Building hope and health for people living with HIV in Fiji

Ourania Mohr 01:05

We might get started. Good afternoon, everybody. Thank you so much for joining us today, just letting you know that we are recording the session, and I kindly ask if you can all ensure that you are on mute for the session.

Thank you so much for joining us today, I'd like to welcome and thank you. My name is Ourania Mohr, and I am the manager of supporter engagement. I'm thrilled to welcome you to our information and Q and A session today titled responding to the HIV epidemic in the Pacific.

I'd like to start by acknowledging and paying respect to the traditional custodians of countries throughout Australia, in particular the Boonwurrung people of the Kulin nation, on whose country our office is located. We pay respect to elders past and present.

Before I introduce our key speakers today, I'd like to take this opportunity to thank you our donors for supporting our research. You are our unsung heroes who make our work possible, and it's a pleasure to have you join us today. I'd also like to welcome staff and esteemed colleagues, some who are abroad today, who work passionately to conduct the research and the programs that you so generously support. Welcome everybody.

Today's session will be co-presented by Professor Brendan Crabb and Dean Cassano. Brendan is not only the director and CEO of Burnet Institute, he's a passionate research scientist with a special interest in infectious diseases of global significance. Brendan is also president of both the Australian Global Health Alliance and Pacific friends of global health bodies that advocate for better health equity. He's the past president of AAMRI, the peak body for independent medical research institutes in Australia.

Today, Brendan will be talking about burnets legacy in HIV research, our historic roots and advancements in this space. We will then hear from Dean Cassano, who will be presenting on the HIV epidemic impacting the Pacific region, including an urgently needed initiative that he is leading to take Burnet peer led HIV counselling model to Fiji, which is currently experiencing a resurgence of HIV.

We will then provide an opportunity for you to ask our experts question where Dr Caroline van Gemert, co-head Pacific Infectious Diseases and Nick Scott, associate professor and head Modelling and Biostatistics, will also be joining us. We will have an opportunity to address some of your questions at the end of the presentation, so please put them through in the chat, and we'll get to them after Dean's presentation.

Thank you, and over to you. Brendan, thank you.

Brendan Crabb

Ourania, can I just get a thumbs up that you can hear me or I? Yes, good, good, fantastic to see you all. I do wish we were in the same room together, but of course, that's really, really hard, and if we did have it in person, at least half of us wouldn't be able to get there.

So this is the next best thing, and it is a great honour to be speaking with you all today, and I begin by acknowledging the traditional owners on the land that I am on, and I know we all feel similarly on the lands that we're on today. For me, it's the land of the Boonwurrung people of the Kulin nation here in Victoria, and pay my respect to their elders past and present, and extend that respect to any First Nations people who might be with us on the on the call today.

What Ourania carefully avoided saying was to to say that I'm an expert in HIV, which I am not so, so, so I'm not speaking to you as the expert. I'm here to help frame things, because HIV has been a very big part of the Burnet and a big part of our future too, I think, and and to to introduce some of the real experts, but it is a big and looming Influence on what we've been and a big looming issue.

I start by saying that the Fiji issue is important in and of itself, and you're going to hear about why that is, but it's also what it says more generally. You know, you can have pandemics or epidemics in all sorts of different ways. The way COVID came about was how we tend to think of of new and emerging infectious diseases, a completely new virus that we've never seen before in causing a major problem for for the human population, HIV, of course, was the last major pandemic of that sort.

But in between and and going on all the time for various reasons, reasons, the emergence, re emergence or, or, you know, change in geographical location of a disease we already know a lot about and and perhaps felt we had some control over. I, I am an expert in malaria, and malaria is any you know exactly in that position. Countries that used to have control programs that were very strong, that now don't have control programs, have a lot of malaria again, very quickly.

Or when drug resistant, drug resistance takes hold, places that even have do have good control measures, can get outbreaks again. Or when climate change changes, where the mosquito goes. You can get diseases in different places. My point of saying all that is that that disease epidemics are disease epidemics. They can be new things. They can be old things, which, for change, circumstances become a really big deal again, and they're no less of a big deal than they were before.

So, so as we hear today's story about Fiji, that's the that's the underlying context of of infectious diseases and the emergence of re emergence of things we know a lot about, not just, not just new things.

The other major point I want to make is, is about HIV. It's influence on Burnet. We're effectively an institute that is has has been shaped by that one infectious disease of HIV, more than any other way, more than any other in fact, mostly timing related and the nature of the institute. We were before HIV came along. At exactly the same time as Burnet was being born. We were, this was 1985 we were a part of an infectious diseases hospital, for those who don't know that, Fairfield infectious diseases Hospital in Melbourne, the research arm of that was our Burnet ancestors.

We weren't called Burnet then, and it was closing down, and to preserve the research arm of it, a new institute was formed called the Burnet center. At the time Burnet himself, so McFarland, Burnet had recently died, and his his name, the family permitted us to use his name with the hell inaugural director Ian gust being quite friendly with with the Burnet family, and welcome to any of those who might be on the call today. And so that's that's how Burnet happened.

But of course, something else was happening in 1985 and that is this new virus was was being recognised. Firstly, a disease AIDS (Acquired Immune Deficiency Syndrome), and later on, the virus that was responsible for that acquired immune deficiency syndrome was identified. This was all happening at the same time.

