Special clinical considerations
The rate of human immunodeficiency virus (HIV) infection is rising in Aboriginal and Torres Strait Islanders (hereafter referred to as Indigenous) Australians. Between 2013-2017, the age standardised rate of HIV notifications increased by 41% in Indigenous populations, compared to a 12% decline in Australian-born non-Indigenous people (1). Furthermore, a greater proportion of HIV notifications during 2015-2017 in Indigenous populations was ascribed to heterosexual sex (21%) and injecting drug use (18%), compared to Australian-born non-Indigenous populations (18% and 3%, respectively) (1).
There are few data currently available regarding pre-exposure prophylaxis (PrEP) knowledge, acceptability and use in Indigenous populations. Notably, 2.1% of participants in the Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) study identified as Indigenous (2) as did 2.94% in the QPrEPd study in Queensland (3). A recent qualitative analysis examined the obstacles to PrEP use faced by Indigenous men who have sex with men (MSM) (4). These obstacles included individual barriers, such as unwillingness for Indigenous MSM to identify with mainstream gay communities, stigma towards HIV and MSM within Indigenous communities and attitudinal differences towards the use of Western medicine (4). Provider barriers that were identified include overburdened and under-resourced Aboriginal medical services, a perceived lack of confidentiality in these services and a lack of government leadership and funding. Regarding the way forward, many respondents felt community involvement was essential for effective PrEP promotion and that sexual health and PrEP promotion should be better funded and driven by the community. Respondents felt that both mainstream sexual health clinics and Aboriginal Community Controlled Health Organisations can provide appropriate services, although general practitioners, nurses and indigenous health workers need to improve HIV and sexual literacy (4). Healthcare practitioners must provide an environment that does not stigmatise Indigenous patients. Health-care practitioners must take a careful and culturally appropriate history to ascertain risk factors for HIV infection and PrEP suitability and must provide appropriate treatment and referral to support people who inject drugs.
In 2017, the notification rate of newly diagnosed hepatitis B infection in Indigenous populations was more than double that of non-Indigenous population (45.1 per 100,000 versus 19.2 per 100,000) (5). Given the higher rates of hepatitis B infection in Indigenous versus non-Indigenous people, clinicians caring for Indigenous patients must carefully follow these ASHM PrEP guidelines and screen for hepatitis B infection and, as required, provide hepatitis B vaccinations. Note that people with chronic hepatitis B should only be offered daily PrEP to maintain sustained virological suppression of hepatitis B.