STI and HIV testing: examining factors that influence uptake among domestic Australian-born, domestic overseas-born and international tertiary students studying in Australia.

OBJECTIVES: Sexual health knowledge among international students in Australia is lower than domestic students, however, little is known about what factors affect the uptake of STI testing, nor if there are differences for overseas-born domestic students. METHODS: We included sexually active respondents from a survey of university students in Australia (N = 3,075). Multivariate regression and mediation analyses investigated associations of STI and HIV testing with STI and HIV knowledge respectively, sexual risk behaviour and demographics, including comparisons among: domestic Australian-born, domestic overseas-born, and international students. RESULTS: STI and HIV knowledge was positively associated with STI and HIV testing respectively (STI OR = 1.13, 95% CI: 1.09, 1.16; HIV OR = 1.37, 95% CI: 1.27, 1.48). STI knowledge was significantly lower for international than domestic Australian-born students (10.8 vs. 12.2 out of 16), as was STI testing (32% vs. 38%); the difference in knowledge accounted for half the difference in STI testing rates between these two groups. International students from Southern Asia, and Eastern Asia reported the lowest STI testing rates. HIV testing was highest amongst international students from Africa and North America. Higher sexual risk behaviour, younger age, and identifying as gay or bisexual were positively associated with higher STI and HIV testing rates. CONCLUSIONS: Our study supports greater investment and commitment by universities for the provision of sexual health education that can promote access to testing to improve the health of their students.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages.

BACKGROUND: Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required. METHODS/ RESULTS: To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health. CONCLUSION: Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

Market strategies used by processed food manufacturers to increase and consolidate their power: a systematic review and document analysis.

BACKGROUND: The public health community has become increasingly critical of the role that powerful corporations play in driving unhealthy diets, one of the leading contributors to the global burden of disease. While a substantial amount of work has examined the political strategies used by dominant processed food manufacturers that undermine public health, less attention has been paid to their use of market strategies to build and consolidate power. In this light, this paper aimed to systematically review and synthesise the market strategies deployed by dominant processed food manufacturers to increase and consolidate their power. METHODS: A systematic review and document analysis of public health, business, legal and media content databases (Scopus, Medline, ABI Inform, Business Source Complete, Thomas Reuters Westlaw, Lexis Advance, Factiva, NewsBank), and grey literature were conducted. Data extracted were analysed thematically using an approach informed by Porter's 'Five Forces' framework. RESULTS: 213 documents met inclusion criteria. The market strategies (n=21) and related practices of dominant processed food manufacturers identified in the documents were categorised into a typological framework consisting of six interconnected strategic objectives: i) reduce intense competition with equivalent sized rivals and maintaining dominance over smaller rivals; ii) raise barriers to market entry by new competitors; iii) counter the threat of market disruptors and drive dietary displacement in favour of their products; iv) increase firm buyer power over suppliers; v) increase firm seller power over retailers and distributors; and vi) leverage informational power asymmetries in relations with consumers. CONCLUSIONS: The typological framework is well-placed to inform general and jurisdiction-specific market strategy analyses of dominant processed food manufacturers, and has the potential to assist in identifying countervailing public policies, such as those related to merger control, unfair trading practices, and public procurement, that could be used to address market-power imbalances as part of efforts to improve population diets.

The influence of corporate market power on health: exploring the structure-conduct-performance model from a public health perspective.