Now, the Burnet Institute, as it was just being born, was a place that specialised in blood-borne viruses, especially hepatitis viruses at the time, hepatitis B and and viruses that we didn't know at the time was hepatitis C, non a, non B, hepatitis as as just as two of the special specialist viruses that were specialists in. So we're of course, going to get heavily involved in in characterising this new virus and doing something about it. And that's the first thing.

Obviously, we were infectious diseases Institute specialising in virology and patients that were infected by viruses. So. That was obvious, what perhaps we also were and were rapidly were to become much more of was an agency that recognised that technical solutions to infectious diseases were essential through knowledge, had to develop diagnostic tests to develop therapies. Had to develop drugs to cure people or to keep it at bay. You had to understand how it was transmitted, so you could come up with with ways to to intervene with with transmission and so on. So there's a science and evidence based to that science that was crucial.

But HIV, more than any other infection in history, I think, has shown us that it's only half the story, and if you only address that half of the story, you don't get very far at all. And that's because the real barriers to doing something about HIV were not only technical, but were social and legal and humanitarian barriers that were very strong, even in our own, you know, a developed Western economy and society, just as they Were throughout throughout the world.

The main risk groups at the time in this country from HIV were sex workers. Were gay men were injecting drug users, the people that society didn't know much about didn't want to know much about, who were often considered outside illegals, literally criminals. It was very, very tricky space to be asking people like that to come forward and to be a part of of the solution.

So Burnet grew in that environment. We grew to become to recognise we needed to be a technically astute agency, one very interested in generating the knowledge that could lead to solutions, but also one that an agency that had to be activist in nature, that they had to break down all barriers to care whether they be even if they be legal barriers to care. And so that shaped us.

When I arrived in 2008 at the institute, with Margaret Heller and her team's help, we surveyed the institute outputs. You know, publication measures what people self identified as having worked on and so on. And at that time, two thirds of our, I guess, about 350 staff, worked on HIV. To give you an idea of how big an influence that's had. At the moment, it's about five to 10% if you can't, if you strictly count what working only on on HIV. So it's been a very big part of of our history.

We've had some, had some activities that we are very proud of. I'm just going to mention a few of those, only to give you a sense of the breadth of work that we've been involved in in HIV over the years, in in 1995 now, so so 30 years ago, Burnet published a very high profile paper in Science on on, on a group of non, so called non respondents. These are people who got infected with HIV and didn't get sick. And we published a paper to show that there was a deletion in a particular gene that was responsible for that, the so called meth gene.

But the whole concept was a new idea. You know, you could have, you could have groups of people who who got an HIV that didn't make them sick. That was, that was not a well understood context. And then the genetic basis for that, you know, the biomedical basis for that was being revealed, turns out to be even more complex than that. That was, you know that Burnet in the in the lab, in a discovery sense, this long pathway now through the world to understand these non progresses and whether that information can lead to cures, is an area that that we are passionately involved in only if.

At about the same time, in fact, as that work was going on, Burnet sets up Australia's first nationwide HIV and STI surveillance program that is still going to this day. And a few years after that, and it took.

Brendan Crabb 15:01

For almost 10 or more years to develop this, we developed a point of care diagnostic test for immune function. So this is linked. This is not diagnosing HIV, but it's diagnosing whether HIV is damaging your T cells to the point at which you need therapy and and so this, the short story is, there was this big, fancy test with a big piece of equipment needing a lot of technical input and expense to measure how many T cells that sort of immune cell we all have in our blood.

And Burnet converted that into a very simple point of care test, like a rat test you've had for COVID, finger prick of blood, and you can measure your CD for T cell count, and and the treating healthcare worker can decide whether you need any retroviral therapy or not that's being sold throughout the world today.

In 2014 we established a thing called PRONTO! in collaboration with the Victorian AIDS Council and government, Victorian Government, and this is a HIV prevention effort, sort of the first, as we called it at the time, shop front for community based, peer led HIV testing service for gay men. And the background here is, is Australia has been enormously successful in in addressing the HIV pandemic.

But there were, there were bits. There was still stubborn persistence of the infection. And this was trying to get at why is there this stubborn baseline level of infection, and what can we do about that? And there was some science to that, and that science led to this intervention of peer testing, not going to a fancy health facility, but your peers actually doing the testing and counselling for you.

Then we extended that internationally, or the patient counselling services to PNG, again, from the evidence point of view, we're not there as service deliveries where we're testing out different ways of of intervening. And png has a very substantial HIV problem that burnets been heavily involved in trying to reduce the impact of. And then that extends out across the Pacific into today's topic of of Fiji that I'm going to leave to to Dean and the team to describe.

Our work extends beyond the lab to the field to modelling. And one of our speakers today is Nick Scott. And just in the last few weeks, you you might have seen Burnet in the news a bit, and if you have it's probably been Mick and his team's work around assessing the impact of the changes the US administration's changes to funding, which are quite profound for global health efforts on the rates of HIV in the world.

So if, if, say, it was modelling certain scenarios that, if they're not turned around, we could have, you know, quantifiably, much larger HIV problem in the next three to five years, and much larger, again, in the next 10 years, in in a way that is, totally frightening. And I'll leave Nick to describe what that mean, what that says, what that means, and what we hope it drives, of course, that sort of modeling, and that's that's changes on behalf of governments and others to step into to ensure that it doesn't happen.

