Sexual health care for Aboriginal and Torres Strait Islander patients in NSW
Serena
Welcome to this evening's forum, Sexual Health care for Aboriginal and Torres Strait Islander patients in New South Wales. My name is Serena, your RACGP representative for this evening. We are joined by our speakers Dr Tim Senior, Dr Annalyse Crean, and Jess Wilms. Before we get started, I would like to make acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders, past, present and emerging. I would also like to acknowledge any Aboriginal or Torres Strait Islander colleagues that have joined us online this evening. There are speakers for this evening. Tim is a GP at Tharawal Aboriginal corporation in southwest Sydney. He is a medical advisory to the RACGP in Aboriginal and Torres Strait Islander Health and is a clinical senior lecturer in General practice and Indigenous Health at the University of Western Sydney. Anna is a GP with a special interest in aviation medicine. She is a Kamilaroi woman with family from Murri and Tingha. Anna co-owns two large GP practices in the southern Sutherland Shire. As a passionate about menopause, medicine and all kinds of families, she is a mum of three sporty kids, a Qantas wife and petrol captain at Cronulla SLSC where she had a dreadful fear of sharks but loves ocean swimming. Jess is a Wiradjuri woman. She is an Aboriginal sexual health education officer for the Nepean Blue Mountains Local Health District. She co-leads the statewide Aboriginal Sexual Health Portfolio for New South Wales Health and sits on the working groups for Take Blaktion and Play Safe Pro. Jess work alongside community creating safe, inclusive environments. She is passionate about safe and equitable healthcare for all and tackling stigma and discrimination faced by Aboriginal and LGBTQIA+ communities. I will now hand it over to Tim who will be going through the learning objectives.
Dr Tim Senior
Good evening everyone. Thank you so much for joining us tonight. I am coming to you from Tharawal country where the land that I live and work on. These are our learning objectives for tonight, which is essentially educational speak for what we hope to get out of the next hour or so. By the end of this online CPD activity, we should all be able to build our own confidence in delivering culturally safe, respectful and effective sexual health care for Aboriginal and Torres Strait Islander people. We should be able to explore models of care that identify at risk populations, enhance STI, HIV and BBV testing rates, and equip GPs with strategies for partner notification, contact tracing and ongoing patient support. We should all be able to maximise the impact of the Aboriginal health check MBS Item number 715 by integrating it into primary care to improve early detection, prevention and health outcomes and we should all be able to reflect on epidemiological data and historical context to gain a deeper understanding of the healthcare experiences of Aboriginal and Torres Strait Islander people in our local communities, and consider how these factors shape engagement with primary care.
Like any good medical education talk, we start off with some epidemiology and everyone with heart leaps at the idea of some statistics, but if we move on to the next slide, it is really important as I have learned this as a non-Indigenous GP, that it is very easy for us to start thinking about Aboriginal and Torres Strait Islander health as if it is just a collection of diseases and bad statistics. The thing that I have learned is that we start asking the wrong questions, and actually when I am showing these statistics that inform what we are doing, there are reasons behind that, and it is not until we understand the reasons and that we listen to our Aboriginal and Torres Strait Islander colleagues and Aboriginal and Torres Strait Islander patients that we start to understand the reasons behind the statistics, and that is when we start to actually improve what we are able to do. I raised that important context, I think in the statistics that we are about to go through and for the for the webinar tonight as being the non-Indigenous person facilitating the panel tonight.
This is the population of Aboriginal Torres Strait Islander people across Australia, and because we are the New South Wales faculty, we have highlighted the New South Wales faculty numbers. The highest proportion of Aboriginal Torres Strait Islander people live in New South Wales, and actually it is 35% of the Aboriginal Torres Strait Islander Thailand population who are in New South Wales, second highest is in Queensland, and so in absolute numbers at extrapolated from the census is close to 340,000 Aboriginal and Islander people. The meaning for that is that they are not all living in one place, and that wherever we are, we will have Aboriginal and Torres Strait Islander people in our communities, and coming to see us as patients. That is important for us to recognise, and identification of those people is really important because it affects our clinical care.
This is the notification rates for different STIs and bloodborne viruses, and it compares Aboriginal and Torres Strait Islander people and non-Indigenous people, and then because of the different age rates in the two populations epidemiologically, it standardises that according to and then sets it out as a rate per 100,000 people. You can see the rates there for chlamydia. You can see it highlighted in red there, but I am also going to concentrate on the fold difference. For chlamydia, it is two-fold higher. In Aboriginal and Torres Strait Islander people gonorrhoea is four-fold higher. Syphilis is nearly five times higher in Aboriginal Torres Strait Islander people. HIV and hepatitis B are much closer to similar rates, but newly diagnosed hepatitis C is over six times higher. Now, the important thing about that is that the rates are much higher than we would expect per 100,000 population. The absolute numbers are higher in the non-indigenous populations simply because the numbers of people in those populations are higher. So again, this is why it is important for us to identify our Aboriginal Torres Strait Islander patients, I think.
