Blood Borne Viruses (BBVs) - 2017

1. The availability of new, regularly evaluated treatments for blood borne viruses (BBVs), alongside an increased focus on screening, immunisation and prevention.
2. Improved access to reliable and affordable screening, identification, and referral pathways, particularly for populations and groups at elevated risk, to identify and treat the large numbers of people with undiagnosed BBVs.
3. Health promotion interventions, with particular attention given to resources and approaches that are accessible for at risk groups.
4. Strategies that improve understandings of the context in which risky behaviours occur, and the cultural and social attitudes, expectations and social determinants that contribute to unsafe behaviours, such as mental illness, homelessness/insecure housing, unsupportive social relationships, limited literacy, and low levels of education.
5. The standardisation of infection control precautions in health care, aged care, and community settings to prevent occupational exposure and transmission of BBVs.
6. Investment in specialist services to build the capacity of primary care providers to identify, monitor, and manage people with chronic BBVs; and ensuring primary care providers have appropriate supports to provide quality care and service to patients.
7. An enhanced focus on Aboriginal and Torres Strait Islander people at risk of BBVs, including specific resourcing of management and research to address HTLV-1.
8. Uniform model legislation that protects and supports the health and safety of people engaged in sex work, incorporating peer education and support services that promote sexual health among people engaged in sex work.
9. Evidence-based prevention strategies that reduce the risk of transmission of BBVs in custodial facilities, and establish a safer custodial environment for detainees and corrections staff, including regulated access to sterile injecting equipment (i.e. prison-based needle and syringe programs (NSPs)), to complement other harm minimisation measures.
10. Strategies that ensure detainees and people who are in custodial facilities do not return to the community with undiagnosed and untreated BBVs. 
11. The provision of non-judgmental, confidential, and quality care by medical practitioners as integral to the prevention, detection, and treatment of BBVs.

2. Guiding Principles

The prevention, treatment, and management of BBVs should be informed by the following guiding principles:

• Responding to, preventing, and treating blood borne viruses must align with the five key Commonwealth strategies:
  • The Fourth National Hepatitis C Virus (HCV) Strategy 2014-2017
  • The Second National Hepatitis B Strategy 2014-2017
  • The Seventh National HIV Strategy 2014-2017
  • The Fourth National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2014-2017
  • The Third National Sexually Transmissible Infections Strategy 2014-2017
  • The prevention, treatment, and management of BBVs is a public health priority that requires a coordinated and strategic policy response, with national leadership driving actions to sustain improvements in their prevention, detection, and treatment.
    • Allocation of resources, health services, and strategic responses to BBVs must be coordinated with all jurisdictions to ensure the most at-risk cohorts have access to appropriate preventions and treatments.
    • Removal of discrimination and stigmaassociated with BBVs (including the right to participate in the community without experiencing stigma and discrimination), and the same rights to comprehensive and appropriate health care as other members of the community, including the right to confidential and sensitive handling of personal and medical information.
    • Development of evidence-based and accountable policies and programs that are underpinned by research, systematic data collection, and ongoing evaluation and monitoring.
    • All people in custodial settings should have access to Medicare and PBS services, or the equivalent thereof.
    • Strengthening the linkages between interdependent policies and strategies at local, state and national levels, including improved coordination between BBV strategies, drug and alcohol policy, sexual and reproductive health strategies, and policies targeting mental health and homelessness, to reduce the behavioural and environmental risks associated with BBVs. 
    • Regular training, education, and continuing professional development are needed to support medical practitioners and other health care providers, to deliver quality prevention, detection, and treatment services.  Ongoing education, training, and professional development is essential, given growing service demand and constantly evolving treatment modalities.

3. The Medical Profession

• Doctors have a professional responsibility to be aware of all their patients’ medical conditions.  This information should be used to improve the quality of care, and not as a means of discrimination. 
• Everyone in the community should have ready access to voluntary BBV testing. This testing should only occur after informed consent has been obtained within the context of pre-test counselling to minimise the trauma of positive results.
• Medical practitioners have the right to work in the safest possible environment.  It is the responsibility of employers and healthcare workers to operate in a way that minimises the risk of occupational exposure to BBVs.
• There are mutual obligations by both doctors and patients concerning the risk of BBVs during treatment.  It is reasonable to expect that patients will voluntarily agree to testing in the event of a possible occupational exposure to a healthcare worker.
• A national surveillance system is needed to support accurate monitoring of health care-associated occupational exposure in Australia.
• The AMA supports the Australian National Guidelines for the Management of Health Care Workers known to be infected with Blood Borne Viruses, and measures related to the prevention of transmission and management and treatment of health care workers (HCWs) who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV).  [http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdna-bloodborne.htm]

4. Background

Blood borne viruses (BBVs) are viruses that are carried in the blood and are spread from one person to another.  They can be transmitted through infected blood, exposure to contaminated blood products, unsterile injecting practices, sexual contact, failures in infection control in healthcare, mother to child transmission, and unsterile tattooing or body piercing practices.