BACKGROUND: The detrimental impact of dominant corporations active in health-harming commodity industries is well recognised. However, to date, existing analyses of the ways in which corporations influence health have paid limited attention to corporate market power. Accordingly, the public health implications of concentrated market structures, the use of anti-competitive market strategies, and the ways in which market power mediates the allocation and distribution of resources via market systems, remain relatively unexplored. To address this gap, this paper aimed to identify and explore key literature that could inform a comprehensive framework to examine corporate market power from a public health perspective. The ultra-processed food (UPF) industry was used to provide illustrative examples. METHODS: A scoping review of a diverse range of literature, including Industrial Organization, welfare economics, global political economy and antitrust policy, was conducted to identify important concepts and metrics that could be drawn upon within the field of public health to understand and explore market power. The Structure-Conduct-Performance (SCP) model, a guiding principle of antitrust policy and the regulation of market power, was used as an organising framework. RESULTS: We described each of the components of the traditional SCP model and how they have historically been used to assess market power through examining the interrelations between the structure of industries and markets, the conduct of dominant firms, and the overall ability of markets and firms to efficiently allocate and distribute the scarce resources. CONCLUSION: We argue that the SCP model is well-placed to broaden public health research into the ways in which corporations influence health. In addition, the development of a comprehensive framework based on the key findings of this paper could help the public health community to better engage with a set of policy and regulatory tools that have the potential to curb the concentration of corporate power for the betterment of population health.

Maximising the wealth of few at the expense of the health of many: a public health analysis of market power and corporate wealth and income distribution in the global soft drink market.

BACKGROUND: Many of the harms created by the global soft drink industry that directly influence human and planetary health are well documented. However, some of the ways in which the industry indirectly affects population health, via various socio-economic pathways, have received less attention. This paper aimed to analyse the extent to which market power and corporate wealth and income distribution in the global soft drink market negatively impact public health and health equity. In doing so, the paper sought to contribute to the development of a broad-based public health approach to market analysis. A range of dimensions (e.g., market concentration; financial performance; corporate wealth and income distribution) and indicators (e.g., Herfindahl Hirschman Index; earnings relative to the industry average; effective tax rates; and shareholder value ratios) were descriptively analysed. Empirical focus was placed on the two dominant global soft drink manufacturers. RESULTS: Coca-Cola Co, and, to a lesser extent, PepsiCo, operate across an extensive patchwork of highly concentrated markets. Both corporations control vast amounts of wealth and resources, and are able to allocate relatively large amounts of money to potentially harmful practices, such as extensive marketing of unhealthy products. Over recent decades, the proportion of wealth and income transferred by these firms to their shareholders has increased substantially; whereas the proportion of wealth and income redistributed by these two firms to the public via income taxes has considerably decreased. Meanwhile, the distribution of soft drink consumption is becoming increasingly skewed towards population groups in low and middle-income countries (LMICs). CONCLUSIONS: Market power and corporate wealth and income distribution in the global soft drink market likely compound the market's maldistribution of harms, and indirectly influence health by contributing to social and economic inequalities. Indeed, a 'double burden of maldistribution' pattern can be seen, wherein the wealth of the shareholders of the market's dominant corporations, a group over-represented by a small and wealthy elite, is maximised largely at the expense of the welfare of LMICs and lower socioeconomic groups in high-income countries. If this pattern continues, the appropriate role of the global soft drink market as part of sustainable economic development will require rethinking.

Economic evaluation of alternative testing regimes and settings to detect undiagnosed HIV in Australia.

BACKGROUND: The study aimed to estimate the comparative costs per positive diagnosis of previously undetected HIV in three testing regimes: conventional; parallel and point of care (POC) testing. The regimes are analysed in six testing settings in Australia where infection is concentrated but with low prevalence. METHODS: A cost model was developed to highlight the trade-offs between test and economic efficiency from a provider perspective. First, an estimate of the number of tests needed to find a true (previously undiagnosed) positive diagnosis was made. Second, estimates of the average cost per positive diagnosis in whole of population (WoP) and men who have sex with men (MSM) was made, then third, aggregated to the total cost for diagnosis of all undetected infections. RESULTS: Parallel testing is as effective as conventional testing, but more economically efficient. POC testing provide two significant advantages over conventional testing: they screen out negatives effectively at comparatively lower cost and, with confirmatory testing of reactive results, there is no loss in efficiency. The average and total costs per detection in WoP are prohibitive, except for Home Self Testing. The diagnosis in MSM is cost effective in all settings, but especially using Home Self Testing when the individual assumes the cost of testing. CONCLUSIONS: This study illustrates the trade-offs between economic and test efficiency and their interactions with population(s) prevalence. The efficient testing regimes and settings are presently under or not funded in Australia. Home Self Testing has the potential to dramatically increase testing rates at very little cost.

