Evaluation Report Australian HIV Antiretroviral Guidelines Session Australasian HIV/AIDS Conference Thursday 18 October 2012 Melbourne 1
Table of Contents Background to the Antiretroviral Guidelines Conference Session. 3 Summary of Key Findings....... 3 Overview of 2012 program... 4 Evaluation and Feedback. 5 A. General Questions... 5 B. Presentations in the Conference Session....6 C: HHS Antiretroviral Guidelines and Australian Commentary... 9 2
Background to the Antiretroviral Guidelines Conference Session The annual Antiretroviral (ARV) Guidelines session of the Australasian HIV/AIDS Conference is designed to examine issues of importance arising from the USA Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents (HHS ARV guidelines), which is a widely used reference in Australia. The ARV Guidelines Panel produces a commentary to the HHS ARV Guidelines. This activity is managed by the Australasian Society for HIV Medicine (ASHM). The Guidelines (including Australian commentary) and a list of Panel members are available on the ASHM website at http://arv.ashm.org.au/. Summary of Key Findings Attendance at the ARV Guidelines session of the HIV conference was about the same as in 2011, with over 350 people attending. The session was evaluated by a two-page questionnaire, with 169 of 350 participants (similar to 2011) completing the evaluation. In 2012, 79% of survey respondents were Australian practitioners whereas 2011 was distinguished by a large proportion of overseas practitioners. Australian prescribers of HIV s100 medication comprised 43% of total respondents. Of the remaining participants overseas delegates and specialist nurses were the main sub-groups, followed by pharmacists, researchers, health promotion and other Australian practitioners. Delegates found the presentations of a high quality and were particularly interested in case based presentations. Almost all feedback was very positive. 79% of respondents practice in Australia 45% of respondents prescribe antiretrovirals in Australia Australian based prescribers overwhelmingly found the sessions practical and useful for their clinical practice Comments on topic evaluation questions tended to reflect how, and how long, HIV medicine has been practised by the practitioner whether they were overseas or Australian practitioners: s100 prescribing General Practitioners (GPs) comments indicated they would like hard and fast, practical information on prescribing ARVs and patient management. They also did not accept everything presented at face value Infectious diseases or sexual health Specialists and Physicians were interested in the controversies and debates behind recommendations. Registrars seemed to appreciate the learning experience and the debate. Comments suggest they appreciated being given both sides of an argument Nurses who wrote comments appreciated hearing both sides of the current debate Other occupations had insufficient numbers to summarise fairly. Overview of 2012 Program and Presentations As in 2011, the annual ARV Guidelines session was incorporated into the clinical stream (Stream B) of the Australasian HIV/AIDS 2012 Conference program. The 2012 ARV Guidelines session was 3
open to all registered HIV/AIDS Conference delegates, including representatives of the pharmaceutical industry, and was held during the morning of the second day of the conference. There were 1025 registrations in total for the conference. The ARV Guidelines program consisted of three topic sessions, two of which were delivered by invited speakers, including a member of the US HHS ARV Guidelines panel. The third topic was case discussions using a panel that included Australian experts and the speaker from the HHS Guidelines panel. The case discussions used interactive keypads to solicit audience responses. All delegates attending the 2012 ARV Guidelines session were provided with the opportunity to raise questions or make a comment. Antiretroviral Guidelines Symposium Program ARV Guidelines Session - Early antiretroviral treatment Thursday 18 October 10.30am - 12.00pm The session was chaired by Dr Jeffrey Post and Professor Jennifer Hoy, Chair and current member of the Australian ARV Guidelines Panel respectively. (The title of the topics below link to audio and slides of each session) Topic 1: HIV therapy: When to start Professor Steven G. Deeks Steven Deeks MD is an invited international speaker at the conference and member of the HHS ARV Guidelines panel. Prof. Deeks is a professor of medicine at the University of California, San Francisco, and a faculty member at San Francisco General Hospital. Prof. Deeks also maintains a primary care clinic for HIV infected patients. His research program investigates immunopathogenesis of antiretroviral-treated HIV infection and has recently expanded to include long-term non-progressors. Topic 2: Early antiretroviral therapy: Modelling the potential impact on the Australian epidemic Associate Professor David Wilson A/Prof David Wilson is Head of the Surveillance and Evaluation Program for Public Health at the