This goes on age standardised STI notification rates. This is nationally. I think the previous one excluded some jurisdictions, and syphilis is a real standout there as nearly five times higher in Aboriginal and Islander people. Still chlamydia is twice as high in gonorrhoea is four times as high. It is really important that we are identifying this. The next slide shows the main reason why syphilis is so important because the consequences of congenital syphilis are so high, and this shows each year since 2019, the cases in Aboriginal and Torres Strait Islander people of syphilis reported and in non-Indigenous people. We can just see the numbers have gone up each year. Now the absolute numbers are not high, but that is a significant increase, and that will keep on going up if we are not identifying those patients, and we will be saying quite a bit today about how we identify and that is partly testing, but it is also giving the conditions that in our practices that people feel comfortable seeing us and talking to us and, and being tested. If we do not do that, these numbers will only go up because of course it is sexually transmitted.
This is an interpretation of those increases along with a considerable increase in the number of congenital syphilis cases, and that is really important because the consequences of congenital syphilis are huge, and that emphasises the need to enhance culturally appropriate health promotion, testing and treatment strategies in partnership with Aboriginal Torres Strait Islander stakeholders and communities, and that is part of what we are doing tonight. Those numbers go up when people do not feel comfortable accessing healthcare, and also education. When people are unemployed and live in poverty and experience discrimination and racism and expect that they might experience discrimination and racism, people do not go to get tested. They do not trust the treatment, and so those figures keep on increasing. While we are providing clinical care, it is really important that we acknowledge those social circumstances that people live in have an impact in the way they are relating to us and the way they are choosing to seek care, and the bottom line for me is that every Aboriginal Torres Strait Islander person in Australia should be able to choose to access care wherever they want and be confident of getting good care.
I am going to hand over to Annalyese to start us off on discussing some of the solutions to the surface statistics that we have just seen.
Dr Annalyse Crane
Thanks, Tim. As I was introduced, I am a GP in southern Sydney and most of us listening here today are also GPs. I want you to think about your practice and the cohort of patients that you see, and if you see 100 patients in a week, it is highly probable that 2 or 3 of those patients will identify as Aboriginal and/or Torres Strait Islander. You may have a family in your practice where you might see the mum, someone else might see the dad, someone else might see the kids. How are you bringing all of that care back together? It is really important to look at, as we have said, making sure those patients are identified and that box is ticked. Do they identify as Aboriginal? Are they signed up to CTG? Are they signed up to the practice incentives for your practice so that you are able to provide them with the best model of care to service their needs?
I am going to introduce you to a case study that hopefully you can relate to in your practice. Some of you might do GP shared care. This is a patient that I have concocted up but also comes from experience of patient experiences that we have heard about. You have got Jannali. She lives in Sydney in the inner West, and she is a 32-year-old professional. She is presented to you eight weeks pregnant. She is asked to birth at RPA hospital in Newtown there, and she wants to do shared care. This could be any one of your patients. It could be any of your shared care patients. When you encounter her as this 32-year-old professional with her first pregnancy, what would you do differently if she was Aboriginal?
My question to you is if that woman was sitting in front of you, would you know what to do differently? Would you need to do anything differently? And how are you going to offer her culturally appropriate care? I think firstly, going right, I can provide shared care. I am good at being a GP and doing that, knowing what your capabilities are and then looking at right, she is going to have her initial lot of screening antenatal bloods. Do you need to do anything differently for her? We all everyone who presents gets tested for syphilis. Not everyone necessarily may get a urine chlamydia and gonorrhoea. Does this woman need it? What other services in your local community could you link this woman up with? For example, did you know that RPA has a specialist program for women who identify as indigenous to be managed within RPA hospital a little bit like group midwifery practice, where they may see the same team of midwives throughout their care or those midwives are able to link them in with other services down the track, such as early childhood services, allied health and other things that they may need. It is knowing what is available to you locally, but also I think the stop point here is do not just assume because she is Aboriginal that she does need something different, but because she is Aboriginal, it is possible that she may have a different risk profile.
Before I flip the script and we go a little bit rogue, just think again back to Jannali, and perhaps it is a good opportunity for you to think about this for your Q&A later if you saw Jannali in North Sydney or you saw her in Penrith or you saw her in Cronulla, what would you do for her in that initial consult? That is different. Would you automatically assume she was a high-risk patient? She might be the principal of the local high school. She might be a nurse in your local area health service. How does she present compared to every other 32-year-old antenatal patient that you have seen? We will go through some of those scenarios in a little bit more depth soon, but I suppose what I am going to ask now is if Jannali was male, what would you do? Of course, probably would not be presenting for antenatal care, but if you had a 32-year-old professional who identifies as Aboriginal and Torres Strait Islander and they were a guy, what may you need to do differently? I suppose in my practice, I offer STI screening to everyone under the age of 30. You should have a test at least once a year, if not twice a year. If you have got high risk patients who are having multiple sexual partners or they are employed in that industry, they may need to have more frequent tests than that. Similarly, if Jannali happened to be a gay male, what would you do differently? Would you offer syphilis testing whether he was Aboriginal or not? We have certainly looked at the numbers that Tim has discussed and identify that, yes, the raw numbers show that there is increased risk, but you need to make that reflective to your practice and your community and the cohort of patients that you see without assumptions and presumptions there.