STI and HIV knowledge and testing: a comparison of domestic Australian-born, domestic overseas-born and international university students in Australia.

University students usually consist of young people from culturally and linguistically diverse backgrounds, and a group recognised as being at increased risk of STI. This study found lower levels of STI knowledge and STI testing among international students and to a lesser extent, domestic overseas-born students, compared with domestic Australian-born students. International students exhibited lower risk sexual behaviour but were more likely to have had a HIV test than domestic students. This diversity in sexual health knowledge, sexual health services utilisation and sexual experience indicates the need for a variety of public health approaches to improve sexual health.

Reasons for Not Seeking Hepatitis C Treatment among People Who Inject Drugs.

BACKGROUND: Despite increases in treatment uptake for hepatitis C viral infection (HCV) in Australia since the introduction of direct acting antiviral (DAA) therapy, a large proportion of HCV-infected people who inject drugs (PWID) have not sought treatment. Purpose/Objectives: To examine predictors of treatment uptake and reasons for not seeking treatment among PWID. Methods: PWID (n = 404) recruited through five needle and syringe programs in South East Queensland were interviewed about HCV testing, status and treatment, recent injecting drug use, mental health and reasons for not taking up treatment. Predictors of treatment uptake were examined using unadjusted and adjusted logistic regression analyses. Proportions were calculated for participants reporting each reason for not taking up treatment. Results: We recruited 404 PWID. Of those tested for HCV (94%), 55% were HCV antibody positive and 31% with active infection. Approximately 36% of eligible participants had begun or completed DAA treatment. In adjusted analyses, injecting drugs three or more times per day was associated with not taking up HCV treatment (p = 0.005). Common reasons for not seeking treatment ("applied a lot") included experiencing no HCV-related symptoms (25%), HCV treatment not being a priority (23%), fear of treatment side effects (18%), and no knowledge of DAA treatments (15%). Conclusions/Importance: HCV education efforts for PWID should target misperceptions and lack of awareness of DAA therapy, and highlight the likely benefits of treatment even when asymptomatic. The use of peer workers and increased investment in integrated treatment facilities will likely aid treatment uptake.

Australian interdisciplinary healthcare providers' perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study.

Background The addition of pre-exposure prophylaxis (PrEP) for HIV prevention to the Australian Government-subsidised Pharmaceutical Benefits Scheme (PBS) enables any doctor or nurse practitioner to prescribe it and has increased accessibility options. However, understanding of Australian healthcare providers' (HCP) knowledge and preparedness to prescribe PrEP remains limited. METHODS: Semistructured interviews, conducted before PBS listing (October 2016-April 2017), explored PrEP knowledge and prescription experiences of 51 multidisciplinary HCPs involved with the Queensland Pre-Exposure Prophylaxis Demonstration study. RESULTS: Thematic analysis revealed that participants viewed PrEP as a necessary HIV prevention option, but there was concern about confusing prevention messages and potential risk compensation. Clinical capacity, stigma, cultural norms, rural access and PrEP-associated costs were identified as barriers to access and uptake. Some of these barriers may be addressed by the PBS listing; nonetheless, there was strong specialist concern about the preparedness of general practitioners without sexual health experience to prescribe PrEP. Participants identified a need to educate all HCPs, implement multidisciplinary supply models and provide timely access to PrEP for vulnerable populations and those ineligible for Medicare (Australia's universal healthcare insurance system). CONCLUSIONS: Although PrEP listing on the PBS addressed structural barriers to access, this study highlights the role of nurses and other interdisciplinary healthcare workers in the provision of PrEP in addressing the sociocultural barriers that still affect the access of certain populations to HIV prevention measures. These findings will inform further professional training as PrEP is more widely accessed and requested outside specialist sexual health services. Future work is needed to ensure that the primary healthcare workforce is prepared to provide competent and safe access to PrEP across diverse locations and population groups.