Kirby Institute, University of NSW. Research interests include understanding HIV transmission risk, monitoring the trends and forecasting the future trajectories of HIV and related infections. Topic 3: Case presentations and expert panel discussion Panel facilitator: Dr Jeffrey Post Expert panel: Prof. Steven Deeks, Prof. Jennifer Hoy, Dr Alan Street & Mr Bill Whittaker This session was a case discussion led by Dr Jeffrey Post, Chair of the Australian Antiretroviral Guidelines panel and an infectious diseases physician with clinical appointments at Prince of Wales and Prince of Wales Private Hospital. Approximately 200 audience members with interactive keypads responded to the scenarios. The expert panel was formed with Prof Steven Deeks; Prof Jennifer Hoy, Director of HIV Medicine with the Alfred Hospital, Melbourne, and Professor of Medicine at Monash University. Prof Hoy is a current member of the Australian Antiretroviral Guidelines Panel and also a member of the International Antiviral Society Guidelines panel; 4
Dr Alan Street, Deputy Director of the Victorian Infectious Diseases Service and Head of the HIV service based at Royal Melbourne Hospital. Dr Street is a current member of the Australian Antiretroviral Guidelines Panel; and Mr Bill Whittaker, Special Representative, National Association of People with HIV (Australia). Mr Whittaker is a current member of the Australian Antiretroviral Guidelines Commentary Panel. Abstracts and copies of the slides of the presentations from the Antiretroviral Guidelines session are available on the ASHM conference website by selecting the session time Thursday 10:30: ARV Guidelines Session - Early antiretroviral treatment https://secure.ashm.org.au/ei/rs.esp?id=101&scriptid=sppp1 Evaluation and Feedback Evaluation Response 350 surveys were distributed and a total of 169 forms were returned completed after the session, giving a 48% response rate. Information for this report is derived from those surveys. Delegate numbers were estimated from the number of surveys distributed. The total number of delegates was approximately 360. A. General Questions Response to Question 1 (n=163). Did you attend the 2011 ARV consensus discussion? Of the 163 people who answered the question, 34% reported attending last year. In 2011, 56% people reported attending in the previous year. Response to Question 2 (n=158). In which country do you practice? Of the 158 people who answered the question, 79% practice in Australia and 4% in New Zealand. 9% practice in Indonesia, Thailand or Vietnam, with the reminder practising in other countries of the South East Asia or Western Pacific regions. Of overall prescribers responding, 19 of 92 (21%) were from somewhere other than Australia. Response to Question 3 (n=161). Do you prescribe antiretroviral medication (ARVs)? 69 of the 161 respondents (43%) do not prescribe ARVs and 92 (57%) do prescribe. Of the respondents that practice in Australia (n= 124), 73 (59%) prescribe ARVs. Of those Australian prescribers, 32 (44%) reported prescribing in hospitals, 30 (41%) in the community and 7 (10%) in both. Response to Question 4 (n=159). What is your occupation? Of those Australian practitioners who described themselves as non-prescribers (n=69), occupations included nurses, GPs, other medical officers or specialists, pharmacists, educators, researchers, counsellors, scientists and managers. B. Presentations in the Consensus Discussion 5
Topic 1: HIV therapy: When to start Presented by: Prof Steven Deeks Professor Deeks talked about the evidence that the DHHS panel used to recommend treatment at various CD4 levels. He also talked about chronic inflammation in HIV infection and consequent harm as it relates to when to start antiretroviral therapy. Table 1. Participant Responses to Topic 1 Please rate the session HIV therapy: When to start Answer Options Response Percent (n=166) Response Count Excellent 60% 100 Good 36% 60 Satisfactory 2% 4 Poor 1% 2 Not answered 3 When asked if this session was useful for their clinical practice, all bar two Australian based prescribers (n=73) thought it was quite or very useful. All 19 prescribers who did not identify themselves as Australian-based also found it useful for their clinical practice. Comments by Australian based prescribers indicated that they thought it was an excellent presentation and that the content was thought provoking. Their comments are best summarised by this example: Excellent speaker choice. Good to have the 'debate' and controversy. Comments by other Australian respondents were a bit more varied: accepting the content as it was delivered; challenging it; saying the debate needed to be broader or needed to have more local content. Selected comments: Present US data and add relevance to the Australian/Asian setting Not balanced but didn't have to be. Would have liked a counter argument End of story? treat everybody? hmmm... I like the idea of individualized therapy with a fully informed patient 6