I think this is really interesting again. As I work in a private billing normal general practice, Tim works in an Aboriginal medical service. Jess works in a hospital health service more of a community setting. Therefore, who we see our patient demographic is slightly different, but what is not different is how we communicate with our patients, how we explain to them what to expect when you are expecting, what to expect out of that consultation, and of course, it is respect and rapport and making sure the patient is in control of their own journey, and that could be, Jannali, you are pregnant. As a part of your routine antenatal testing, we would like your permission to order these STI tests that will involve a blood test and a urine test. and all of the women in New South Wales are offered these tests. It is about protecting you and protecting the baby and able to offer treatment if necessary because we have certainly heard of scenarios where tests were provided to the patient and there was no informed consent. Patients were just assumed to be at high risk and therefore additional tests without any informed patient involvement were made, and I think also looking at how do we improve birth outcomes, antenatal outcomes, general women's health by including them in that process and explaining it in a way not everyone understands transmission of STIs. We do not know the dynamics of people's relationships, and again, we do not know the type of relationship people are in unless we actually have that conversation and a GP is best suited to do that. I would argue we know our patients well once we have that established relationship with them, and similarly, if Jannali was a male, what assumptions are we making? Are we assuming Jannali is gay? Are we assuming Jannali has one sexual partner?
I think is this the bit where Jess is going to start to talk or is this still me? And then I am getting stone cold silence from Tim. We will just we will flip that one and we will come back to it, but of course, some of these future slides are looking at how we notify people, how we communicate that information and how we set out those expectations, and I am really hoping that Jess is now going to take over and know exactly what these next slides are about.
Dr Tim Senior
We were going to go over about the importance of contact tracing and patient referring for that, and I think that highlight there is all of these different resources that can do that. Drama down under is really geared towards men who have sex with men, and so it communicates in that way. There is let them know, which is a fairly more generic one for the purposes of what we are talking about today. Better to know is really excellent for Aboriginal and Torres Strait Islander people set up for that, and that allows people to notify partners that they have had by SMS text message without the partner necessarily knowing who it is, who has sent it. Those are really useful tools for us as GPs to enable partner notification to happen. The sexual health info link now I have come across these people before and they are really helpful that if we are feeling a bit stuck or not quite sure what to do or difficulty with contact tracing, they can give us advice on doing that, and I think we are all from Sydney, but the so that is quite metro centric, but the sexual health clinics and particularly sexual health info link are able to provide advice when there is not a sexual health clinic anywhere near you might not be any specialists near you, and that is a really good resource for people to be able to do that.
Dr Annalyse Crane
Especially if they are for infections that you may not come across very frequently. I know that earlier in the year, in one of my other job roles, we needed to do some test and treat for MPOX, and of course, that was something that I was not necessarily familiar with in a suburban setting. However, we were able to speak to public health Unit and speak to other and our local short street clinic to be able to get the advice and then also to order in vaccines and be able to provide that service.
Jessica Wilms
Warami, everyone, from Dharug Land. I am Jess, a proud Wiradjuri woman. I am an Aboriginal health education officer within a local health district. I work for New South Wales Health. I am going to talk a bit about 715 and how we can utilise them to get better outcomes for Aboriginal people when it comes to sexual health.
715 are health checks are a great way for people to access sexual health screening in a safe space. They are an annual holistic health check for Aboriginal and Torres Strait Islander people, and they are very normal and embraced within Aboriginal communities are often mob are really embarrassed or ashamed to go and get a sexual health screening, building it into their 715 is a great way to take the pressure off them and to try and engage them in services. The 715 is a preventative health measure. It focuses on having a proactive health behaviour as opposed to a reactive one, which is often what we see when it comes to sexual health. A really good opportunity for practitioners to promote regular STI testing between 715 and link it into their 715 so people can go back under the guise of getting a general blood tests, that kind of thing, without them needing to disclose that they are getting a sexual health screening. Therefore, it removes the stigma around actively seeking testing and allows for that regular monitoring and provide pathways for additional services. In the 715 screening here, when it comes down to the sexual health question, is there anything you are worried about in relation to your sexual health. Yes or no? So that question is quite vague, and in my view, not a very strength based way of asking about people's sexual health. Sex, sexual health, contraception, all those kinds of things are very uncomfortable topics for a lot of community, and you need to go out and explain the questions and explain to people that those questions are going to come up and letting people know that there is no right or wrong answer, that they are not going to get it wrong, that they are not going to get into trouble, and that it is not mandatory to answer to complete their 715. I think a lot of the time mob think that they need to answer everything in because health systems are seen as a very punitive kind of measure in a lot of communities. We need to make it really safe and really clear that people can answer what they are comfortable with, and I think analysts went into this a bit like giving context to why you are asking questions so that you can get as much information from the health assessment as you can and explaining that it is completely confidential and that practitioners can give some of those details and ways to refer people to more culturally appropriate services if they feel that that is necessary.