So so that's kind of setting the scene for for HIV at the Burnet. And now I'd like to hand over to Dean Cassano. Dean is a senior international health project officer. He works in our in our international development team as a project and technical advisor on HIV and sexual health programs right across the Pacific, and the technical focus of it, of his work, is on improving the accessibility of sexual health services and supporting and strengthening the region's healthcare responses to HIV, particularly for people who are already living with HIV.

Dean, I hope it wasn't too embarrassing to have me next to you on the posters, but I'm sorry if that gave created the impression I knew what I was talking about with HIV, but it was a great honour for me to co present with you today and over to you to tell us about HIV in Fiji.

Dean Cassano 19:58

Thanks so much, Brendan. And not embarrassing at all, quite, quite the opposite of privilege. And it's also great to be here with Nick Scott and Caroline van Gemert, and to be with so many other peers and colleagues online today. I can see in the in the name list, many familiar names there. I'm going to share my screen and then kick off.

Dean Cassano 20:33

Now, could I just get a thumbs up? If my screen is beautiful? Great. So my name is Dean Cassano. I've been with Burnet for near on five years. My current role is as a senior international health project officer, and today I'm going to be speaking to some of our work in the Pacific and specifically around HIV.

Before I do start, I'd like to recognise that I'm on the lands of the Wurundjeri people, and I pay my respects to their elders, past, present and future.

So as many of you know, Burnet is quite a unique institute. We cover basic science, public health research and international development. We are the only medical research institute in the country to be an accredited international, non-government organisation, and so what we have is quite a suite of expertise ranging from laboratory work to research, to implementation.

And my work is really the implementation side of things. I get the privilege to work closely with the people you can see on the screen in Papua, New Guinea, in Fiji in Thailand, on a range of programs, predominantly community led programs in the HIV space looking at, how do we increase access to HIV testing, how do we increase the uptake of HIV treatment, and how do we improve HIV care globally.

If we zoom out a little bit from Asia Pacific, though, we know that HIV is still an urgent concern. It is everybody's business, particularly now that we've seen quite a large withdrawal of funding from the United States. But I wanted to just paint a bit of a global picture for where we're at now.

As of 2023 there were 39 million people living with HIV in the world, and an additional 1.3 million people that newly acquired HIV in that same year in many places around the world, HIV is considered a generalised epidemic, and what that means is that it doesn't just impact one segment of the population, one age group or gender or profile. It is more generalised. It impacts the public at large.

We also know that HIV is a lifelong condition. It's manageable with treatment, but it's not curable, and for the majority of people around the world, it requires one tablet daily. And while there is still no cure, there are ongoing efforts to change that. There are many of our colleagues who work in HIV cure research at the Doherty, but as it currently stands now, HIV is considered a chronic disease that is managed with ongoing treatment.

So let's talk about the Pacific. Burnet has quite an established presence in the Pacific region, with country programs in Papua New Guinea and Vanuatu. But for the purposes of today, I'm going to be speaking very specifically about PNG, or Papua New Guinea and Fiji, where there are very concerning HIV problems, and where over the past 10 to 15 years, we've seen a tremendous acceleration in new cases.

To start off, I'm just going to provide some really high level information about the situation in both countries. So when we think about the HIV situation in Papua, New Guinea, the government speaks to this as a mixed HIV epidemic. And again referencing what I said earlier, what this means is that HIV doesn't just impact one segment of the population in PNG, but rather there are new cases among all sections of. Of the Papua New Guinean population, and over the past few years, we've seen the overall prevalence, or the overall number of people living with HIV, continue to increase.

What we do know, though is that there are certain groups that are at a higher risk, and these groups are referred to as key populations because they are key to overcoming the HIV epidemic in Papua New Guinea when we think about key populations, we think about men who have sex with men, sex workers and trans and gender diverse people. But we also know that HIV is increasing among young people, particularly those between the ages of 10 and 24 as well as among pregnant and breastfeeding women.

We also know that there is a high incidence of parent to child transmission, meaning that that there are increasing numbers of babies born HIV positive, and that that number is increasing year on year. The Papua New Guinea government recognises that HIV is a health economic and development challenge. It increases poverty, social vulnerability and gender inequality, and it affects citizens when they are their most productive between the ages of 15 and 49.

Fiji is slightly different. However, the government this year declared a HIV outbreak, and that's because there's been a sharp increase in new cases over the last 15 years. This is also because there have been new and emerging issues, including injecting drug use, which Fiji has never seen before, and which are driving the HIV outbreak in that country.

We also know that HIV is increasing among key populations. When we spoke about the key populations in Papua, New Guinea I said that this meant men who have sex with men, sex workers and trans and gender diverse people. But in Fiji to that list, we also add people who inject drugs as as well as people who are incarcerated.

But there are also blind spots. For example, we don't know how pregnant women are affected. We don't really have clear data on how many pregnant women are living with HIV, either when they're planning to have a family or when they are indeed pregnant and pregnant people pregnant women, are a priority population, but in this space of an increase among key populations and priority populations. We do have gaps in our knowledge, which is really, really concerning when we think about Fiji.

And I'm sure many of you have heard in the headlines, what we are also talking about is a regional threat, and that's because Fiji is an international hub in the Pacific. It is by far and away, the most connected country to the world because of its large tourism industry. And as a result of this, there are emerging concerns among neighbouring countries of transmission.

When we look at these two epidemiological graphs of Papua New Guinea up the top, and then Fiji down the bottom. We can see that in both countries there has been a positive trend in new infections over time. However, as of 2010 we can see that in both countries the situation changes gear. It goes up further in Papua New Guinea Since 2010 that rate of increase is 104% whereas in Fiji, it is 241%.