Reduced sensitivity from pooled urine, pharyngeal and rectal specimens when using a molecular assay for the detection of chlamydia and gonorrhoea near the point of care.

Background The aim of this study was to compare the performance of pooled self-collected urogenital, pharyngeal and anorectal specimens to that of individual specimen results for the molecular detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) near the point of care (POC) for diagnostic sensitivity. METHODS: Clients (mostly men who have sex with men) attending an urban community testing service and three sex-on-premises venues in Brisbane, Australia, were offered CT and NG testing by trained lay providers. Participants provided three self-collected specimens (urine, pharyngeal and rectal) for testing by GeneXpert (Cepheid, Sunnyvale, CA, USA). If any of the individual specimens from a participant were positive, all three specimens were pooled and retested. RESULTS: Of the 388 participants who provided three individual anatomical specimens, 76 (19.6%) were found to be positive for CT and/or NG at one or more sites. The pooling approach failed to detect five CT rectal and four NG pharyngeal infections. The overall performance (sensitivity) of the pooling approach compared with individual specimen testing and Cohen's κ were 90.0% and 0.86 respectively for CT and 89.7% and 0.89 respectively for NG. CONCLUSIONS: Reduced sensitivity was observed when using pooled specimens for the detection of CT and NG using GeneXpert near the POC, similar to results reported in laboratory-based CT and NG pooling studies. These data suggest specimen pooling is feasible near to the POC, potentially saving time and costs when screening at-risk populations for CT and NG. Our data also suggest a reduction in pooled urine could improve overall test sensitivity.

Peer-delivered point-of-care testing for Chlamydia trachomatis and Neisseria gonorrhoeae within an urban community setting: a cross-sectional analysis.

Background The advent of fully automated nucleic acid amplification test (NAAT) technology brings new public health opportunities to provide Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) point-of-care testing (POCT) in non-traditional settings. METHODS: This pilot study evaluated the integration of the CT/NG Xpert diagnostic assay into an urban peer-led community setting providing HIV and syphilis POCT. A comprehensive protocol of testing, result notification, referral and follow up, managed by peer test facilitators, was undertaken. RESULTS: Over 67 weeks, there were 4523 occasions of CT/NG testing using urine, oropharyngeal and anorectal samples with 25.7% (803) of the 3123 unique participants returning for repeat testing. The prevalence of CT and NG was 9.5% and 5.4% respectively. Where CT and or NG infection was detected, 98.4% (604/614) of participants were successfully notified of detected infection and referred for treatment. Evaluation Survey responses (11.4%, 516/4523) indicated a substantial proportion of respondents (27.1%, 140/516) 'would not have tested anywhere else'. Of note, 17.8% (92/516) of participants reported no previous CT/NG test and an additional 17.8% (92/516) reported testing more than 12 months ago. A total of 95.9% (495/516) of participants 'Strongly agreed' or 'Agreed' to being satisfied with the service. CONCLUSION: The project successfully demonstrated an acceptable and feasible model for a peer-delivered community-led service to provide targeted molecular CT/NG POCT. This model offers capacity to move beyond the traditional pathology and STI testing services and establish community-led models that build trust and increase testing rates for key populations of epidemiological significance.

COVID-19 and Private Health: Market and Governance Failure.