There is a lot of resources out there for GPs when it comes to 715s. Pictured here are a couple that have been done in conjunction with NACCHO and RACGP. They give you some information on how to be a bit more culturally competent. How to ask questions. What is required when you are doing a 715? And there is also some information here you will see on the right from the health.gov.au kind of services. You can look at those and getting some more information, and there is a few more on the gov website that are really great as well.
There are many resources that you can access when it comes to Aboriginal sexual health. I am just going to cover a few that I use quite regularly, but if you do a bit of a Google deep dive, there is plenty out there not only from New South Wales but also other states that are really relevant. I saw something from shine SA in an earlier slide which have great resources as well. We have covered better to know as somewhere where we can use for contact tracing, but they also have really comprehensive sexual health information and as you can see here on their website they cover 715 health check stuff specifically. They also have a Remind Me page, which can get people to put their phone number in, and they get a reminder to let them know that it is time to go and get an STI check, which is a great option for a lot of people that cannot actively remember that they need to do those kinds of things. There are also service directories for sexual health info for AMS, HIV support services, all that kind of stuff, and they also have a really great resource page for national resources. For mob that is not based in New South Wales but might be accessing services within New South Wales while they are here gives you some options on where to refer people Interstate. In the middle here, we have the Aboriginal Health and Medical Research Counsel's printable resource that comes from they are doing it right training. That is training specifically around really extensive options for people to know how to do sexual health conversations, screenings, all that kind of stuff, and you can download this resource. It has a lot of information in it. It is a pamphlet so it covers a lot of different topics. Really well done, and it is done by Aboriginal people for Aboriginal people. It is a really great option if you have a client that maybe needs a bit more information, needs a bit of time to go away and think about things. Also, people that are just not keen to have a chat. It is great to have those options just sitting around so people can access them. On the right here, we have some research done by D4 Heather McCormack, who is a research fellow at the Kirby Institute at UNSW. Heather did her PhD on optimising annual routine health assessments to increase testing for sexually transmissible infections and HIV in Aboriginal and Torres Strait Islander young people. Her research is centred entirely around how 715 are vital to improving the sexual health of Aboriginal young people, and also this information can be provided in context for Aboriginal adults as well. It is perfectly placed to help you gain further knowledge and insight into how you can do it well. You can find her articles and her papers on her UNSW page or on her website, which I have linked in a later slide.
Play Safe Pro is something that we provide a lot of information about in the services that I do out in community. It is something that we push really hard for people to have a look at, because it is done by people that work in sexual health all day, every day. It is about making sure that we have options for all kinds of workers that work with community, young people, that kind of thing. Play Safe Pro has this checklist here, which is a youth friendly checklist which is for general practitioners, and it is a tip sheet on how to ask sexual health questions in a casual, relaxed kind of way that is going to help engage young people. Many of the tips on the sheet also work for mob and part of it is about making physical spaces more welcoming, about looking at your cohort and figuring out how you can make your space less clinical and less sterile. Ways you can do this for Aboriginal people is perhaps having an acknowledgement of country on your wall or on one of your screens. Looking at putting up some artwork, that kind of thing. It is about showing genuine care and compassion for your mob. From the reception staff to the doctors and nurses in your practice. It is about knowing which of your patients are Aboriginal and knowing more than that, who their mob is and what does their family look like? This is not a performative exercise. The whole practice needs to be culturally appropriate. More damage can be done than good can come from well-meaning but poorly executed endeavours. On Play Safe Pro in the middle here, you will see ‘take action’ which is also a service done by Aboriginal workers for Aboriginal community. You will see here a fact sheet which literally walks you through. I think there is ten steps on it about engaging with Aboriginal people. Again, it is about knowing people, asking them who their mob is, finding ways to have those conversations in a culturally appropriate way. There is step by step guide on working around sexual health with mob includes things like do your patients want an Aboriginal health worker? Would you know where to access an Aboriginal health worker? Is there anything that is culturally inappropriate to be done in regards to men's and women's business? Do you need to refer that person onto a different GP so that their sexual health needs can be met in a culturally appropriate way? All these are questions to ask of your patient. No two people are the same, so you need to find out what works for mob. What happens in Sutherland might not work out in Penrith. It is about each community, each person being different. They need to lead this and it is about being respectful and curious. You are rarely going to receive a complaint from someone because you tried to meet their cultural needs, but more will speak with their feet if they do not feel safe in your practice. Start by finding out who they are, who their family is and what that looks like for them. We are people and we are not a tick a box. I would be really interested to find out who remembers who my mob is from the start of my preso and also where I live because I acknowledged both of those at the start.