Topic 2: Early antiretroviral therapy modelling: The potential impact on the Australian epidemic Presented by: A/Prof David Wilson A/Prof Wilson showed estimates of Australian numbers at each level of the HIV treatment cascade. A/Prof Wilson s Australian treatment cascade estimated the number of people with HIV down to the number in care with suppressed viral loads. Table 2. Participant Responses to Topic 2 Please rate the session Early antiretroviral therapy modelling: The potential impact on the Australian epidemic Answer Options Response Percent (n=165) Response Count Excellent 48% 78 Good 47% 76 Satisfactory 4% 7 Poor 1% 2 Not answered 4 When asked how useful this topic was for clinical practice, Australian or New Zealand prescribers described A/Prof Wilson s presentation as: not so useful for clinical practice, but very useful for service planning and prioritising care. Prescribers thought the estimates provided were hugely important and were sobered by awareness that Australian data were poor. 43 of 53 (81%) of Australian and New Zealand non-prescribers found the presentation useful and relevant to their practice. 21 of 38 (55%) of practitioners who were not from Australia or New Zealand found the presentation quite or very useful for their practice. Selected comments: Demonstrates the need for 'good information' in seeing where we are in managing the epidemic Quantified the potential impact of treatment as prevention, but assumptions were not able to factor in impact of increased STI potential Critically important work - should be sent to the health ministers Superb Topic 3: Case presentations and panel discussion. Panel facilitator: Dr Jeffrey Post Panel: Prof Steve Deeks, Prof Jenny Hoy, Dr Alan Street and Mr Bill Whittaker Dr Post led a panel discussion on hypothetical and existing cases probing the question of when to start people on ARV therapy. The audience was invited to vote on the action they would take at various steps on the decision making pathway. Table 3. Participant Responses to Topic 3 Please rate the session Case presentations and panel discussion Answer Options Response Percent (n= 156) Response Count Excellent 52% 81 Good 36% 56 Satisfactory 10% 15 Poor 3% 4 Not answered 13 7
64 of 73 (88%) of responding Australian and New Zealand prescribers found this session useful or very useful for their clinical practice. Comments from prescribers covered the spectrum from thought provoking to more complex cases would be useful, but prescribers enjoyed hearing differing points of view discussed. 31 of 53 (58%) of Australian and New Zealand non-prescribers found this session useful or very useful for their clinical practice. A number of comments indicate that some non-prescribers were expecting more of a social focus and did not have the clinical background to fully participate in the session. However, they still enjoyed participating in the session and would like to make the session accessible for all to participate. Selected comments: No GPs (on panel) so only HIV issues discussed with total disregard for co-morbidities and other non-hiv problems. e.g. CNS HAND, Diabetes, toxicities. Need to have GP in next panel Interesting and thought provoking cases Great discussion generated, nice to see different views and some practical tips I think the considerations were too narrow and theoretical you need to get a bigger perspective on the person's life. I think people should be able to start immediately if they choose, as soon as diagnosed Overall comments/suggestions for improvement There were somewhat contradictory suggestions about which Guidelines or commentary might be useful for Australia: It's good for Australia to make up its own mind and say so Add pregnancy ART commentary I'm aware of BHIVA and cost is not in the best interest of the patient Both are important and relevant [referring to guidelines such as BHIVA, EACS, IAS] Attach Australian commentary to EACs guidelines? Europe has more synergy than the Australian health system We don't need a commentary locally - a waste of time, we need to add to the [illegible] expert analysis Very conservative currently - not of much use Further comments were about the Conference session: Why was there no session on the details of the 2012 guidelines? (i.e. ARV choice). Usually one of the most useful sessions of the conference Very prescriber focused - psychosocial please! One of the best of the conference - interactive sessions are great. Where is the health promotion at this conference? We are not all clinicians and health promotion has a part to play if we have any chance of meeting the Melb declaration goals!!!! Enjoyed the interactive element of this session Excellent Session. Good Practical suggestions were also made: Hard copies available upon request with supplementary updates Remove CD4 500 PBS barrier then guidelines can be [illegible] by patient choice and physicians real position. When you design surveys you aren't really thinking about the diversity of your audience. Need an App 8