The COVID-19 pandemic has produced mass market failure in global private health, particularly in tertiary care. Low-and-middle income countries (LMICs) dependent on private providers as a consequence of neglect of national health systems or imposed conditionalities under neoliberal governance were particularly effected. When beds were most needed for the treatment of acute COVID-19 cases, private providers suffered a liquidity crisis, itself propelled by the primary effects of lockdowns, government regulations and patient deferrals, and the secondary economic impacts of the pandemic. This led to a private sector response-involving, variously, hospital closures, furloughing of staff, refusals of treatment, and attempts to profit by gouging patients. A crisis in state and government relations has multiplied across LMICs. Amid widespread national governance failures-either crisis bound or historic-with regards to poorly resourced public health services and burgeoning private health-governments have responded with increasing legal and financial interventions into national health markets. In contrast, multilateral governance has been path dependent with regard to ongoing commitments to privately provided health. Indeed, the global financial institutions appear to be using the COVID crisis as a means to recommit to the roll out of markets in global health, this involving the further scaling back of the state.

Integrated HIV self-testing (HIVST) service delivery in Queensland for policy and service development: study protocol.

This study aims to pilot and evaluate an integrated model for HIV self-testing (HIVST) service delivery in a peer-led Queensland community setting to increase access to HIVST, particularly for men who have sex with men (MSM) living in regional, remote and rural areas. It seeks to provide evidence that would overcome some of the key objections previously raised to HIVST. Recruitment strategies have been designed to engage hard to reach MSM populations in testing. Awareness of the trial will be generated through advertising on social media platforms, including dating applications, word of mouth and HIV related websites. Participants will access an HIVST online ordering system hosted by a HIV community organisation. This system: (1) enables on-line informed consent; 2) gives clients the choice to accept verbal pre-test information from a trained peer test facilitator or not; and (3) allows for ordering of the HIVST kit after completion of an online survey (with demographic information and testing history etc.). Clients receive the kits via the post; and at 2 weeks receive a follow-up phone-call and SMS link to a post-test survey. If the test is non-reactive, clients can opt for test reminders. If reactive, referral to clinical services, peer navigation and support systems are provided. This study addresses important gaps in understanding of acceptable and feasible methods to integrate HIVST into an existing peer-led testing service and into the broader suite of HIV testing options and services. The findings will inform the actions needed to enhance access to HIVST for MSM wishing to use this technology in Australia and elsewhere, especially those who have never tested and infrequent testers.

Knowledge and awareness of HIV self-testing among Australian gay and bisexual men: a comparison of never, sub-optimal and optimal testers willingness to use.

This paper explores the willingness to use and pay for HIV Self-testing (HIVST) among Australian gay and bisexual men (GBM). Bivariate and univariate multinominal logistic regression of data from an online survey was performed. Thirty-one (13%) had never HIV tested and 41.9% (88) were testing sub-optimally by Australian guidelines. Half (58.4%, 136) had never heard of HIVST, however, 56.2% (131) reported willingness to use HIVST, with sub-optimal (OR=2.13; p < 0.01) and never-testers (OR=2.01; p < 0.10) significantly more likely to do so than optimal-testers. Most were confident (51.7%, 119) or somewhat confident (29.1%, 67) accessing support following a reactive result, however, never-testers were significantly less confident compared to previous testers (OR=3.47; p< 0.05). Less than a quarter (23.6%, 57) were willing to pay for a kit with AUD$15 (R2 = 0.9882) the estimated preferred price. This research confirms that HIVST is an important and accepted adjunct to established HIV testing modalities, particularly among sub-optimal and never-testers and that online (61.6%, 143) or clinic-based (61.6%, 143) dissemination are preferred. Research examining how best to disseminate HIVST in a range of safe and effective models needs to continue to ensure HIVST is part of a comprehensive strategy that facilitates usage and linkages to care.

Implications of the on-line market for regulation and uptake of HIV self-testing in Australia.

