Margaret Hellard’s research while affiliated with University of Melbourne and other places

Introduction Long‐acting injectable buprenorphine (LAIB) reduces the frequency of contact with opioid agonist therapy (OAT) service providers. Limited data exist on OAT prescribing in Australia after the introduction of subsidised LAIB prescribing in September 2019. This ecological study describes trends in OAT prescribing between 2015 and 2023 across a network of primary care services in Victoria, Australia. Methods We utilised electronic medical records from 17 clinics in Victoria that provide services to people with opioid dependence to describe OAT prescribing patterns. We described the annual number and type (methadone, buprenorphine, LAIB) of OAT prescriptions issued, individuals prescribed, and individuals initiating OAT. Interrupted time series assessed changes in quarterly OAT prescribing following the introduction of LAIB. Results Between 2015 and 2023, the average annual number of OAT prescriptions issued, and the average number of recipients prescribed OAT were 47,648 and 6470, respectively. Between 2020 and 2023, the proportion of individuals initiating on LAIB increased from 7% (73/1078) to 31% (357/1146). There was increasing quarterly OAT prescribing before the introduction of LAIB, after which methadone and buprenorphine prescribing declined by 2.6% (CR 0.974; 95% CI 0.968–0.980) and 3.2% (CR 0.968; 95% CI 0.963–0.973), respectively. After being introduced, quarterly LAIB prescribing increased by 13.1% (CR 1.131; 95% CI 1.096–1.167). Discussion and Conclusions We found substantial changes in OAT prescribing patterns in Victoria between 2015 and 2023, with shifts away from oral methadone and sublingual buprenorphine to LAIB. Alongside ongoing monitoring of prescribing patterns, future research should assess how LAIB impacts patient health and social outcomes.

Background Successful treatment of hepatitis C virus (HCV) can lead to liver fibrosis regression. It is not known who will experience fibrosis regression or how quickly it will occur. Methods We modelled transient elastography (TE) measurements from 1470 HIV-HCV coinfected participants followed in cohorts contributing data to InCHEHC, an international collaboration. Participants were eligible if they had at least one TE measurement in the year prior to starting a successful direct acting antiviral treatment for HCV. This measurement was used to classify participants into one of three fibrosis subgroups. We analysed measurement sequences in each subgroup using a covariate adjusted generalised additive mixed model, with an adaptive spline representing changes in the mean measurement before, during and after treatment. Results Each fibrosis subgroup had a distinctly different response. Most participants with cirrhosis (F4, TE ≥14.6 KPa) prior to HCV treatment did not show meaningful fibrosis regression – almost 70% were predicted to remain above 12 KPa three years after treatment ended. Participants with significant fibrosis (F2-F3, TE ≥7.2 and <14.6KPa) showed appreciable regression in the first two years after treatment, falling on average to levels below 7.2 KPa. Those without fibrosis prior to treatment (F0-F1) did not progress. Conclusion Most coinfected people with cirrhosis prior to HCV cure will remain cirrhotic. For those with significant fibrosis, regression can be expected within two years to levels not normally associated with an increased risk of endstage liver disease. A TE measurement two years after cure should give a reliable estimate of residual fibrosis.

Background During the COVID-19 pandemic, governments worldwide introduced law enforcement measures to deter and punish breaches of emergency public health orders. For example, in Victoria, Australia, discretionary fines of A$1,652 were issued for breaching stay-at-home orders, and A$4,957 fines for ‘unlawful gatherings’; to date, approximately 30,000 fines remain outstanding or not paid in full. Studies globally have revealed how the expansion of policing powers produced significant collateral damage for marginalized populations, including people from low-income neighboorhoods, Indigenous Peoples, sex workers, and people from culturally diverse backgrounds. For people who use drugs, interactions with police are commonplace due to the criminalization of drug use, however, little empirical attention has been given to their experiences of pandemic policing; we aimed to address this gap in the literature. Methods We conducted a mixed methods study involving participants of two prospective observational cohort studies of people who use drugs (n = 2,156) in Victoria, Australia, to understand impacts of the pandemic on their lives. Between 2020 and 2022 pandemic-related questions were added to survey instruments; during this period, 1,130 participants completed surveys. We descriptively analyzed the data of participants who reported police interactions related to pandemic restrictions (n = 125) and conducted qualitative interviews with 89 participants. Qualitative data were analysed thematically and integrated with quantitative results. Results 11% (n = 125) of survey respondents reported pandemic-related interactions with police; most (26%) were for breaching curfews and 30% received COVID-19 fines. Qualitative interviewees observed increased policing in street-based drug markets and local neighborhoods; many felt harassed and believed policing practices were targeted and discriminatory. Thirty-eight interviewees received COVID-19 fines; some were fined while homeless or travelling to or from harm reduction services. All lacked the financial means to pay fines, resulting in fear of additional criminalizing effects such as additional financial penalties, court orders, criminal convictions, and incarceration; for some fears became a reality. Conclusion Our study demonstrates how public health emergency responses centred around policing and criminalization exacerbated harms for people who use drugs, with detrimental effects enduring beyond the pandemic. Results provide insights for future public health emergencies, including highlighting the need for responses that protect, rather than abrogate the health and safety needs of marginalized and criminalized groups.

