverage. The number of units of injecting equipment
Updated PrEP Guidelines remove barriers to PrEP distributed in NSW increased by 17% between 2015 and
access by simplifying the risk criteria and enabling 2019, while the number of NSP outlets increased by
on-demand PrEP use. On-demand or event-driven 6%, including primary and secondary outlets, dispensing
PrEP use means taking PrEP pills only around the time machines and pharmacies.
of sex according to the prescribed dosing schedule. This Strategy aims to reduce sharing of injecting
Additionally, people may choose to use PrEP during equipment in NSW. In 2020, 16% of people who
times when their risk behaviour changes, such as accessed NSPs reported at least one episode of
during festivals or while travelling to a country with receptive syringe sharing (i.e. using a syringe that has
high HIV prevalence. been used by another person) in the month prior to data
This Strategy will ensure that all priority populations collection, down from 20% in 2016. People attending
attending public sexual health services and general NSPs who reported being prescribed opioid substitution
practices are assessed for PrEP eligibility. PrEP therapy were also significantly less likely to report
prescriber availability will be expanded for greater recent receptive syringe sharing.13
geographical coverage to ensure equitable access This Strategy will strengthen links between primary
for at-risk populations. There is an opportunity to and secondary NSPs including sexual health services
extend PrEP prescribing in drug and alcohol services, and alcohol and other drug services. The next NSW
by strengthening links between local health district Hepatitis C Strategy 2021 will focus on developing the
sexual health services and alcohol and other drug NSW response and priorities for the NSP over the next
services, specialist stimulant treatment services and five years.
non-government alcohol and other drug services.
Post-exposure prophylaxis (PEP)
Viral load suppression: ‘undetectable viral
If a person is or suspects they might have been exposed
load’
to HIV (such as after having unprotected sex with
Taking HIV treatment effectively to achieve an someone whose HIV status was not known, or having
undetectable viral load (U=U, or undetectable = a needle-stick injury), post-exposure prophylaxis (PEP)
untransmissible) means that when HIV viral load is within 72 hours of exposure can be prescribed in sexual
below 200 copies/ml of blood measured by a viral load health clinics and emergency departments, and in
test, an HIV-positive person cannot pass on the virus to general practices by s100 prescribers. This Strategy
someone else (referred to as ‘treatment as prevention’; will ensure that PEP is available to those who require it,
or ‘TasP’). In 2020, 95% of people living with HIV are on and that clients are assessed for transition to PrEP for
treatment, of whom 95% have an undetectable viral ongoing HIV prevention.
load.1 This Strategy promotes undetectable viral load
as an effective risk reduction strategy.
Targets
•
90% of men who have sex with male casual
of people living with
95% diagnosed HIV are on
partners report at least one form of HIV
prevention including:
treatment, and 95% – condom use
– PrEP use
have an undetectable – undetectable viral load.
viral load •
90% of HIV-negative men who have sex with male
casual partners without a condom take PrEP.
•
Reduce sharing of injecting equipment among
people who inject drugs.
NSW HIV STRATEGY 2021–2025 18Initiatives Description Partners
Pilot innovative models of care for PrEP to increase access,
including telehealth, online assessment and access and
peer-led models.
Ensure regular comprehensive screening for sexually Ministry of Health, STIPU, ASHM,
transmissible infections for people on PrEP. local health districts, Multicultural
1.1
HIV and Hepatitis Service, ACON,
New models of Trial local initiatives and new technologies, such as Pozhet, Pharmacy Guild, Kirby
care for PrEP injectable PrEP, that have the potential to scale-up. Institute (UNSW) and Centre for Social
Deliver culturally tailored models for CALD and overseas- Research in Health (UNSW)
born MSM. Increase access for young MSMInitiatives Description Partners
Deliver education, targeted health promotion, community mobilisation
and behavioural prevention interventions, including peer-led initiatives
for priority populations and emerging sub-populations, to promote and
support the uptake of condoms, PEP, PrEP, screening for STIs and other Ministry of Health, STIPU,
prevention and risk reduction strategies. local health districts,
ACON, Positive Life,
Deliver a community education campaign promoting different options to
Pozhet, Multicultural HIV
take PrEP (daily, on-demand, seasonal).