In Papua New Guinea, there are some. There are a mix of reasons as to why there has been this significant increase in Fiji. There are many as well, but there are predominantly two. The first one is that in 2011 2012 Fiji graduated from being a low income country to a middle income country, and as a result of that, there was a withdrawal of donor funding and an expectation that the Fijian government would be able to supplement their already small pool of funding with with more money because they were now middle income, but that left a real deficit in money for key programs and services, and that is one of the the primary reasons that we are where we are today, because there was that pullback of really significant funding for their programs.

But also, as I said earlier, there has been this emergence of a new issue, and that is injecting drug use, and injectable drugs, which is why now we are. Seeing this humongous increase in cases, and why Fiji has the fastest growing epidemic in the region.

So what is happening in the Pacific? Why are we in this position? And as Brenton Brendan mentioned earlier, we are here because, for the most part, we've been thinking about HIV as a technical problem, as a medical issue, but HIV is as much an infectious disease as it is a social and political issue,

Dean Cassano 30:36

And so when we look at the social context in PNG and Fiji, we can see some key areas that are of concern. We know that the factors surrounding HIV, such as sex drugs, sex work, they're all taboo. People don't like to talk about these things because of local customs, religious beliefs and norms. There is a marginalisation of high risk groups, such as men who have sex with men, or transgender people, people who have sex or people who inject drugs.

There are also high rates of gender based violence, meaning, particularly women are at a much higher risk of HIV. We also know that in PNG and Fiji, the prevention methods are far behind what we have here in Australia and in many other high income countries. And there are also misconceptions around HIV, both around how you prevent it, how you treat it, but also misconceptions around witchcraft and sorcery.

In Papua, New Guinea, where people see HIV as the result of a spell or a curse put on them. Or in Fiji, this, this belief that you can you know, that you can go to church and you can pray and that you'll be cured by HIV, which we know is not true, and in both countries, poverty and low health literacy contribute to this situation. Overall.

We know that in both countries there are also issues within the health systems. Data Collection is very poor, meaning that we don't always understand who is contracting HIV, when or where or how. There's limited funding as well for these programs, and there's also limited capacity at laboratories to do that testing to confirm whether somebody has a HIV diagnosis or not, or what their viral load is.

And more broadly, there is a mistrust in the health system, particularly for high risk groups, those who have experienced stigma because they are same sex attracted, or they're trans, or they inject drugs, they don't want to go to their health clinic to access testing or treatment, or they don't always trust meeting with their healthcare provider because of a bad experience in the past.

And I mention all of this because when we think about HIV, we really need to think of it as a much broader issue, and we can conceptualise that with a problem tree or a palm tree, where we think about the leaves as the outcomes, such as low uptake of testing or low engagement in care, mistrust in the health system. We can see the trunk as the problem that is public health. That is HIV as a public health emergency. But what we really need to be considering other routes. What is below all of this? What are the causes and a major cause in HIV, in the HIV epidemics in our region are indeed these social and political issues. They are what are driving the epidemics.

But I also want to pause here for a second because many of these problems we also face in Australia. We have a health system that is constantly under threat of funds being taken away. Australia also has a huge problem with gender based violence. We also have key groups that are marginalised and who experience stigma and discrimination. And I mentioned this because I don't want us to think about Fiji and Papua New Guinea as having these problems that we don't have and and somehow we should be looking on to them as to how we can help them with these issues, because we face them ourselves, but we have these problems, and we are able to manage and control HIV here, and we do so effectively.

And I think that leaves hope for us to be able to provide support where it's asked for with success. And that's sort of what I want to speak to today, with regard to some of the work that that we're currently doing in the region.

When we think about HIV and a HIV response, we can really break this down to three core pillars around HIV prevention, HIV testing and HIV treatment. But it's specifically the treatment side that we're going to focus on today. And what that means is, once somebody is diagnosed as HIV positive, how do we ensure the best care and support for them? How do we deal with the social factors surrounding a positive HIV diagnosis? How do we help somebody to live well with HIV? And how do we change HIV from being a public health threat?

To respond to some of these questions, I want to speak to you about Mark, who is an Indian-Fijian man who lives in Suva and who was diagnosed as HIV positive this time last year. Mark and I have worked together quite closely for the past year, and he told me that when he was first diagnosed, he thought it was a death sentence. He didn't know about the treatment. He didn't know how he was going to be able to live with HIV, let alone tell other people.

But once he spoke to his doctor, he realised that okay, treatment was something that he could take, but it was actually through his partner that he found the most support. His partner was there with him. He said that he would support him and stay by his side. And then it was through the contact with somebody else who works in the HIV sector in Fiji that he managed to access some more social support and really get that assistance and that that emotional and social care to process this diagnosis.

In December 2024 Mark came out as the youngest person living with HIV in Fiji, and he has since started Living Positive Fiji, which is one of the biggest advocacy platforms for people living with HIV in Fiji, and one of the biggest community based HIV health promotion groups today.

But this concept of peer support, social support and counselling shouldn't just be luck or because you are, you know, blessed to have that partner, because we know that peer led support and counselling is one of the most researched and well understood programs to support people living with HIV and ultimately provide a locally sustainable component to the HIV response.