Background Chlamydia is one of the most common sexually transmissible infections globally and can lead to reproductive complications, including pelvic inflammatory disease and infertility. Interventions to reduce disease burden, including retesting for reinfection, partner management, and early detection of complications, are the focus of the Management of Chlamydia Cases in Australia (MoCCA) study, an implementation and feasibility trial aiming to strengthen chlamydia management in Australian general practice. This study aimed to identify factors influencing participation in and adoption of a multifaceted chlamydia management intervention within the general practice setting. Methods We conducted semi-structured interviews with general practice staff (n = 13) from clinics (n = 9) participating in the MoCCA study. Data were analysed using inductive content analysis to identify facilitators and barriers to study participation and intervention adoption. Results Participants felt that practice champions, motivated staff and interventions that improved workflow efficiency, integrated with existing processes and improved patient interactions, facilitated participation in, and adoption of, study interventions. A perceived lack of staff engagement related to time constraints, competing priorities, staff retention issues and interventions that were less convenient to use or had reduced patient uptake were identified as barriers to participation. Conclusions Identifying perceived facilitators and barriers to successful implementation of a multifaceted chlamydia intervention enables public health practitioners to better support general practice in the ongoing uptake and use of evidence-based chlamydia management strategies, ultimately aiming to reduce the burden of chlamydia and its complications in Australia.

Background Partner notification is an important step in the control of sexually transmissible infections (STIs). STIs remain at high rates among young people and can have serious reproductive consequences if left untreated. This study aimed to determine the preferences and motivations for partner notification among young people in Australia. Methods Quantitative and free-text qualitative data were collected through the 2024 Sex, Drugs and Rock ‘n’ Roll survey, an annual cross-sectional survey conducted among people aged 15–29 years old in Victoria, Australia. Respondents were recruited using convenience sampling through social media advertisements. Counts and proportions were calculated for the preferences and motivations for partner notification by regular and casual sexual partners as well as methods of communication. Inductive content analysis was used to analyse free-text responses. Results The partner notification module of the survey was completed by 1163 people (60.3% identified as women, 40.2% as heterosexual) who provided a total of 1720 free-text responses. The majority, 1056 (90.8%) stated that they would notify their sexual partners and 1142 (98.2%) would want to be notified by a sexual partner of an STI risk. Qualitative analysis highlighted that respondents felt that partner notification is the responsible thing to do to look after their own and their partner’s health and protect others by reducing transmission. Few stated that embarrassment and fear of repercussions may make them less likely to notify their partners or that it would depend on the type of relationship. Most preferred to notify regular partners face-to-face (941, 80.9%) and casual partners via text message (785, 67.5%). Conclusion Almost all young people want to notify and be notified by partners of an STI risk regardless of age, gender or sexual identity. Tailoring resources by communication method and partner type is one way in which practitioners and public health authorities can support young people in undertaking this important step in STI control.

Background We aimed to identify motivators for people who inject drugs to pursue treatment for hepatitis C virus (HCV) infection and uncover opportunities that could make treatment more appealing. Methods Between November 2023 and January 2024, we conducted semi-structured interviews with 15 HCV RNA-positive individuals with a history of injecting drug use and self-reported as either untreated or treated but delayed treatment for more than 6 months. Thematic and framework data analysis was employed and interpreted using the Capability, Opportunity and Motivation (COM-B) framework of behaviour change. Results The findings suggest that a combination of stability through secure housing, mental readiness and overcoming drug dependence supported by OAT (Capability), accessible and convenient healthcare like mobile outreach services coupled with financial incentives (Opportunity), and supportive relationships (Motivation) could serve to help people who inject drugs take up HCV treatment. Conclusion Alcohol and other drug and primary care services for people who use drugs should adopt person-centred approaches and recognise the gradual nature of behavioural change to foster empathy and supportive relationships to promote engagement in HCV care. Additionally, integrating HCV treatment with mobile outreach services and providing practical assistance, such as housing and financial incentives, are critical to ensuring that individuals remain engaged in HCV care.