The most prevalent BBVs in Australia are:

• human immunodeficiency virus (HIV) - a virus which causes acquired immunodeficiency virus (AIDS);
• hepatitis B (HBV);
• hepatitis C (HCV); and
• HTLV-1, which is prevalent in Central Australia.

Priority populations for preventing, managing, and treating BBVs in Australia include:

• People living with chronic BBVs;
• People Who Inject Drugs (PWID);
• People from refugee and culturally and linguistically diverse backgrounds (CALD);
• Aboriginal and Torres Strait Islander people;
• Prisoners and those in custodial settings;
• Gay men and men who have sex with men;
• Communities prone to HTLV-1; and
• People engaged in sex work.

Prevention, Treatment and Health Promotion  

Managing the spread of BBVs is best achieved through the continuation of successful ‘partnership models’, such as the models of collaboration initiated to combat HIV/AIDS. 

Strategies that address the spread of viral hepatitis, HIV, and HTLV-1 must be supported by the close collaboration of governments, medical practitioners, health workers, and relevant non-government organisations (NGOs).

Individuals found to have a chronic BBV infection should be linked to care and support for ongoing monitoring and lifestyle modification, and to reduce the risks and impacts of co-morbidities.  Among people infected with viral hepatitis, this includes raising awareness of self-management strategies, reducing risk factors such as the use of alcohol, and stressing the importance of adopting a healthy lifestyle to prevent progression to liver cancer or liver cirrhosis.  Of particular importance is the provision of hepatitis A and B vaccinations for patients with chronic hepatitis C.

Early diagnosis provides the best opportunity for effective medical support, the prevention of onward transmission to others, and improved long-term health outcomes and associated co-morbidities.  Treatment for BBV infection can also contribute to preventative efforts; for example, HIV antiretrovirals can reduce the viral load and thereby reduce the risks of onward transmission.

People Who Engage in Sex Work

People who engage in sex work in Australia have lower rates of sexually transmitted infections than the general population, and very high rates of condom use. The rates of HIV (and STIs) among people who engage in brothel-based sex work in Australia are at historically low rates due to successful health promotion strategies, including screening, testing, and language appropriate education programs that are provided by sexual health services, multicultural health services and community organisations,¹ and the provision of safe sex equipment.  

Maintaining low rates of BBV transmission, and high rates of safe sex among people who engage in sex work in Australia, requires ongoing legislative, policy, and programmatic responses, including continued health promotion and outreach among a constantly changing and increasingly diverse workforce.

Custodial facilities

The prevalence of BBVs is significantly higher in prisons due to a number of factors, including: the high-rate of imprisonment for drug-related offences, the prevalence of people who inject drugs, the apparent availability of drugs and injecting equipment in prisons, the rate of pre-existing infection among prisoners, and unsterile injecting drug practices in prisons.²

Custodial facilities provide a unique opportunity to protect the health of those in custody, and the general community.  Providing evidence-based prevention, testing, treatment and management, and harm reduction strategies (such as access to condoms and lubricant, regulated NSPs, and access to disinfectants such as bleach), are proven to be effective in the prevention of transmission of viral hepatitis and HIV in prisons,³ and establishing a safer environment for both prisoners and prison officers, who are both in elevated risk categories.

The AMA supports NSPs as a frontline approach to prevention of BBVs, and other harms among people who inject drugs.  The published evidence supporting the needle and syringe programs is very strong.

The well-being and health of people in custodial facilities has wider community health implications, as any detainee infected with a BBV may transmit that infection within the prison population or to the wider community if they are released with an untreated condition. 

Prison-based NSP trials have been shown to reduce the risk of needle-stick injuries to staff, and increase the number of detainees accessing drug treatment. Similarly, trials have revealed no adverse effect on illicit drug use or overall prison security.³

Prisoner health is a human rights issue.  Every Australian has the right to access equitable healthcare, and a custodial sentence is not a caveat to this.

BBVs and the application of criminal and public health law to transmission and/or exposure offences

The AMA believes that BBVs (including HIV) are first and foremost, health issue and, as such, the criminal law should only be used as a last resort in management of people who intentionally put others at risk of BBV infection. There is no evidence that laws which criminalise BBV transmission function to prevent or deter BBV transmission.

Criminalisation of people living with BBVs, people who engage in sex work, and people who use illicit drugs can be a barrier to the prevention and management of BBVs.  Criminal sanctions may, in fact, have a negative impact on preventive public health efforts by discouraging BBV testing, disclosure, and engagement with health services, and increase the stigma and discrimination faced by people living with BBV.  Doctors are at the front line of BBV diagnosis and treatment, and should therefore be well informed about legal issues (particularly their own legal obligations), so that they can provide optimal information and support to individual patients.

References