1.5 and Hepatitis Service,
Community Utilise new and innovative online technologies to deliver prevention NUAA, Aboriginal
mobilisation and education messages to priority populations, including micro-targeting Community Controlled
health promotion identified groups and geo-location services. Tailor campaigns to better Health Services,
resonate with people with diverse sexual and gender identities. AH&MRC, tertiary
education institutes,
Build on existing community-led programs to develop online peer
RACGP, Sex Workers
education, increasing the accessibility of prevention programs for regional
Outreach Project (SWOP)
and remote priority populations.
Promote condom use through the Play Safe website, Take Blaktion and
social media channels.
Partner with non-government organisations to provide health education
1.6 information, peer education and outreach to reduce barriers to Ministry of Health, SWOP,
Sex worker peer engagement with healthcare services for NSW sex workers. ACON, Positive Life NSW,
outreach Support HIV prevention among gay and bisexual men and support local health districts
HIV prevention among male sex workers.
Invest in harm minimisation strategies to limit HIV transmission via
injecting drug use (NSPs, Opioid Treatment Program) which have resulted
in the virtual elimination of HIV among people who inject drugs.
Continuous improvement in the delivery of the NSP to increase access to
sterile needles and syringes and monitor reach and coverage. Ministry of Health, NUAA,
ACON, local health
Strengthen links between primary and secondary NSP providers,
1.7 districts, Pharmacy Guild,
including alcohol and other drug services, opioid treatment program
Needle and non-government alcohol
clinics and peer support services such as NUAA.
Syringe Program and other drug services,
Support programs and strategies to address stigma and discrimination private opioid treatment
in healthcare settings and support strategies for the education of health clinics
workers, including HETI e-learning modules.
Ensure supportive laws and regulations, which are integral to enabling
safe practices, protecting people from discrimination and supporting
public health.
Fund services, including the NSW Sexual Health Infolink (SHIL), which
provide culturally specific HIV and sexual health information, referral and
support to the NSW general public and clinicians. NSW Ministry of Health,
1.8 NSW Sexual Health
Information and SHIL is a specialised, anonymous, confidential nurse-led service using Infolink, local health
referral telephone and internet-based technologies. The service works with districts, Multicultural
diverse people and communities at risk and healthcare providers to HIV and Hepatitis Service
support testing, contact tracing, PrEP, PEP and treatment in line with
current evidence and guidelines.
NSW HIV STRATEGY 2021–2025 20Initiatives Description Partners
Strengthen systems, service integration and community
engagement for HIV prevention, testing, treatment and care
for Aboriginal people at risk.
Ensure all NSW healthcare services including sexual health
clinics and general practice are focused on improving
the health outcomes of Aboriginal people by providing
culturally appropriate services.
To ensure adequate coverage, conduct an audit of the
number of GP services in areas where there is a significant
population of Aboriginal people.
Improve the uptake of PrEP among Aboriginal people.
Ministry of Health, Centre for
Improve the availability of sterile injecting equipment in
Aboriginal Health, Aboriginal
1.9 areas where a high number of Aboriginal people who inject
Community Controlled Health
Aboriginal drugs live.
Services, local health districts,
services
Establish formal relationships between publicly funded RACGP, Justice Health and Mental
sexual health clinics and Aboriginal Community Controlled Health Network, AH&MRC, STIPU
Health Services (ACCHS) to develop programs and support
blood-borne virus and STI capacity development in the
ACCHS sector.
Increase the number of Aboriginal sexual health
professionals across NSW.
Create a NSW governance group to drive and monitor
Aboriginal HIV responses.
Improve educational pathways with a sexual health
promotion focus and provide opportunities for Aboriginal
health workers to develop new skills, including a sexual
health specialisation.