So what is peer led support and counselling? Essentially, it means that somebody living with HIV is trained and supported and empowered to provide counselling and support to somebody else. It places lived experience at the core, and it offers a way for somebody living with HIV to guide and mentor somebody who is newly diagnosed through the different phases of their journey with HIV.

It's shaped around the shared experience of stigma, but it also de-medicalises HIV care because it takes that person outside of a doctor's clinic to somewhere more familiar, somewhere safer where they can talk about HIV. It also reduces isolation and loneliness and the benefits to this program, as as documented in a wide body of global research, is that peer counselling really improves a person's overall well being by connecting them with somebody with that shared experience.

It also improves the adherence to HIV treatment, which is better for their for that person's overall health, it improves quality of life, and it also reduces strain on the health system by taking that care, that that social and emotional care, away from the doctors and nurses, so that they can focus on the medical care, and placing it within community where there's more capacity, but also more strength and resilience and more knowledge of how to deal with it.

And Burnet has quite a lot of experience in this space. In fact, we were one of the partners that worked with IGAT HOPE in Papua New Guinea to set up the country's peer counselling initiative. It started in 2018 where Burnet and I got hope realised that the existing peer counsellors in PNG didn't necessarily have the right tools or training or support to actually support their peers, and so the question that we were trying to answer. Was, how can we strengthen this existing program? And so there were two main goals. One was to improve the treatment adherence among people who were living with HIV and who were accessing this service. But the second goal was also to supply counsellors with the accurate information to support their clients.

Dean Cassano 40:20

And so we developed a suite of tools in this toolkit. We did really broad community consultation with clinicians, doctors, nurses, but also with people living with HIV to look at what are the 10 most important things that you need to know once you've received a diagnosis. We tested and refined this over and over, and then we launched this is what the HIV peer counselling toolkit looks like. It's a plastic briefcase which has the 10 different modules, of which you can see four on the screen here.

But now it's time for Fiji. We want to scale this up and take it to Fiji, where we know it is needed, and we know that it's needed because we've heard this from Fijians in 2023 our team led a study tour for three weeks where we had four health advocates from Papua, New Guinea, and we had seven health advocates and clinicians from Fiji, and there was a resounding yes, we need this from the Fiji inside, because, as clinicians, many of them knew that they just didn't have the training or the time to be providing that peer support that their clients needed.

And so from 2023 in July onwards, what I've been doing is working with partners in Fiji to look at, how do we implement this over there, how do we work with you to scale it up? And so this partnership approach has really been central to the work that I and our team has been doing for the past two years, looking at how we do a locally led, community driven program.

And Rebecca, the woman in the middle with her two daughters, has been key to this, as a counsellor and a woman living with HIV, she has been my key partner to talk about how we actually introduce this toolkit, and so working with community partners is really what we see as our way forward. Also engaging closely with the Ministry of Health to align this peer counselling program with the national priorities, so that we can support a national scale up and integrate it alongside the other interventions and this partnership approach is also central to make sure that Burnet and our partners can work together for the future to empower the counsellors and provide that ongoing mentoring and support.

And so the objective of what we see with this peer counselling program in Fiji is that we can have services in Labasa in the north as well as Suva and Lautoka, the places where we're really seeing the highest number of new HIV cases, and where that support for treatment And for peer engagement is really necessary.

So what happens next? We know that Fiji is experiencing an unprecedented acceleration in new HIV cases. We know that there are some underlying social causes to this. We know that there are low levels of treatment uptake, and that HIV really poses a public health threat to the country, but the future looks like a network of peer counselors who are empowered to support their peers and ensure the people living with HIV can live well.

The future is also a higher uptake of HIV treatment and programmed to support and address the social issues, and we also want to see a de escalation of the threat of HIV. So while we are here now in May 2025 we're very confident that this is where we'll be moving to, and that the peer support program is going to play a major part of that. And so with that said, I would like to thank you for taking the time to listen to me today and to hear about the work that we've been doing, and also to welcome any questions that you might have. Thank you very, very much.

Ourania Mohr 44:36

Thank you so much, Dean for your very informative presentation, and thank you also, Brendan, for the overview that you've provided. We will be allowing some questions in just a few minutes, but we do have some questions that some of you have sent through that we will address before we do that.

I do also want to acknowledge and thank Mark for sharing his story. It takes a lot of confidence and courage. To share that, and we do appreciate that he was comfortable with us telling that story. Thank you.

So starting off, we have a question from Emma, which is, while HIV is well controlled in Australia, it's still present and continues to spread, both here and in countries we work with, like Fiji, Myanmar and Papua New Guinea, what are the main barriers to ending transmission across these different contexts, and how can organizations like ours play a stronger role in supporting both local and regional HIV responses, I might ask Dean and Caroline, introducing Caroline van Gemert as well, if you'd like to tackle that one, please.

Caroline van Gemert 45:39

No one. Thank you very much, and thanks, Dean for your excellent presentation. So my work is in epidemiology of infectious diseases, so focusing on the Pacific region, and from an epidemiological perspective, the very low testing rates and low treatment rates are the biggest concern in Fiji.

Only 54% of people know their status as being HIV positive, and amongst these people, only 20, 28% are engaged in treatment at the moment. So those low numbers really show that we need to increase the number of people who are tested to reduce the number of undiagnosed people, and it therefore also increase the number of people who are treated for HIV.

