Diese Präsentation wurde erfolgreich gemeldet.
Die SlideShare-Präsentation wird heruntergeladen. ×

2019 Central Clinical School Public lecture - Prof Christopher Fairley

Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Wird geladen in …3
×

Hier ansehen

1 von 80 Anzeige

2019 Central Clinical School Public lecture - Prof Christopher Fairley

Herunterladen, um offline zu lesen

2019 Central Clinical School Public Lecture by Professor Christopher Fairley AO, Monash University, on "Whose fault is it that Bob got syphilis? It is not as simple as it sounds."

2019 Central Clinical School Public Lecture by Professor Christopher Fairley AO, Monash University, on "Whose fault is it that Bob got syphilis? It is not as simple as it sounds."

Anzeige
Anzeige

Weitere Verwandte Inhalte

Diashows für Sie (20)

Ähnlich wie 2019 Central Clinical School Public lecture - Prof Christopher Fairley (20)

Anzeige

Weitere von Central Clinical School, Monash University (14)

Aktuellste (20)

Anzeige

2019 Central Clinical School Public lecture - Prof Christopher Fairley

  1. 1. Whose fault is it that Bob got syphilis? Christopher Fairley Melbourne Sexual Health Centre and Central Clinical School, Monash University .
  2. 2. Bob • 33 year old married man • He was married 5 years ago and was celebrating his 5th wedding anniversary in Darwin – when they were struck with lightening (24,000 people a year die lightening) 2
  3. 3. Bob • He survived but his husband died. • A year later Bob’s sister introduced him to a man at dinner party and after their 3rd date they had sex and condom broke. • This was his first sexual partner since his husband died. • Developed primary syphilitic chancre. – Who was to ‘blame’? – Whose ‘fault’ is it? 3
  4. 4. Individual responsibility • Some Politicians talk of – ‘individual’ or ‘personal’, responsibility’- implication ‘blame’ • Individual Responsibility is the idea that human beings choose, instigate, or otherwise cause their own actions (are at fault). 4
  5. 5. 1940-50’s Poster- ‘blame, fault’ 5
  6. 6. Whose ‘fault’ it is that Bob got syphilis? • Whose is to ‘blame’? • Who do you hold ‘responsible’? • Destructive, emotional. • Frame it differently in the 21st century….let’s ask…. 6
  7. 7. What were the main causes of Bob getting syphilis? • Was it because he had sex with someone? • Was it because that person who he had sex with had syphilis? 7
  8. 8. The night Bob got syphilis • In Melbourne that night – ≈ 500 men who had sex with new male partners and • only 3 caught syphilis • 1 in 150 • In Melbourne that same night – ≈ 16,000 heterosexuals had a sex new partner and • No one caught syphilis (1/3 of a person) • 1 in 50,000 8 Calculations based on Survey data
  9. 9. Risk of syphilis per partner 2019 330 1 0 50 100 150 200 250 300 350 Gay man Heterosexual Times higher 9
  10. 10. One reason he got syphilis was only because he was a gay man? This was not a choice! 10
  11. 11. What if it were 2003 and not 2019 • In Melbourne one night in 2003 – 500 men who had sex with new male partners and • only 1/7 caught syphilis • 1 in 3500 • In Melbourne one night in 2019 – 500 men who had sex with new male partners and • only 3 caught syphilis • 1 in 150 11
  12. 12. Risk of syphilis 2003 vs. 2019 1 23 0 5 10 15 20 25 2003 2019 12
  13. 13. The reason he got syphilis was because there is now lots of syphilis circulating This is not a choice he made 13
  14. 14. What determines the incidence of a sexually transmitted infection in a population? This caused the high rate of syphilis 14
  15. 15. 15 0 2,000 4,000 6,000 8,000 10,000 12,000 1931 1935 1939 1943 1947 1951 1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015 Numberofcases Number of infectious syphilis England Male Female Source www.hpa.org.uk 2000 What are the most important factors that ‘drive’ syphilis up and down?
  16. 16. Penicillin (access to health care) single most powerful predictor of incidence 16
  17. 17. Incidence is determined by • Basic reproductive rate (Ro) • Product of; – Probability of transmission per partnership – Rate of partner change – Duration of infectiousness • <1 – infections dies out • >1- epidemic 17