Fund the BBV and STI Research, Intervention and Strategic
Evaluation Program (BRISE) 2020–2024 at the University
of NSW to undertake policy-relevant research to provide
evidence and strategic advice that focuses on the
prevention and diagnosis of infections and on the treatment
and care of people living with infection.
Enhance data and behavioural surveillance systems to Ministry of Health, Kirby Institute
1.10 improve monitoring of the Strategy for priority populations (UNSW), Centre for Social Research in
Research and including people with diverse sexual identities and gender Health (UNSW), local health districts
surveillance identities. Implement enhancements to the NSW Minimum and Multicultural HIV and Hepatitis
Data Set for publicly funded sexual health clinics and the Service
Notification form for new HIV diagnoses. These changes
will enable better monitoring of the needs of people
attending health services.
Strengthen systems for timely collection and reporting of
data to monitor progress, report outcomes and refine or
scale focus.
NSW HIV STRATEGY 2021–2025 212. TEST
Normalise HIV testing for people at risk
Rates of HIV testing have increased each year
since 2012. However, additional focus is required. No recent test for
Despite increases in testing, it is estimated that 65% of overseas-
only 91% of people living with HIV in Australia have
been diagnosed.7 In 2019, 56% of Australian-born
born MSM
MSM diagnosed with HIV had not been tested in the diagnosed in 2019
12-months prior to diagnosis, and 20% had evidence
of late diagnoses (i.e., they have had HIV for some
time before being diagnosed). Among overseas-born
MSM, 65% had not had a recent test and 42% had Normalisation
late diagnoses.27
Interventions that normalise testing include
Late HIV diagnosis leads to increased mortality campaigns with messages that resonate with sub-
and morbidity, reduced life expectancy,28,29 and populations, comprehensive clinic-based testing,
higher costs to the health system.30 Early diagnosis peer-led testing models, community-based testing
linked to treatment improves health outcomes and models, GP education, and clinical workforce
prevents transmission to others. development. Opportunistic testing across the
healthcare system ensures that testing is available
regardless of where the patient presents. The rate
of testing in MSM has not increased at the same rate
No recent test as PrEP uptake, even among men who engage in
for 56% of higher risk activities.32 This Strategy aims to increase
HIV testing frequency among people at risk who are
Australian-born not taking PrEP, and to monitor testing in people
MSM diagnosed in on PrEP. Everyone should be offered an HIV test in
2019 conjunction with STI testing and diagnoses.
HIV prevention messages, HIV education programs,
and direct offers of HIV testing increase the
uptake of testing among recent immigrants.33 The
Availability
expansion of peer-led tailored programs beyond
Testing services that are easily accessible inner metropolitan areas may reduce barriers to
encourage more frequent testing among people testing for Asian MSM who do not have established
at risk. Innovative testing modes, rapid testing and connections with gay networks by facilitating
express testing clinics in community-based settings access to culturally acceptable local services.34
have been successful in engaging MSM, particularly This Strategy aims to increase HIV testing and PrEP
young MSM with high-risk behaviour and a history uptake among at-risk international students who
of infrequent testing.27,31 During HIV testing, clients attend general practices by addressing the cost
should learn about HIV prevention strategies such and confidentiality concerns of services.35 Peer-led
as condoms, PrEP and PEP, and how often to test. services have been successfully developed and
Services must be convenient and confidential for attract younger and Asian-born MSM.24
everyone in NSW, including people with diverse
sexual and gender identities, and people living in
regional and remote areas.
NSW HIV STRATEGY 2021–2025 22Comprehensive sexual health screening Barriers to testing for clinicians can be reduced
HIV testing should be part of comprehensive sexual through training that addresses consent in line with
health screening in all public health services, guidelines and through awareness of the NSW HIV
general practices and other primary care settings. Support Program, which connects them to local
Comprehensive STI screening should also be offered specialists who support them in delivering a positive
to people prescribed PrEP. Rapid HIV testing can diagnosis and quickly linking the patient to care.