We also have very little limited understanding of the like new and emerging risk groups for HIV transmission. And as Dean alluded to, there's a there's evidence of increasing rates of injecting drug use in in Fiji and also in other Pacific Island countries. And we really need more data and evidence to explain the new increase in in transmission, and also to describe the numbers, it's really hard to get a sense of the number of new, newly detected cases of HIV, HIV in different Pacific Island countries.

And at a similar time, Dean referred to changes in the Pacific around 2010 2012 at that time, there hasn't been regional HIV surveillance conducted since that time period. So it's really hard to get a sense of the incremental increase in the number of cases in in different countries since that time and in terms of how Burnet can support, I think our role in research can really contribute to the response in terms of developing and generating evidence for new ways of doing things, which is really important, and also and really importantly, is identifying new and emerging local researchers in Fiji PNG and other Pacific Island countries to lead the research, to describe what's happening to this, to develop new interventions and to be involved in the response in these countries.

Ourania Mohr 47:43

Thank you. Caroline Dean, did you want to add anything to that? Or nick or Brandon?

Dean Cassano 47:50

I think in Fiji, you know, Burnet can also play quite a big role in supporting the local response what the Fijian government has defined as their priorities. And as Caroline said, you know, training local researchers to be part of that. So there is a sustainable kind of body of knowledge and expertise in the country.

One of the major issues in Fiji is that there are only three clinics in the entire country where HIV treatment is is provided. This number is likely going to grow as the country grapples with the epidemic. But for for the most part, these three really are carrying the burden. And even when private GPS, you know, refer their clients on for HIV treatment or for counseling. It's going to these three clinics, and that that that patient load is just not sustainable.

And you know, Burnet can play a role in supporting them, in in looking at how you can actually bring in community based testing and treatment, as well as, you know, supporting their other locally led initiatives. Absolutely.

Ourania Mohr 49:02

Thank you, Dean. The next question we had was from Belinda, what impact has withdrawal of USAID funding had? I might ask Nick Scott to join us now, please. Thank you, Nick. Thanks a lot.

Nick Scott 49:16

So firstly, in terms of service coverage, others might be able to answer this part better than me, but it's had quite a severe impact in terms of people not being able to access treatment, and in many places, there's been entire prevention programs that have been shut down and reduced access to testing.

The questions that we've tried to look at is what impact would these things have on the overall epidemic when we project it forward, and we've run some modeling scenarios, what that means is that we make different assumptions about the recovery period that countries might need, and we look at the implications for this on future HIV. Infections and deaths.

So we started with looking this is globally at a worst case scenario where there might be a slow recovery for countries, and this is where a lot of services have been shut down, and it would take until 2030 for countries to just get back to where they were before the withdrawal of funding. So this is a slow recovery scenario. And it's, it's quite devastating impact.

So we're looking at an additional 11 million new infections, nearly 3 million additional deaths, many of them in children. And it's, it's sort of decades of progress lost in the space of a few years.

But we also looked at faster recoveries. So for example, if countries could be supported to recover their services within 24 months, rather than up till 2030 things are much better. So nearly 75% of those deaths could be prevented by having a faster recovery of those services, and even more of those infections and deaths can be prevented if the recovery is even faster than that.

So the short answer of what have the impacts been is that it's uncertain and the future can change. We know that doing nothing is likely to be quite bad, but we also know and have shown with the modeling that there's enormous potential to prevent all of these infections, and so governments and society really have the capacity to do that.

Ourania Mohr 51:39

Thank you. Nick, Would anyone else like to add to that?

Brendan Crabb 51:42

Yeah, look, I might a little bit thanks, thanks, Nick. And just just to add a little bit more context for those who don't live and breathe this that the US withdrawal from Global Health effectively, is, is, is, is so enormous, it's about 40% of all of the the high income countries contribution to low income countries development, of which infectious diseases like HIV, TB and Malaria are at the core of what they do.

So overnight, 40% of all of the world's expenditure in this space was was stopped, no off ramp, no no easing away from it over a three to five year period or so on, which would have been bad enough. And why I say that is, is Dean's point about Fiji in particular. You know, Dean showed that in a planned way, services so so funding from from high income countries was reduced in about 2012 1314, because Fiji had graduated to become what's called, technically, a middle income country, from a from a low income country. It's a good thing, of course.

And so this is, this is what's meant to happen, meant to graduate from that but, but even even when that's planned, and when the government even does a reasonable job, as they have in Fiji. It's still a hard transition to make, but, but what's happening here is, is the funding that the rug has been pulled out from the global health support overnight and and so the sort of modeling that that Nick and team have done is not at all fanciful or pessimistic. It's a it's an extremely worrying period that we face very hard to imagine anything turning around or, you know, stop gaps being found to to mitigate that in the next few years, we have to try hard with, we're pleading with, with our own governments and with philanthropists everywhere to do that.

You might have all noticed Bill Gates response, just two days ago, announced where he's greatly accelerating the speed at which the Gates Foundation is going to give away all their all their funding, effectively doubling the speed of it. So his his fortune goes to zero, effectively by 2045 and that's in response to this and and you know, it's important. But as big as the Gates Foundation is, it's nowhere near big enough to compensate for for these effects.

So so the world needs to take inspiration, I think, from from from Bill Gates and what he announced the other day and and the reasons you've heard today are why HIV is at the the top of the tree, but together with tuberculosis, malaria. Immunization rates, safe pregnancies, safe deliveries. These are really serious threats, and as Dean has explained, that go way beyond the health impact directly is what impacts on society's capacity to go from low income country to middle income country to high income country, effectively blocks that makes them less economically strong, makes them less secure, makes them weaker trading partners. It's just bad for for everyone.