Down the side here, you will see a bunch of resources that I have spoken about, and I would love for you to take a look at the Take Action page. There is a video tab up the top where you can see a bunch of videos and skits done for community by the Ministry of Health. Done in a really fun, humorous kind of way, which is how we engage with people. Looking at the resources that they have on Play Safe Pro. There are so many things that are great, 144 free condoms for your practice each month, all those kinds of things. Trauma informed care booklets. We have a Talk Soon Talk Often booklet which can be put out in waiting rooms about talking to children about their bodies, puberty, sex. There is a Yarning Quiet Ways one coming soon which is an Aboriginal version adapted from WA. There are lots of different options that you can put around your service to make sure that it is more culturally appropriate and welcoming.
Finally, this is a piece of art that was done by all the Aboriginal sexual health workers from across New South Wales. We get to come together once a year from across the state and talk about what is important to our community and what we need to do to have better health outcomes for our community, which is how this came about for me being here tonight is that we have a representative showing you what we need and how we need it. Every health district in the state has a sexual health blood borne virus and STI team. Within those, a lot of them have an Aboriginal worker like me. If you need any answers or you have any questions, all you need to do is reach out. We are there to help you do this better and we are there to help you to know where to start. My contact details will be at the end, so if you have anything that you want to ask me, please feel free and also in the chat box. Thank you.
Dr Tim Senior
Excellent. Thank you very much. That was really good. We are going to move on to a panel discussion where I fire questions at Annalyse and Jess where we bring all that together about how we use 715. We will think about Jannali and some people like Jannali in working out how we actually put this into practical action. As we go through this, think about your own practices and your own communities and what might work in your areas where you can steal ideas from other people. I think all of this has to be localised, it is about knowing our own communities.
We will move on to the next slide. At some point as well, Serena, we might pop back to the some of the questions that we had about Jannali as well because I think that will inform some of our discussions. I would like to ask Jess first, actually. From what you know about the way that the contact you have had with people across different sections of the health system in talking about sexual health history, what are ways that we as GPs can do it better?
Jessica Wilms
Giving context to why you are asking the questions. People will go in having some knowledge of what an STI or BBV test would be, but probably would not have the context of history taking all those kinds of things. It is about explaining to people. We do not want to know everyone you have slept with. We do not need to know all the details, but we are just trying to get a bit of an idea about what has been happening, what kind of tests you are going to need, that kind of thing. It is all about providing as much knowledge as you can to people because a lot of discomfort and shame comes from fear of not knowing what is coming. Giving good information and providing that before you start asking the questions is really important.
Dr Tim Senior
Absolutely. Annalyse, what you have heard from patients? How can we improve doing this as GPs?
Dr Annalyse Crane
I have just lost the entire WiFi in my whole house, so I am now running off my phone, and of course my children are screaming that the internet has gone off. I have just missed the whole last 5 minutes and have no idea where we are. Looking at this question in front of me, looking at the context of who is sitting in front of you and what you think is clinically appropriate at the time. For example, the 32-year-old professional may not need high risk screening at regular intervals throughout her pregnancy if she is in a monogamous, married relationship for the last 10 years. Again, knowing that it is an open door where they can come and ask questions and have appropriate tests, for example, when they present for their self-collect HPV screening, saying we offer all women the opportunity to do a urine PCR or a swab or all of our men may be offered x, y, z. Knowing that relationship goes back and forth between both of us.
Dr Tim Senior
Thank you. There are some themes that I have picked out from what you both have been saying earlier as well. I am really struck by being aware how often people have had a bad experience in the health system before they come and see us, and that seems really common and that they often come to us expecting another bad experience. If we are aware of that, then we can do everything we possibly can to say, look, I understand that and it will make this experience not a repeat of your bad experiences. With STIs, often it is quite secret stuff, so they are only seeing us. One of the advantages we have in general practice is they are sat in our waiting room, an auntie comes in and goes, "oh yes, I am just coming about my sore elbow" and then come in and ask about the discharge that they have got. If you sat in the waiting room of a sexual health clinic, everyone knows why you are there. We have this advantage in general practice of reassuring people about confidentiality. No one can guess the reason that people are there, which means that they can come. The other thing that I took from one of the things that both of you said is that this giving information beforehand, this making sure you get consent and explaining the tests and things is allowing people to have control over their own healthcare and their own decisions. Too often people are bounced into doing "well, you have got to do this". In the case of Jannali, I feel she is going to be in hospital or being coming into contact with midwives who may well say "no, you are an Aboriginal, you have got to do this". To some extent, when we are making those decisions, we are also protecting people from the rest of the health system making different decisions. Sometimes I say to my patients look, they are going to annoy you in the hospital. Do not do not fight back. Do not answer. Come back to me and moan in my consulting room. Come back and have a shout with me and come back and just moan about it with me. We will be your release valve for that just because we know that can happen. This idea of allowing people to keep control over their healthcare as they go through it. I have learnt again as a non-indigenous person, this will be different for Annalyse and Jessica because they will be able to say things to patients that I cannot get away with. Where people like me in positions of power, non-indigenous people, have been telling Aboriginal people what to do for over 200 years now and it is rubbish. Giving people that control is actually really important. People understand that historical context. Jess, I am sure you can say things to patients about, well no, you really need this test done, getting them have it done that I would actually just have people walk out if I said that to them.