increase HIV testing frequency among MSM.36 Rapid Increased attention to HIV indicator conditions in
HIV testing should be more available and online primary healthcare and specialist medical settings
booking expanded to more sites. enables earlier HIV diagnosis.38 HIV testing should
be undertaken according to the Emergency Care
Innovative testing models Institute’s clinical indicators, irrespective of HIV risk
factors. Testing is now simpler and previous barriers
Innovations in service design and delivery have made
such as concerns about managing HIV results and
testing more available. HIV self-testing supplements
obtaining written informed consent have been
clinic-based testing and increases the frequency of
removed.
testing among MSM and stigmatised populations
including people who inject drugs.37,38 The Atomo
Phylogenetics
HIV Self Test was approved by the Therapeutic
Goods Administration in 2018. The NSW HIV dried Phylogenetics uses genome sequencing to track
blood spot (DBS) self-sampling test also provides how a virus evolves and spreads over time and can
an alternative for at-risk people who experience link, or map related mutations of a virus making it
barriers to testing through conventional services, easier to trace routes of transmission.
with 46% of people who register having never
previously tested for HIV or tested more than two This Strategy will explore the use of HIV
years ago.27 phylogenetics to improve understanding in
transmission patterns and the impact of HIV
Testing barriers infection acquired overseas. The detection and
characterisation of active transmission clusters
Barriers to testing include low perceived risk of
will be used to guide interventions such as focused
infection, lack of symptoms, fear of an HIV diagnosis,
education campaigns, targeted testing, partner
fear of stigma, and not wanting to tell others of a
notification, and promoting engagement with
positive diagnosis.39–41 Opportunities are missed
treatment and care.
for HIV diagnoses at medical services despite
clients having symptoms that are indicators for HIV
testing.40–42
Targets
•
95% of people living with HIV in NSW are
diagnosed.
•
Reduce the time between arrival in Australia
and the first HIV test for all at-risk overseas-
born people with the aim of increasing early
detection of HIV infection and linking people
with care.
•
Reduce the time between arrival in Australia
and HIV diagnosis for overseas-born MSM, in
cases where infection was probably acquired
overseas.
NSW HIV STRATEGY 2021–2025 23Initiatives Description Partners
Deliver a mix of options to make testing easy and
accessible, including encouraging self-testing at
community-based rapid testing and comprehensive clinic-
based testing.
Expand and adapt innovative models including person- NSW Ministry of Health, STIPU,
centred care, culturally tailored, peer-led services to NSW Sexual Health Infolink, local
selected new sites with low concentrations of gay- health districts, ACON, RACGP,
2.1 identified men and sites with CALD communities. primary health networks, AH&MRC,
Innovative testing Aboriginal Community Controlled
Pilot new technologies and online models, in collaboration
models Health Services, Kirby Institute
with partners and the community.
(UNSW), Centre for Social Research
Ensure that HIV and STI testing models are widely available in Health (UNSW), Positive Life NSW,
for Aboriginal people across NSW in a range of Aboriginal Multicultural HIV and Hepatitis Service
Community Controlled Health Services and culturally
competent settings.
Ensure services meet the needs of people with diverse
sexual and gender identities.
DBS testing has created a confidential, convenient
Ministry of Health, Sydney Sexual
alternative to conventional testing.
Health Centre, NSW State Reference
Extend the NSW HIV DBS testing pilot to ensure the self- Laboratory for HIV, St Vincent’s
2.2 sampling home test kit is available free to people at risk Hospital Sydney, NSW Sexual Health
Dried blood spot until the transition to Therapeutic Goods Administration Infolink, Multicultural HIV and
(DBS) testing listing. Hepatitis Service, Health Protection
NSW, Kirby Institute (UNSW), Centre
Expand the number of settings in which DBS is available,
for Social Research in Health (UNSW),
including NSPs, drug and alcohol services, mental health
local health districts
services and CALD services and events.
Deliver workforce development, training and resources
to normalise HIV testing in a range of settings, including
public healthcare services and primary care.
Develop a range of GP engagement models, with behaviour
change focus, covering both testing and PrEP prescribing.