So this is a moment in time. You know, there's a one in 100 year moment in time that has just happened, that that we're facing, and that's the sort of modeling is in that context.

Ourania Mohr 55:45

Thank you, Brendan, it is alarming, isn't it? The next question that we have is from Irene. I hope I've said that correctly. I might direct this to Caroline and Dean, what approach should be applied to encourage a person to have its HIV status checked.

Caroline van Gemert 56:03

I'll jump in to talk about how we can increase antenatal testing. So HIV testing amongst pregnant women. And there's two things that we're currently working on in some of my projects. One is around the use of rapid diagnostic tests used at the point of care, and one is around changing from opt in to opt out testing.

So back to the rapid diagnostic test. So rapid diagnostic tests have only really been available in the Pacific for the past 10 years or so. So these are tests very similar to a COVID test that can be used outside of the laboratory. But I mean, obviously using blood, not not saliva. So use outside of the outside of the laboratory to diagnose HIV or detect HIV before going on to confirmatory testing.

So some research that we are doing at the moment has identified that many countries are still using these tests in a laboratory environment. So antenatal care is most commonly provided in community clinics around the Pacific, but it means that you can't get the HIV test when you attend that community antenatal clinic. It means you have to go into a laboratory to receive the test, or to have the blood collected and then to have the test conducted, and it can be several weeks until you receive the the results, which means that there's a delay to receiving a positive diagnosis and and a delay to Linkage to Care, which is a real problem.

So we're doing some work to understand the use of rapid diagnostic tests and to increase their use in the at the point of care in across the Pacific. The other thing that we are starting to work on is around changing the approach to HIV testing in antenatal care from opt in to opt out.

So opt in is a really old fashioned way of doing antenat for doing HIV testing, where you need to do a lot of pre test counseling and conversation with the patient to get their agreement and have them really comprehensively understand the reasons for HIV testing and what a positive test would mean before the test. Because of this approach, there's a lot of midwives and nurses that avoid doing HIV testing at all, and we know that HIV testing in antenatal clinics is really low, so we're looking at trying to change that, and working with governments to see if it's acceptable or feasible to change to an opt in, opt out approach. Sorry, instead, and there's a lot of evidence around the world that the opt out approach increases HIV testing rates in antenatal clinics. Dean, I'll throw to you.

Dean Cassano 58:31

Thanks, Caroline. I think you know, when we when I reflect back on the three pillars that I had around prevention, test and treat, you know, I think we also need to change how we talk about HIV and how health promotion, how health promotion refers to HIV as being something that is just for gay and bisexual men or people who inject drugs. That's just not true.

You know, it is increasingly impacting women and children and parents as much as anybody else, right? And so that that needs to change. I think that by doing so, we need to also be, you know, looking at addressing the stigma that's attached to HIV, so that getting a test is no longer seen as this hurdle that you have to overcome, or this, this scary thing that you've never done before. It needs to become a lot more, a lot more accessible to people in their own minds.

But once we do the test, as Caroline said, the test needs to be accessible. You don't you shouldn't have to go to a laboratory to do it. You shouldn't have to go to a clinic. That's why pronto was so successful, because it was in community. It was a storefront that we helped create. So getting the tests out there is also really important.

And then once somebody is diagnosed, unless there is actually a support system to work with them, we're going to be undermining the HIV response. There needs to be adequate support up. Diagnosis, around treatment, around emotional care, social support, so that once somebody is diagnosed, they know how to actually manage it, and they have the support to do so, so that, again, that that HIV test is not this thing that you just fall off a cliff once you've once you've tested, because there's an absence of services, no you test, and if you do receive a positive diagnosis, you're aware that there's a continuum of care that's there for you.

Ourania Mohr 1:00:27

Thank you, Dean. We have just one more question, and then we'll jump to the questions in the chat. This one is from Roger. Will there ever be a vaccine for the HIV virus with the introduction of ARV treatment? Has HIV, new infection reduced or still at a rise. I'll ask Caroline and Dean to tackle that one, please. That's all right,

Dean Cassano 1:00:49

yeah. So ARV has been an incredible, you know, tool for HIV prevention, because once somebody starts the ARV or the antiretroviral therapy after about, after a couple of months, I won't say how many, because it depends on the person, but after a couple of months, that person is no longer able to transmit onwards the HIV virus, right? So prevention, the treatment is actually way preventing HIV transmission.

And in countries like Australia and many, many other countries, HIV treatment has been integral to our HIV response and really bringing back that number of of new cases. However, in countries like up in New Guinea and Fiji, where the understanding around HIV transmission and treatment is at a different place to where it is in Australia, obviously, we haven't seen that same impact of antiretroviral that's not because the drugs aren't effective in those contexts, not at all. It's just because some of the social circumstances are not seeing the drugs break through as much.

With regards to a vaccine, that's definitely something that science is looking to progress and move forward. And there are multiple sort of vaccines in in trial phase. And we can certainly see that with with HIV treatment overall, there is a move towards injectables as well, such as preventative treatments through, you know, two monthly or a six monthly injection that that prevents HIV, or, you know, antiretroviral therapy, that's no longer a tablet a day, but, you know, an injection every every couple of months. So it's certainly moving in that direction, and a vaccine is definitely on the horizon, but just not here yet.

