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In Australia HIV notifications are increasing among overseas-born men who have sex with men (MSM) and particularly among Asian-born MSM.1 Despite the ‘test and treat early’ paradigm in Australia, a steady proportion of people are diagnosed with late HIV infection and a large proportion (35%) of these are from East Asian countries.1 Globally, marginalised populations are reported to experience inequalities in treatment uptake and response. Although these inequalities are not consistent across all ethnic subpopulations,2 and once accounting for CD4 count at diagnosis, ethnicity might not be a factor at all.3 Australian evidence suggests that culturally and/or linguistically diverse populations are less likely to start treatment early irrespective of CD4 cell count at diagnosis,4 but little is known about response once in care. The Australian HIV Observational Database (AHOD) is used to investigate treatment response in overseas-born MSM from non-English-speaking countries compared with Australian-born MSM, further categorised based on participation in the Australian Temporary Residents Access Study (ATRAS).5 The Australian government provides fully subsidised antiretroviral therapy (ART) through the Pharmaceutical Benefits Scheme, but to receive ART patients must be entitled to a Medicare card. ATRAS participants were temporary residents ineligible for Medicare and were chosen as the closest surrogate to identifying the newly arrived overseas-born MSM. Time to first virological suppression (VS) (viral load (VL) <400 copies/mL) and time to virological failure (VF) (>400 copies/mL after suppression) were assessed. The definition of VS at <400 copies/mL was chosen as AHOD includes patients commencing ART as early as 1997. A current cut-point at <50 copies/mL with restriction to treatment initiation after 2007 was performed as a sensitivity analysis. CD4 cell counts and VL measurements were taken at treatment initiation; adjusted HRs (aHRs) are reported with 95% CI.
Our results, as shown in table 1, indicate that overseas-born MSM did not differ significantly in the rate of VS (aHR 1.01, 95% CI 0.86 to 1.17) or in the rate of first VF after suppression (aHR 0.93, 95% CI 0.71 to 1.21).
This result is different from findings in other settings,2 6 and differences may, in part, be explained by the nature of healthcare provision. In Australia, all residents can access ART for free or with a small co-payment; those ineligible for Medicare can get pharmaceutical company-provided ART which is not necessarily straightforward for non-English speakers.
Newly arrived overseas-born MSM are most likely to experience a delayed diagnosis.7 Late diagnosis can be a result of barriers to engagement with the health system and isolation from community campaigns, fear of disclosure, concerns over cost of consultations, language barriers and a lack of a sexual health screening culture, and/or experience with criminalisation in home countries.8 Similarly, marginalised populations are more likely to experience lower levels of retention in care,9 and this could be for several reasons including expense and/or language barriers.
Once treatment access has been ensured, overseas-born MSM have similar treatment response to Australian-born MSM. Ensuring early engagement and access to treatment for overseas-born people with HIV remains a priority.
Handling editor Anna Maria Geretti
Collaborators Australian HIV Observational Database contributors: New South Wales: D Ellis, Plaza Medical Centre, Coffs Harbour; M Bloch, T Vincent, Holdsworth House Medical Practice, Sydney; D Allen, Holden Street Clinic, Gosford; D Smith, A Rankin, Lismore Sexual Health & AIDS Services, Lismore; D Baker, East Sydney Doctors, Surry Hills; DJ Templeton, N Manokaran, R Jackson, RPA Sexual Health, Camperdown; E Jackson, K McCallum, Nepean and Blue Mountains Sexual Health and HIV Clinic, Penrith; N Ryder, G Sweeney, B Moran, Clinic 468, HNE Sexual Health, Tamworth; A Carr, K Hesse, T Chronopoulos, St Vincent’s Hospital, Darlinghurst; R Finlayson, C Tan, J Le, Taylor Square Private Clinic, Darlinghurst; K Brown, V Aldous, JL Little, Illawarra Sexual Health Service, Warrawong; R Varma, H Lu, Sydney Sexual Health Centre, Sydney; D Couldwell, J Walsh, Western Sydney Sexual Health Clinic; DE Smith, V Furner, D Smith, Albion Street Centre; S Fernando, Clinic 16 Royal North Shore Hospital; A Cogle, National Association of People Living With HIV/AIDS; C Lawrence, National Aboriginal Community Controlled Health Organisation; B Mulhall, Department of Public Health and Community Medicine, University of Sydney; M Boyd, University of Adelaide; M Law, K Petoumenos, R Puhr, J Hutchinson, T Dougherty, The Kirby Institute, University of NSW. Northern Territory: M Gunathilake, K Jackson, Centre for Disease Control, Darwin. Queensland: M O’Sullivan, S White, Gold Coast Sexual Health Clinic, Southport; D Russell, F Bassett, M Rodriguez, Cairns Sexual Health Service, Cairns; D Sowden, K Taing, P Smith, Clinic 87, Sunshine Coast Hospital and Health Service, Nambour; D Orth, D Youds, Gladstone Road Medical Centre, Highgate Hill; D Rowling, J Langton-Lockton, N Latch, F Taylor, Sexual Health and HIV Service in Metro North, Brisbane; B Dickson, CaraData. South Australia: W Donohue, O’Brien Street General Practice, Adelaide. Victoria: R Moore, S Edwards, S Boyd, Northside Clinic, North Fitzroy; NJ Roth, H Lau, Prahran Market Clinic, South Yarra; T Read, J Silvers, W Zeng, Melbourne Sexual Health Centre, Melbourne; J Hoy, M Giles, K Watson, M Bryant, S Price, The Alfred Hospital, Melbourne; I Woolley, T Korman, J O’Bryan, K Cisera, Monash Medical Centre, Clayton. Western Australia: D Nolan, A Allen, G Guelfi, Department of Clinical Immunology, Royal Perth Hospital, Perth. New Zealand: G Mills, C Wharry, Waikato District Hospital Hamilton; N Raymond, K Bargh, Wellington Hospital, Wellington.
Contributors JLH wrote the first draft of the manuscript and performed all statistical analyses. DAL, ML, BRB, RP and KP provided clinical advice and expertise and played a substantial part in the interpretation of results and editing of the final report. KP developed the initial concept.
Funding The Australian HIV Observational Database is funded as part of the Asia Pacific HIV Observational Database, a programme of the Foundation for AIDS Research, amfAR, and is supported in part by grant no U01-AI069907 from the US National Institutes of Health with funding provided by the National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, and the National Institute on Drug Abuse, and by unconditional grants from ViiV Healthcare, Janssen-Cilag and Gilead Sciences. The Kirby Institute is funded by the Australian Government Department of Health and is affiliated with the Faculty of Medicine, UNSW, Australia.
Disclaimer The content is solely the responsibility of the authors and the views expressed in this publication do not necessarily represent the position of the Australian Government or the official views of any of the governments, institutions or funders mentioned above.
Competing interests None declared.
Patient consent for publication Obtained.
Ethics approval The study was approved by the St Vincent's Hospital Human Research Ethics Committee (IRB00002019).
Provenance and peer review Not commissioned; internally peer reviewed.
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