Jessica Wilms
I think it is hard in the hospital system. You are completely right. Having an advocate that you know, knows you and knows your needs and knows your context because you do walk into a hospital and you have the little flag pop up. You are not asked for consent and you are not asked your history or treated as a person, you are treated as a number. That is the advantage of accessing a GP for community. We talk a lot about accessing, like you work at Tharawal, so a lot of mob often are reluctant to go to an AMS because they have family there or have all that kind of stuff. Even though you can tell them that their information is confidential, it is still a worry. That is why events like this are amazing to try and upskill general GPs to be a safe space for mob to go to because we do not want them having to go to a sexual health clinic because it is not a positive experience a lot of the time.
Dr Tim Senior
Absolutely. The other thing, just on this question, what you were saying, Jess, about the importance of Aboriginal health assessments actually makes taking a sexual health history easier because we can say "look, we are testing over your whole health. That includes your sexual health as well. We ask everyone these questions, and so do you mind if I just ask you these questions too?" It normalises it that this is a legitimate part of the consultation that we ask everyone as part of preventive health. If that is all right, we will do that. It does not look like prying because it is part of a health assessment, so that gives us another opportunity to ask those questions and make it a normal part of asking.
Jessica Wilms
Yeah.
Dr Tim Senior
This is moving on to talking about the results that we get with patients. For a patient often, a positive result for an STI or for a blood borne virus is terribly bad news. Any advice for how we go about giving those results?
Dr Annalyse Crane
I am just going to start that 20 odd years ago, I worked in a small Riverina town near Griffith and was given bad news over the phone on a Friday afternoon as a young person. It was actually probably part of the reason why I decided to become a doctor so that nobody else would ever have that experience ever again. It was like the perfect storm and I think most of us as experienced GPs know how to set that groundwork. It has been really interesting to observe our registrars in our local community as well. Those skills do not come naturally for some people. The classic starting point is if you order a test, make sure the person understands what the result may mean. My colleague who is also listening in here tonight, the patient walks out of the door knowing I will contact you by SMS, by email. I will phone you, I will schedule you an appointment or you are having a test on Monday. Come back and see me on Thursday so that you know they are going to receive that information on Thursday in front of you when that is what they are coming for. If you are telling someone they have got chlamydia versus you are telling someone they have got syphilis or HIV, we do not know how they are going to understand that because we do not know what their health literacy is. We do not know what their past experiences, family experiences are with those other diseases. I was actually speaking to a patient on the weekend who works as a remote area nurse in another state, and she said, we literally chase people into the bush to try and go "we need to treat you for this infection. Please come into town, please" or she is providing that service on the ground in the community. We are lucky, in New South Wales, we have buildings. We see most of our patients in buildings or even in gardens and outside environments, but we are probably giving them penicillin for syphilis inside. That context is really important. Again, setting it up, if it is an antenatal patient or it is a mother going "this is for you and your family", that mantra works well. Going "it is not just about you, it is about your kids. It is about your ability to care for your family. It is about your relationships and your job and your social responsibilities." It is not just "you are a bad person. You have got syphilis. We need to give you these large needles in your bum". It is "if we test and treat now, this will stop it in its tracks". Clearly that message is being watered down a little bit because we have got increased cases of syphilis. It is also looking at "does anybody know how much these medications cost". A week of doxycycline versus a month of doxycycline versus Benpen injections. They are all luxuries, if you have got a pharmacy nearby or you are working in an AMS where those medications may be provided as a part of the service. Even if they are signed up to CTG where they are getting discounted PBS medications, they are not always going to have $10, $20, $30 to be able to return. One of the questions in the Q&A box is, well, what about the transport to get to the service? My practice is next to a train line. If you do not have a car, you can get there, but if you have a disability and you need to come with a carer, you have to line it up on a day that they can bring you. There is often logistics that we do not think about once the patient sits in the little box that is our consultation room.