C: HHS Antiretroviral Guidelines and Australian Commentary Tables 4 and 5 show the responses to questions regarding the relative use and ease-of-use of the internet based and PDF based Australian commentary on the DHHS guidelines. The number of people using both versions has increased by about one-third from last year. Overwhelmingly, people answered that they would find it beneficial to have HIV management in Australasia: a guide for clinical care, accessible from the ARV guidelines website. Of 80 people who report using the PDF copy of the Australian guidelines, 61 (82%) save it to an electronic device rather than print it. Table 4. Comparison of internet and printable resources How often do you use the Australian Commentary to the USA Department of Health and Human Services Guidelines on the Use of Antiretroviral Agents for the Management of HIV 1 Infected Adults and Adolescents available on the ASHM website? Never used but intend to Never Rarely Sometimes Frequently Web (n=137) 19 (14%) 20 (15%) 20 (15%) 64 (47%) 14 (10%) PDF (n=123) 22 (18%) 31 (25%) 12 (10%) 49 (40%) 9 (7%) Table 5. Comparison of internet and printable resources How would you rate the ease of use (finding information) in the Guidelines? Not Answer Options applicable Good Satisfactory Poor Web (n= 110) 14 (13%) 47 (43%) 44 (40%) 5 (5%) PDF (n= 68) 23 (25%) 30 (32%) 37 (40%) 4 (4%) Regarding Web usage: respondents were asked if they thought it would it be beneficial to have HIV management in Australasia: a guide for clinical care, accessible from the ARV guidelines website. Of 82 respondents, 96.3% (n=79) said yes, and only 3.7% (n=3) said no. Regarding PDF usage: of those respondents who download the PDF of the Australian Commentary to the USA Department of Health and Human Services Guidelines on the Use of Antiretroviral Agents for the Management of HIV 1 Infected Adults and Adolescents, 82.4% (n=61) indicated that they save the PDF to an electronic device such as a desktop or tablet; while 25.7% (n=19) indicated that they would print a copy of the Commentary. Table 6. Independence of the Australian Commentary How much do you agree with the statement: Independence of the Australian commentary on the HHS guidelines is important? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree All respondents (n=129) 47 (36%) 53 (41%) 25 (19%) 1 (<1%) 3 (2%) Australian prescribers (n= 67) 26 (39%) 32 (48%) 8 (12%) 0 (0%) 1 (1%) The majority of respondents either agreed or strongly agreed that it is important that the Australian commentary on the HHS guidelines be independent.. 9
Table 7. Reason for use (Total responses, n= 116) What is your reason for using the guidelines? Answer Options (multiple responses possible) Response Percent Response Count To determine treatment regimens for patients 42% 36 For training purposes 25% 33 To update my knowledge 70% 63 As a resource/reference tool 75% 60 To determine when to start treatment 31% 36 Other responses given: To better be able to explain to patients when they have questions away from clinic Advocacy and education for people living with HIV Balance when writing protocols To support discussion of treatment regimens with patients Table 8. Other Guidelines used (Total responses, n=80) Which other antiretroviral guidelines do you use? Answer Options (multiple responses possible) Response Percent Response Count British HIV Association 45% 36 European (EACS) 45% 36 International Antiviral Society 49% (IAS) USA 39 Other (please specify) -WHO Guidelines 8% 6 -Other single country guidelines only 3% 2 A handful of people indicated they used DHHS guidelines as an alternative, indicating they were not aware of the original guidelines to which we were referring. CONCLUSION Overall, a broad range of Australian and overseas practitioners in clinical HIV medicine found the ARV Guidelines session at the ASHM Conference useful. People who practice the social side of HIV medicine did not appear to achieve the same utility. Community prescribers seek hard, practical information on how the latest information about ARVs affects their daily practice. Hospital based prescribers benefit from discussion of the evidence behind the recommendations. A few people proposed different ways of producing Australian recommendations for ARVs, ranging from no Australian voice to the need for an Australian voice. Advantages and limitations of other ARV Guidelines were mentioned but no definite picture emerged. Most people were comfortable with an internet based version of the Australian ARVG although there were calls for versions at both ends of the technology spectrum. Respondents overwhelmingly found the conference presentations of good or excellent quality and generally useful or very useful, depending on the clinical situation. Although sometimes the information to them as providers may not have been directly useful, it was thought to be very important: information that Australia could not easily count the number of people in the treatment cascade surprised many. Overall responses to the sessions indicated people were more than satisfied with the content and delivery of the presentations. 10
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