Deliver more education in a range of clinical settings
around consent and indications for HIV testing as set out
in the National Testing Guidelines and ensure links are
in place for clinicians to provide test results via the HIV Local health districts, RACGP,
Support Program. STIPU, Ministry of Health, AH&MRC,
2.3 Deliver targeted communications and education for GPs to Aboriginal Community Controlled
GPs and primary normalise HIV testing in a diverse range of patients; support Health Services, ASHM, RACGP,
care workforce concurrent testing for HIV and STIs as part of routine care; primary health networks, Positive Life
and deliver culturally appropriate services to CALD and NSW, Multicultural HIV and Hepatitis
Aboriginal people. Service, NSW Sexual Health Infolink
Use new education models to train and upskill GPs in using
innovative service delivery for patients, including telehealth.
Refine and implement testing guidelines, tools and
resources to: normalise testing in a range of settings;
support concurrent HIV and STI testing; increase testing
frequency among people at risk; monitor testing frequency
in people on PrEP; and ensure comprehensive STI screening
when PrEP is prescribed.
NSW HIV STRATEGY 2021–2025 24Initiatives Description Partners
2.4 Fund non-government organisations and partners to deliver Ministry of Health, STIPU, ACON,
Community community-led culturally appropriate HIV testing campaign local health districts, Positive Life
mobilisation and messages targeting priority populations and emerging sub- NSW, Pozhet, Multicultural HIV and
health promotion populations. Hepatitis Service, SWOP
Discreet Life is an innovative HIV testing campaign to
increase testing among MSM who do not identify as gay.
2.5 Expand the campaign to target CALD and non-gay- NSW Ministry of Health, STIPU, local
Statewide HIV identifying MSM in outer Sydney and in other regions of health districts, Pozhet, Multicultural
testing campaign NSW with lower concentrations of gay-identified men. HIV and Hepatitis Service
Develop and deliver innovative campaigns over the life of
the Strategy.
A range of initiatives are needed to facilitate earlier HIV
diagnosis among overseas-born people who have recently
arrived in Australia.
Promote the international students website ‘hub’ with HIV
testing and prevention information.
Adapt the NSW Play Safe program peer education toolkit STIPU, local health districts, tertiary
for international students and roll it out to tertiary education institutions, English
education institutions including universities, TAFE and Australia, ACON, Multicultural HIV and
2.6 language schools. Hepatitis Service, overseas student
International
Work with universities to deliver HIV/STI testing, prevention health insurance providers, Study
students testing
and educational resources on campus that are culturally NSW, ISANA International Education
appropriate, accessible and tailored to meet the needs of Association, international student
overseas-born students. agents, Ministry of Health
Promote testing through a range of channels including peer
education and social media to reduce barriers.
Explore opportunities to promote testing and provide
HIV awareness information for international students in
COVID-19 quarantine settings.
2.7 Maintain investment in campaigns and community
People visiting education to target heterosexuals and gay men including Ministry of Health, STIPU, Pozhet,
high-prevalence CALD people travelling to countries with high HIV RACGP, Multicultural HIV and
countries prevalence. Hepatitis Service, SWOP, local health
campaign Educate GPs to ensure PrEP is included in travel advice for districts
at-risk individuals.
Release a new policy directive for HIV contact tracing to
provide guidance to medical practitioners on notifying
partners of patients who have been diagnosed with HIV and
2.8 Ministry of Health, Health Protection
information on support services.
HIV contact NSW, STIPU, NSW Sexual Health
tracing Facilitate testing and support for all recent sexual and Infolink, Positive Life, Pozhet, NUAA,
injecting partners of people newly diagnosed with HIV. RACGP, local health districts
Ensure s100 GPs and other services are aware that contact
tracing support services are available.
NSW HIV STRATEGY 2021–2025 25Initiatives Description Partners
Ensure HIV testing for all women is part of routine
antenatal screening in accordance with Royal Australian
and New Zealand College of Obstetricians and
2.9 Gynaecologists guidelines and National Clinical Practice
Guidelines for Pregnancy Care. NSW Ministry of Health, Health
Antenatal
Protection NSW, local health districts
screening Screening at the first antenatal visit provides an
opportunity for timely detection and treatment of
undiagnosed HIV, and significantly reduces the risk of
perinatal transmission.