Dr Tim Senior
Specifically on the transport one, at Tharawal, Aboriginal Medical Services often offer transport to their patients. The Aboriginal chronic care teams in your local areas, they often offer transport to patients to appointments. Sometimes there is community transport. The Gandangara Land Council in Liverpool do transport for many of our patients. In our area, we have Southwest Community Transport where for a fee of $2, you can book and get that. Many areas across New South Wales will have similar schemes to that. We often do not know about those, but it is worth finding out why transport is a particular issue. Sometimes in rural and particularly more remote areas, there are patient travel programs. Sadly, I am more familiar ones with the ones in Northern Territory than in New South Wales, but I know they do exist. Finding out about those from your local health districts will be really useful as well. There are solutions to those problems, but they often take a little bit of digging just to get to the local particular solution because they often arise from local need. Thank you for answering those because that was really useful. One of my favourite bits of evidence is that if you explain to people, not specifically for STI testing, but if you explain to people the potential results of a test before you do the test and particularly of a normal test, then that actually allays anxiety more than explaining a normal test result after the test when they get it. Actually, I very often explain the test and the reasons that we are doing it and the results that we expect and what I expect to get from that so that people are primed in advance for those expectations.
I just want to ask you Jess, what do you think has done well and what has done poorly in sexual health particularly?
Jessica Wilms
I think coming from a health promotion kind of background, I think health promotion has not done well, which is why I have a job. It is about looking at ways of communicating health messaging in a way that works for community. I think a lot of the time it comes from a medical background. Those kinds of things and community just do not understand what you are trying to tell them. It is about linking in with services. If you have a cohort of patients and you are like, what is happening? Why do we have this huge pocket of syphilis like we have that where I am we have a pocket of gonorrhoea at the moment. It is like, well why is not that messaging getting through? It is about trying to link in, and I think medical services and health promotion and all those kinds of things, we are all siloed and we do not work well together. It is about finding ways, linking into the PH, and I know we are always throwing things into their newsletter, but really utilising the services that are around. We do not do that well enough. Getting out into community, like if you work in a community that has a high Aboriginal population, go out to NAIDOC, go say hello to people because it will do so much groundwork to proving yourself in community and showing that you genuinely care. You are then going to have better outcomes for your patients by doing something that you think is not important, but is very important when it comes to Aboriginal communities.
Dr Tim Senior
Okay. Thank you. Annalyse?
Dr Annalyse Crane
It is worth acknowledging that immunisation rates in Aboriginal communities in New South Wales are actually very high, around 94% to 96%. If you think of that in terms of say, Gardasil for prevention of cervical cancer or other HPV in general, there is also lots of emerging projects coming out in the next 12 months about prevention of and treatment of anal cancer. By knowing that if the kid in year 7 is receiving the Gardasil, that is a preventative strategy that New South Wales is currently very good at for patients who are Aboriginal. I was also involved in the rollout of the HPV self-collect cervical screening. Again, it is another measure where the uptake of under screened or never screened Aboriginal women has increased over 50%. By listening to community and going why do not you want to do this test? It could have been a trauma experience. It could have had a negative encounter with the health service. However, if we can go here, this swab, do this to it and give it to the lady at the desk or chuck it in that basket. No one is going to talk to you. No one is going to touch you. It increases that uptake. In the same way, some practices might have urine jars on the counter or in the bathroom, they do that at RPA in the antenatal clinic. You can then go to the nurse's station and going "oh, here is my sample. Can you do a chlamydia test. Can you do a gonorrhoea test for me." It is again looking at what is the barrier and how do you overcome it? In your normal mainstream general practice, there are little tiny things that you can do. Even having the nurse break to, perhaps if you are an older male GP, you may have a female nurse that sees the patient first and goes, "I am just here to check your blood pressure. I am just here to do something". It is that segue into "is there anything that you want to tell me? Is there anything that you would like me to bring up with the doctor that you do not feel comfortable talking about?"
Dr Tim Senior
That is excellent advice. It is worth us remembering as GPs that we can be really proud. We have excellent communication skills and those do not desert us when we are seeing Aboriginal Torres Strait Islander patients. We just have to be aware that the patients have often had bad experiences and use our communication skills to the best. We are still highly trusted as a profession, including among Aboriginal and Torres Strait Islander people and that is worth remembering. As I say that general practice is a great place to do sexual health testing and sexual health discussions often because we are trusted and because people cannot guess what they are there for. We have had some good questions come through already. We have got 8 minutes left, so I think it is worth moving on to Q and A if you want. One of the things that I would like to start with was a question that Tim has already answered in in the text. It is important for us to think about because a lot of people worry about this. Do you have any tips for patients who are lost to follow up?
Jessica Wilms
So hard. We spend a lot of our life chasing people. I saw another question too about mobile patients and people that are only in the area for a couple of days. It is really important to gather some information at that kind of point about where they may be next and how is the best way to contact them. I know we do a lot of inter-service agreements, that kind of thing. Finding someone that knows where they are and getting permission while they are in front of us to be able to contact them so that they are out in the bush. We can call the AMS out there and they can go find them, that kind of thing. I think it is about thinking about that in the moment and building that into the questions you ask when you are screening them.