Ourania Mohr 1:02:39

Thank you. Dean Caroline, or the rest of the panel. Did anyone want to add to that?

Brendan Crabb 1:02:45

I'm happy to add a little bit to vaccine. Sorry, Caroline, if I'm cutting you off just just to on the straight just to two issues here. One is using a drug as a prevention. So this is where you give someone drug before they bit like you take your antimalarials before you travel to a highly intense transmission area. And you don't get malaria because you've got the drug in you. That's one of the things Dean was, was talking about them then as as an injectable prevention.

Then there's vaccine, as we understand, vaccine, you know, stimulating an immune response in you that protects you for a period of time, hopefully for for your life. Polio, smallpox, course, completely eradicated because such a vaccine. Measles, mumps, rubella, ditheria, tetanus, so on, typhoid got good vaccines for all of these.

And then some organisms come along. We try all those methods, and it doesn't work. HIV and malaria are two cases in point. If you know, the world has tried very, very hard to make an HIV vaccine, and the reason is, they change too rapidly. They change their spots so rapidly. So you make a vaccine against one form of HIV, and and, and it doesn't protect you against all the other different forms that are rapidly evolving so so quickly. Same with malaria as well.

So I agree with Dean I there will be an HIV vaccine one day, but it's not going to evolve in the same simple pathway that so many of the others have. It's going to take much more modern scientific insight and new methods to get one and and we certainly it's not around the corner. I don't think we don't want to rely on that sort of vaccine, but we do have brilliant tools that are developing, and the injectable prep, the injectable prevention drug, is is game changer, from my perspective, an absolute game changer that that isn't the same as stimulating an immune response to be protective for life, but conceptually, does protect you for. For a period of time.

And just incidentally, to underscore Dean's point about generalized nature of HIV, 53% of the 39 million people that Dean referred to as being HIV positive are women and girls. Okay, so it's a very different from the perspective that that you might imagine the risk groups to be, and nearly half of all new infections are women and girls as well. So it's a generalized infection anywhere where there's a lot of HIV. That's the way it plays out.

Ourania Mohr 1:05:41

Thank you, Brendan Caroline, did you want to add anything to that? No,

Caroline van Gemert 1:05:44

just to reiterate that, as Brendan said, not that we shouldn't be waiting for the vaccine because it isn't around the corner, but to make sure that we use the tools at our disposal now.

Ourania Mohr 1:05:54

Thank you. All right, thank you to Jenny, who did post a question. I'm wondering, how the church can or are involved in the peer support model. Wondering who might be best to answer that is that specifically, perhaps in Australia, or probably

Brendan Crabb 1:06:13

as an example, PG van or two, Fiji Caroline,

Dean Cassano 1:06:17

I can speak to it in Papua, New Guinea so the the HIV peer counseling toolkit that we've developed and the the counselors that we have supported and empowered over the past kind of eight years, they're all based at church health facilities. So in PNG, particularly, we've worked very closely with the Catholic Church Health Services, and with Anglicare and the peer counselors that we have been working with are at their facilities in Port Moresby and mount Hagan and more recently in Goroka and lay so the church has played a phenomenal role in in This space, and I suspect we'll continue to do so in Fiji because of, you know, the the recency of this, of this outbreak.

We haven't been working closely with the church yet, but I suspect they will be a major partner at this point in time. It's mainly been with people who are living with or affected with HIV that have been our key partners, as well as the Ministry of Health, obviously.

Ourania Mohr 1:07:26

Thank you, Dean. We also have a question from Bronwyn, having identified why some people don't get sick once they have AIDS? Is there any possibility of gene therapy, or is that not possible?

Brendan Crabb 1:07:39

I'm happy to tackle it, because I raised the issue. And it is technically, it is theoretically possible, but it turns out, as I hinted at, to be more complex than the simple meth gene deletion that I mentioned earlier. And, and, but, but, you know, theoretically, it may be possible to turn what is a a virulent virus in you into a non virulent virus in you through gene therapy.

For example, if, if it was just an F gene, by deleting the net an F gene, the problem you have is you'd have to find where all the reservoir cells are in the body, apart from just finding what gene or genetic mutation you had to make, and we don't know where all the reservoirs are in your body, and so having a gene therapy delivered to those cells looks, looks incredibly complex. So theoretically feasible, logistically, really, really complicated, to the point of of not being on the on the horizon yet. But it is of interest to people, absolutely of interest to people.

The other reason is, is, is to a vaccine. Imagine you could make a live, attenuated HIV that was truly 100% attenuated. You weren't at any any concern about it being virulent. Maybe that's your your your vaccine. It probably would never fly, because no one would ever trust it, but, but that's what we do for polio, for example, or for measles, mumps, rubella, they're all live viruses that go into us. They're attenuated to be, to be non virulent, so, but as say, for something like HIV, that's that's very unlikely because of that the connotations around it. But so theory is good practices is pretty hard.

Ourania Mohr 1:09:26

Thank you, Brendan. Did anyone have anything else they wanted to add to the chat? No, I think that's it. I'd like to take this opportunity to say a very big thank you to Brendan and Dean and also our experts, Nick and Caroline, thank you for joining us. And also to our attendees. I hope you found it as informative as I have. It's been wonderful to see you all, and thank you so much for your time this afternoon.

Brendan Crabb 1:09:53

Thanks everybody. Great to see you. Bye, bye, thank you, bye.