Background Hepatitis B infection is a major public health concern in Vanuatu, with approximately 9% of the general population estimated to be living with chronic hepatitis B. Most new infections are due to mother-to-child transmission (MTCT). Hepatitis B vaccination is available in Vanuatu, but coverage rates for first dose within 24 h of birth and third dose are suboptimal. While treatment of chronic hepatitis B infection with tenofovir disoproxil fumarate (TDF) is available in country, there is no capacity to test hepatitis B e antigen and limited capacity to test hepatitis B virus (HBV) DNA viral load, which is a current eligibility requirement for women in pregnancy to access hepatitis B prophylaxis for MTCT per National guidelines. Recently, the World Health Organization guidelines have been updated to recommend universal peripartum antiviral prophylaxis (PAP) of pregnant women living with hepatitis B to prevent MTCT of HBV, without assessment of viral load in places without access to testing. However, these recommendations are conditional based on low-certainty evidence. The aim of this trial is to evaluate the effectiveness and safety of universal PAP and provide evidence for the global guidelines. Methods A single arm field trial compared to real world control sites will be conducted in Vanuatu involving pregnant women attending antenatal care services with positive HBsAg rapid tests. Participants at the control sites will undergo routine care. Participants at the intervention sites will all receive oral TDF prophylaxis from second trimester to completion of infant primary hepatitis B vaccination schedule. Primary data analysis will be by intention-to-treat. Initial analyses will be unadjusted comparisons of the intervention sites and control sites. Adjusted analyses will be performed, as needed, and presented in addition to unadjusted comparisons. Discussion This study will provide evidence of acceptability, effectiveness and cost-effectiveness of prophylaxis for all women with hepatitis B during pregnancy, as per the updated WHO guidelines, compared with current practice. The outcome of this trial will provide critical information to inform national and global guidelines around universal peripartum antiviral prophylaxis for hepatitis B during pregnancy. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: ACTRN12623001202651p. Registered 21 November 2023.

Background Approximately 10% of people with HIV in Australia had active hepatitis C virus (HCV) infection prior to availability of government-subsidized direct-acting antiviral (DAA) therapy in 2016. This analysis evaluated progress toward HCV elimination among people with HIV in Australia between 2014 and 2023. Methods The CEASE cohort study enrolled adults with HIV with past or current HCV infection (anti-HCV antibody positive) from 14 primary and tertiary clinics. Biobehavioral, clinical, and virologic data were collected at enrollment (2014–2016), follow-up 1 (2017–2018), and follow-up 2 (2021–2023). HCV treatment uptake, outcome, and HCV RNA prevalence (current infection) were evaluated. Death and HCV reinfection incidence and risk were assessed. Results Of 402 participants, 341 (85%) had current HCV infection (RNA positive) at enrollment. Among the sample, 83% were gay and bisexual men, 13% had cirrhosis, and 80% had a history of injecting drug use (42%, past 6 months). DAA treatment was scaled up rapidly, with cumulative treatment uptake increasing from 12% in 2014 to 2015 to 92% in 2022 to 2023. HCV RNA prevalence declined from 85% (95% CI, 81%–88%) at enrollment (2014–2016) to 8% (95% CI, 6%–12%) at follow-up 1 (2017–2018) and 0.5% (95% CI, 0%–3%) at follow-up 2 (2020–2023). Sixteen reinfections occurred (incidence, 1.41 per 100 person-years; 95% CI, .81–2.29) as well as 30 deaths (incidence, 1.64 per 100 person-years; 95% CI, 1.11–2.34). HCV reinfection incidence declined over time while mortality remained stable. Conclusions Universal access and rapid DAA uptake were associated with a dramatic reduction in HCV prevalence and reinfection incidence among people with HIV to levels consistent with microelimination. Registration: NCT02102451 (ClinicalTrials.gov).

Objectives Whilst public health measures were effective in reducing COVID-19 transmission, unintended negative consequences may have occurred. This study aims to assess changes alcohol consumption and the heavy episodic drinking (HED) during the pandemic. Methods Data were from the Optimise Study, a longitudinal cohort of Australian adults September 2020–August 2022 that over-sampled priority populations at higher risk of contracting COVID-19, developing severe COVID-19 or experiencing adverse consequences of lockdowns. Frequency of alcohol consumption (mean number of days per week) and past-week HED were self-reported. Generalised linear models estimated the association between time and (1) the frequency of alcohol consumption and (2) heavy episodic drinking. Results Data from 688 participants (mean age: 44.7 years, SD:17.0; 72.7% female) and 10,957 surveys were included. Mean days of alcohol consumption per week decreased from 1.92 (SD: 1.92) in 2020 to 1.54 (SD:1.94) in 2022. The proportion of participants reporting HED decreased from 25.4% in 2020 to 13.1% in 2022. During two lockdown periods, known as “lockdown five”, (OR:0.65, 95%CI [0.47,0.90]) and “lockdown six” (OR:0.76, 95%CI [0.67,0.87]), participants were less likely to report HED. Conclusions Participants alcohol drinking frequency and HED decreased during the pandemic. This study provides a strong description of alcohol consumption during the pandemic and suggests that lockdowns did not have the unintended consequences of increased alcohol consumption.