Dr Tim Senior
Totally. I know for myself, when I know I am going to be needing to specifically check out that result or something, I am asking patients for permission. I am checking that their address and phone number and email are right and up to date and seeing who they can ask. We are really lucky in having Aboriginal health practitioners work with us who again can say things to patients and know the community so well that they can go and they know who they associate with, where they hang out, who their family members are and can go and find them in a way that is not found offensive whereas if I was going hunting them down, they are going "well, what are you doing here?" We are really lucky in having that as a resource.
Dr Annalyse Crane
It is really interesting to also consider if you were chasing someone, you may call their emergency contact or their next of kin, and in this case that result may be unknown to that person or you have got a teenager and you have got to ring the parent. Similarly, thinking if you disclose that there may be some coercive control or some domestic violence involved. Therefore, that is one of the reasons that this patient is avoiding follow up. It is often more complex than they just did not know and they did not care. Again, using those community opportunities even as simple as the patient may have an appointment in a hospital service, but perhaps in our referral going, if you see this patient, can you please make sure that they make contact with us or having some shared communication to be able to say we need to treat this patient? It is a part of their holistic care. We know people are not completing or compliant with all aspects of treatment. Otherwise, we would not be seeing exponential growth in case numbers.
Dr Tim Senior
I think often just finding out in advance who would you like us to contact? Is there anyone that you would not like us to contact in those circumstances? Follow up questions come through as well. You catch a patient in a marketplace or a shopping centre is non-compliant with appointments, and the matter is to be addressed seriously. Jess, would you ever do that?
Jessica Wilms
Probably not, but I would potentially just have a casual wave of "oh, we need to catch up. Can you come in? You need another test or something." I would just make it really vague, but I would make sure that I at least said hello, that kind of thing so that they knew that we needed something.
Dr Tim Senior
Again, you are probably in a slightly different position to myself and maybe Annalyse as well, where I know our Aboriginal health practitioners never feel off duty, like if they are in a shopping centre that people will ask them about their health and stuff whereas I do not get that. I get time off, but Aboriginal health practitioners never do being part of the community.
I have got an interesting question here as well. Is there a mentor or buddy system for patients who need more guidance about their healthcare? Especially on sexual health, including teens? They have got a teenage male who is reluctant to engage because they want someone familiar to answer their questions about the health system and reassure them.
Dr Annalyse Crane
It is like the classic 17-year-old girl who brings her friend with her for her Marina insertion or for her? "Oh my God. My boyfriend on the weekend said he has got chlamydia, so then they all come in together." Men do not do that. I certainly do not think there is a formal system of having someone come. However, like AMS would certainly welcome in the Aboriginal health worker to the consult if required or conduct the consult and perhaps invite a nurse to come and provide that cultural link. In southern Sydney, we do not have any service like that where someone can accompany them. However, we have a sports high school in our area that has a high proportion of Aboriginal students who come and live at a hostel. They are living away from their local community. They have the Nana in the hostel who may accompany them. She will not go in, but she might go and take them or broker some of that information. Similarly, if they are involved in, so we have the Clontarf program that that school is also involved with, they may have a youth worker or a person who may accompany them. Even their sports coach type person would certainly be in a position to support with a phone call but not necessarily provide structured formal advice.
Dr Tim Senior
I do know that it may be that one of the people behind the scenes can help us answer this, but ASHM have some peer sexual health workers from all sorts of different communities represented in New South Wales. I have worked with some in the past and they are often really knowledgeable. They lived experience, they know exactly what they are doing. I do not know if they are the sort of people who might be called on to guide some of our patients that we can put them in contact with ASHM to do that. Certainly, a couple of things, I would rely on our Aboriginal health practitioners because they are really good. Despite my white hair and elderly appearance, I would do everything I can to have what we call a strengths based discussion with someone like this where we are talking about what their strengths are, what they really enjoy doing, what they are worried about and be that doctor who is like showing a real interest in who they are and what they enjoy. Not just, "Hey, where is the discharge coming from your dick." That just becomes this really human interaction. They go, "oh, that is someone I can trust". I would go all out to do that. We have got a few more. Just a comment. ASHM is a great place to start. We have actually hit 830, so we are at our limit and I am keen for you all to get back to your families and enjoy.
Dr Annalyse Crane
Put your pyjamas on and eat your Easter eggs.
Dr Tim Senior
Yes, indeed. If you do have any other questions, I will pass back to Serena because she is going to give you an email address that you can use and also the details about the evaluations that you can do.
Serena
Thanks, everyone. I would like to extend my thanks to Tim and Jess for presenting and also everyone who joined us online. We do hope you enjoyed the session and that also you enjoy the rest of your evening.