Self-Testing for HIV (HIVST) is widely recognised as a feasible and effective means of increasing rates of testing and detection of HIV, particularly in non-testing and infrequent testing populations. Currently in Australia, the only means of accessing this technology is to purchase unregulated products on-line. A search of available on-line distributers was purposefully performed from the perspective of an English-speaking individual, with no clinical background or specific understanding of HIV testing practices, seeking to determine their HIV status. Purchased kits were assessed against a structured extraction tool based on the Australian Therapeutic Goods Administration (TGA) HIV testing clinical performance guidelines. In total, eight HIVST kits were purchased from seven different distributers. Analysis of the purchased kits and linked websites revealed that none met the TGA's requirements for HIV testing kits intended for home use; none also conformed to the additional recommendations for information, quality and links to services developed from this study's review of HIVST associated literature. People seeking HIVST kits are able to purchase sub-standard products that ill-serve their needs, and do so at a time of great personal vulnerability. The fact that Australians are willing to purchase and use these sub-standard products indicates HIVST is in demand. Health policy and models of service are needed in order to ensure people have access to a safe and effective registered device at prices that enable equity of access to all Australians, particularly those most at risk of HIV. Other countries awaiting access to regulated HIVST devices also need to consider the potential implications. Collaboration between manufacturers, distributers, regulatory bodies, service providers and the community is needed globally in order to ensure HIVST is embedded into testing methods in a manner that does not disrupt but rather safely and effectively increases HIV testing rates.

Access to medicines and hepatitis C in Africa: can tiered pricing and voluntary licencing assure universal access, health equity and fairness?

BACKGROUND: The recent introduction of Direct Acting Antivirals (DAAs) for treating Hepatitis C Virus (HCV) can significantly assist in the world reaching the international target of elimination by 2030. Yet, the challenge facing many individuals and countries today lies with their ability to access these treatments due to their relatively high prices. Gilead Sciences applies differential pricing and licensing strategies arguing that this provides fairer and more equitable access to these life-saving medicines. This paper analyses the implications of Gilead's tiered pricing and voluntary licencing strategy for access to the DAAs. METHODS: We examined seven countries in Africa (Egypt, Ethiopia, Nigeria, Democratic Republic of Congo, Cameroon, Rwanda and South Africa) to assess their financial capacity to provide DAAs for the treatment of HCV under present voluntary licensing and tiered-pricing arrangements. These countries have been selected to explore the experience of countries with a range of different burdens of HCV and shared eligibility for supply by licensed generic producers or from discounted Gilead prices. RESULTS: The cost of 12-weeks of generic DAA varies from $684 per patient treated in Egypt to $750 per patient treated in other countries. These countries can also procure the same DAA for 12-weeks of treatment from the originator, Gilead, at a cost of $1200 per patient. The current prices of DAAs (both from generic and originator manufacturers) are much more than the median annual income per capita and the annual health budget of most of these countries. If governments alone were to bear the costs of universal treatment coverage, then the required additional health expenditure from present rates would range from a 4% increase in South Africa to a staggering 403% in Cameroon. CONCLUSION: The current arrangements for increasing access to DAAs, towards elimination of HCV, are facing challenges that would require increases in expenditure that are either too burdensome to governments or potentially so to individuals and families. Countries need to implement the flexibilities in the Doha Declaration on Trade Related Intellectual Property Rights agreement, including compulsory licensing and patent opposition. This also requires political commitment, financial will, global solidarity and civil society activism.

Cautionary Notes on a Global Tiered Pricing Framework for Medicines.

Recently, there has been a policy momentum toward creating a global tiered pricing framework, which would provide differentiated prices for medicines globally, based on each country's capacity to pay. We studied the most influential proposals for a tiered pricing framework since the 1995 World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights. We synthesized 6 critical questions to be addressed for a global framework to function and explored the many challenges of implementation. Although we acknowledge that there is the potential for an exceptional global commitment that would benefit both producers and those in developing countries in need of wider access to medicines, our greatest concern is to ensure that a global framework does not price out the poor from pharmaceutical markets nor threaten current flexibilities within the international patent regime.