New data and surveillance systems are required to better
understand the changing HIV epidemic.
Implement a new HIV and STI minimum data set to
enhance surveillance of priority populations and sub-
populations in publicly funded sexual health services,
including data on gender and sexual identity. This will be
used to understand prevention, testing, treatment needs, NSW Ministry of Health, Health
and service gaps. Protection NSW, local health
2.10 districts, NSW Health Pathology,
Research and Monitor testing stratified by PrEP use to identify changes in Health Protection NSW, eHealth,
surveillance testing rates among those susceptible to HIV. Kirby Institute (UNSW), Centre for
Work with NSW Health Pathology to extend the depth of Social Research in Health (UNSW),
testing data available. community
Support policy-relevant research in priority settings
including the NSP.
Improve understanding in transmission patterns and
the impact of HIV infection acquired overseas using
technologies including phylogenetics.
NSW HIV STRATEGY 2021–2025 263. TREAT
Start and maintain treatment soon after Rapid uptake
diagnosis to maximise health outcomes Rapid uptake of HIV treatment among people newly
and prevent transmission. diagnosed with HIV is associated with improved
health outcomes and reduced transmissions.43 A
Treatment for HIV is effective, and rapid access focus of this Strategy is to ensure that rapid uptake
to treatment after a diagnosis improves health of HIV treatment continues to increase, by working
outcomes, improves quality of life and prevents with community, s100 HIV treatment prescribers,
further transmission.43,44 GPs and primary healthcare providers to strengthen
HIV systems and models of care and increase
Person-centred care acceptability to patients.
Person-centred treatment strategies include
early referral to treatment and peer-led services Care and support
supporting people who are newly diagnosed. It also Primary care support can be strengthened for
includes retaining people living with HIV in care and people living with HIV, particularly older people, to
maintaining a connection to support and services manage their health in general practice. In 2019,
throughout their life, including in aged care. there were over 5,000 people aged 50 years and
Approaches must be culturally acceptable and over in NSW living with HIV, representing 54% of the
address specific barriers experienced by priority total number of people diagnosed with HIV in NSW,
populations, including those in regional, rural and and the number is growing as populations age.*
remote communities and with gender and cultural Linking and retaining people living with HIV in care
diversity, and take into account the range of settings and support throughout their life is critical for
commonly used by priority populations to maximise achieving the goals of this Strategy. Addressing all
their engagement. aspects of health and wellbeing of people living
with HIV is also critical to maximise their health
Medicare eligibility outcomes.
For people not eligible for Medicare, barriers
to testing and treatment should be reduced or
mitigated. Overseas student health insurance cover
provides a rebate of only a small proportion of the
cost of antiretroviral therapy.45 Compassionate
access for treatment is provided to Medicare-
ineligible patients for notifiable conditions under
the Medicare Ineligible and Reciprocal Health
Agreement Policy Directive.
The Ministry of Health will work with the
Australian Government to reduce the impact of
Medicare ineligibility. NSW local health districts
work with Medicare-ineligible patients to access
HIV treatments free of charge. Other strategies
include seeking compassionate access through a
pharmaceutical company, taking part in a clinical
trial or purchasing generic medications through
individual import at lower cost from overseas.
*Unpublished analysis using data to December 2019 by the Kirby Institute, UNSW
NSW HIV STRATEGY 2021–2025 27The NSW HIV Support Program facilitates the
provision of expert advice to clinicians at the critical
time a new HIV diagnosis is made. The Program
streamlines linkage to care and support for people
with newly diagnosed HIV, negotiating health
pathways and rapidly improving access to five key
support services:
1 2 3
Counselling about
prevention of transmission of
HIV to others, including the
Effective clinical management, role of treatment in reducing
including access to treatment Psychosocial support the risk of transmission
4 5
Linkage to relevant specialist, community
Support to ensure that all at-risk contacts and peer support services with a lived
are identified and tested for HIV experience of HIV.