  18. 18. What is the difference in Ro 0 2000 4000 6000 8000 10000 12000 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 Susceptibles Infectious 0 2000 4000 6000 8000 10000 12000 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 Susceptibles Infectious Gonorrhoea in indigenous communities Gonorrheoa in heterosexuals in Melbourne 2005
  19. 19. Why is the reproductive rate high in gay men or why are STIs rising in gay men? 19
  20. 20. Condom use Sexual Practices 20
  21. 21. Anal sex with Casual partners 0 10 20 30 40 50 60 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 % Year Always Not always no anal intercourse Gay Periodic Survey
  22. 22. Condom use always last 6 months casual partners 58 49 0 10 20 30 40 50 60 70 80 90 100 Gay man Heterosexual Percentage 22 Sexual Health, 2014, 11, 495–504
  23. 23. Drug use • Evidence it can change sexual practices. – Sexual acts last longer and increase group sex • Not evidence of this increasing in Melbourne 23
  24. 24. Rate of Partner change 24
  25. 25. Australian data from GPS 25 No increase in number of partners among gay men in Melbourne.
  26. 26. Changes in mixing patterns 26 Increases in high risk mixing with high risk – amplification method due to dating apps
  27. 27. But gay men do have more partners than heterosexuals 27
  28. 28. Why do they have more partners • The Effects of Negative Attitudes on Gay, Bisexual, and Other Men Who Have Sex with Men – ‘many’ effects stigma have include; • Risky sexual behaviour by 3 times (condom use, partners, anonymous partners) •  Substance abuse • Reduce • Ability to maintain long term same sex relationship • Access to health care • Notify partners because anonymous 28 https://www.cdc.gov/msmhealth/stigma-and-discrimination.htm
  29. 29. Why don’t straight people have to come out? 29
  30. 30. Summary partner number • No evidence in Australia about increasing numbers of partners • Evidence of higher risk mixing more with higher risk – Mathematically magnifies partner number • Stigma greatly increases risk • Don’t choose to be stigmatised 30
  31. 31. You may well ask- why not just increase condom use and reduce partner number? 31
  32. 32. Cannot reduce partner number • By counselling • Meta analysis 32 Denison JA 2008 AIDS Behaviour
  33. 33. Can increase condoms a bit 33 But it is; • Expensive • Hard to sustain Meta analysis Denison JA 2008 AIDS Behaviour
  34. 34. Access to Health care = Duration of infectiousness 34
  35. 35. 35 0 2,000 4,000 6,000 8,000 10,000 12,000 1931 1935 1939 1943 1947 1951 1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015 Numberofcases Number of infectious syphilis England Male Female Source www.hpa.org.uk What are the most important factors that ‘drive’ syphilis up and down?
  36. 36. 36 Increases in clinical services for gonorrhoea and effect on prevalence of infection over time Source JID 2005;192:824-836, figure 2 10% 20% 30% 50% Gono rate Service rate
  37. 37. Syphilis infectious stages 25 12 46 108 0 50 100 150 Stages of syphilis Days Symptoms begin Missed Primary, but 2nd Rx ≤166 days Primary and treated ≤12 days Incubation period 37 Missed Infectious Untreated for >166 days 1° 2º incubation 2º disease
  38. 38. How are we going with health care provision for STIs? 38
  39. 39. Number of clinic visits by year 26,294 27,988 31,452 33,630 35,537 37,696 40,819 39,592 40,482 42,466 46,564 49,371 55,862 0 10,000 20,000 30,000 40,000 50,000 60,000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Improved efficiency Total consults The most fabulous staff in the world
  40. 40. Our Team 40
  41. 41. Waiting times- Doubled 0 10 20 30 40 50 60 Time to triage Time to consult 60 20 41 30 10 Efficiency measures
  42. 42. 42
  43. 43. 43
  44. 44. 44
  45. 45. Web site banner 45
  46. 46. 46
  47. 47. Melbourne • Single Sexual Health Service 47
  48. 48. Sydney– 10 in the city 48
  49. 49. State has many 49
  50. 50. Infectious syphilis by year Victoria – Increased pressure 0 200 400 600 800 1000 1200 1400 1600 Victoria 2019 extrapolated on basis of 6 months of data
  51. 51. 51
  52. 52. Consequences of inadequate services 52
  53. 53. ‘Break away’ of STI control New era ? 53
  54. 54. Syphilis rates by state 0 5 10 15 20 25 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Rateper100,000 NSW VIC 54 50% higher in Victoria NSW had 50% more MSM men than VIC
  55. 55. Syphilis in Women Victoria/NSW 0 20 40 60 80 100 120 140 160 180 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Victoria NSW
  56. 56. Syphilis in Women Victoria 0 1 2 3 0 20 40 60 80 100 120 140 160 180 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Congenital Women Congenital syphilis is substantially under reported
  57. 57. Metro enlarged Number of infectious syphilis in females (201 0 1 – 5 6 – 10 11 – 15 16 – 20 21 – 30 31+ Syphilis cases in Victoria 2015-2018 Widespread and not MSM areas
  58. 58. International comparisons who is doing OK? 58
  59. 59. Syphilis in Denmark 59
  60. 60. 60
  61. 61. Why -Syphilis in heterosexuals • May be some initial transmission between risk groups – Travel associated or bisexual men – Always been so …..but now ‘break away’ on going transmission 61
  62. 62. Peak age is 20-30 years of age 62 Outgoing Incoming
  63. 63. People are different in their sexual attraction to other people. Which best describes your feelings?” 95 91 83 67 91 91 76 56 0 10 20 30 40 50 60 70 80 90 100 2002 2008 2014 2018 %onlyattractedoppositesex boys girls 63 % only attracted on opposite sex Secondary School Student Survey
  64. 64. Other International examples of the importance of ‘access’ to health services 64
  65. 65. US HIV infection by race; women 1.7 30 6.5 0 5 10 15 20 25 30 35 Women Rate per 100,000 White Black African American Hispanic www.cdc.gov Primarily due to - % male partners with detectable HIV VL - STI rates Not more sexual partners 65
  66. 66. Lifetime % risk of HIV in MSM 17 9 25 50 0 10 20 30 40 50 60 MSM White Hispanic Black % Lifetime risk Hess http://www.croiwebcasts.org/console/player/29467?mediaType=audio& HIV testing HIV treatment PrEP 66
  67. 67. Clarify the message STI control • I am not saying – All rises in STI are due to inadequate STI services • I am saying – Adequate STI services most power control measure – Inadequate services greatly increase STI rises – Stigma increases STI risk and rates – No control measure I know of that reduces number of partners (? Stigma interventions may) – Increasing condom use has a • ‘weak’ effect, is expensive, is short lived. 67
  68. 68. ‘Brave’ to be entering this new era with our strongest STI control strategy not working properly 68
  69. 69. An important analogy 69
  70. 70. Two things we really like doing • Sex • + • Eating • =7 billion on planet 70
  71. 71. Bob is overweight- ? • Because Bob can’t stop eating? – Needs to take Personal responsibility for his appetite! – His fault he is overweight • ‘mean’ and ‘simplistic’ and ‘ignorant’ view 71
  72. 72. Because failure in government policy? Really plausible that people have become dramatically ‘weaker’ and less responsible in 10 years! 72
  73. 73. Change 73
  74. 74. 74
  75. 75. People don’t choose to live in an obesogenic environment. Governments create them 75
  76. 76. People don’t choose to live in an environment with a high incidence of STIs Government neglect causes them 76
  77. 77. Public need to understand BECAUSE • If they don’t understand then – clinical services won’t get funded. • If clinical services don’t get funded….the public get STIs. Norredam et al: Scandinavian Journal of Public Health, 2007; 35: 655–661 77
  78. 78. Public need to say to Governments Protect ‘me’ by funding STI/HIV prevention properly = clinical services 78
  79. 79. Whose ‘fault’ it is that Bob got syphilis? • Blame and fault no place in vocabulary • What are the causes of ….syphilis • Our politicians are responsible for rises – Not because they had sex with Bob – Didn’t fund strong stronger control strategy • Perhaps we’re responsible for not telling them loudly enough what we want • But…… 79
  80. 80. It was certainly NOT Bob’s fault he got syphilis Thank you 80

×