While the five key services should be offered to
every person diagnosed with HIV infection at the Targets
time of diagnosis, they also have a role across •
90% of people newly diagnosed with
the continuum of care, supporting sustained HIV initiate treatment within two weeks of
engagement with care providers. Ongoing training diagnosis.
and capacity building of the entire workforce
involved in HIV, including primary care and other •
95% of all people with diagnosed HIV are on
non-specialists, ensure the key services are treatment and 95% of people on treatment
incorporated into everyday clinical practice. Other have an undetectable viral load.
practical measures may be required by individual •
75% of people living with HIV in NSW report
specialist services and clinicians to bolster retention good quality of life.
in care such as automatic recall systems, systems
that identify loss to care, and more intensive support
for clients with specific needs.
NSW HIV STRATEGY 2021–2025 28Initiatives Description Partners
Health Protection NSW, local health
Strengthen the HIV Support Program and provide systems districts, HIV reference laboratories,
for linkage to and retention in care, psychosocial support, Positive Life NSW, Pozhet, ACON,
3.1 partner notification and rapid initiation of treatment. ASHM, RACGP, STIPU, NSW Sexual
HIV Support
The NSW HIV Support Program facilitates the provision Health Infolink, AIDS Dementia and
Program
of expert advice to clinicians at the critical time a new HIV HIV Psychiatry Service (Adahps),
diagnosis is made. Bobby Goldsmith Foundation,
Multicultural HIV and Hepatitis Service
3.2
Support rapid treatment initiation by undertaking
Antiretroviral Health Protection NSW, HIV reference
antiretroviral drug resistance surveillance in NSW, and
resistance laboratories, Kirby Institute (UNSW)
routinely reporting results.
surveillance
Improve shared care arrangements between general
STIPU, Ministry of Health, ASHM,
practice, non-HIV specialist providers and HIV specialist
RACGP, Health Protection NSW,
providers to meet the evolving needs of people living with
local health districts, primary health
HIV.
networks, Sexual Health Counsellors’
Develop a statewide shared care model that defines the Association of NSW, HIV social
3.3
roles and responsibilities of general practices, non-HIV workers, HIV reference laboratories,
Shared care
specialist providers and HIV specialist providers. Positive Life NSW, ACON, Pozhet,
AIDS Dementia and HIV Psychiatry
Strengthen referral and communication pathways;
Service (Adahps), Bobby Goldsmith
strengthen links with the HIV Support Program; develop
Foundation, Multicultural HIV and
electronic information sharing mechanisms; and provide
Hepatitis Service
workforce development and training.
Strengthen models of care, including telehealth models.
Models will deliver access to psychosocial and peer
support, and build the capacity of the HIV workforce to
support rapid treatment initiation, treatment adherence
and retention in care over the long term for all people with
HIV.
Ensure everyone diagnosed with HIV is offered the
opportunity to speak to a trained peer living with HIV.
Local health districts, HIV reference
Ensure supports are in place for people who want to laboratories, STIPU, ASHM, RACGP,
commence treatment immediately after diagnosis. Positive Life NSW, ACON, Pozhet,
Social Workers in HIV, AIDS Dementia
3.4 Extend the geographical distribution of specialist
and HIV Psychiatry Service (Adahps),
Models of care psychosocial and peer-led resources.
Sexual Health Counsellors Association
Ensure people living with HIV receive person-centred care of NSW, HIV social workers, Bobby
for comorbidities including mental health, by developing Goldsmith Foundation, Multicultural
strong partnerships and links with multidisciplinary HIV and Hepatitis Service
specialist disciplines.
Ensure everyone living with HIV has a chronic disease
management plan in primary care.
Promote interventions that enhance all aspects of
health and wellbeing of people living with HIV such as
diet, exercise, smoking cessation, and reducing harmful
substance use (including alcohol).
NSW HIV STRATEGY 2021–2025 29You can also read
