Kirketon Road Centre Research Articles

O98 - Optimising antenatal care for marginalised and at-risk women at the Kirketon Road Centre (KRC), Kings Cross, NSW

KRC is an integrated primary health care centre which aims to meet the health and social welfare needs of ‘at risk’ youth, people who inject drugs and sex workers. Pregnant women who engage with KRC are often homeless and have multiple complex needs. Many have had children removed from their care, and many have been in out of home care themselves, have a history of intimate partner violence, sexual abuse, financial instability, and have substance using partners. These women often lack social support and their networks encourage instability. KRC operates under a non-judgemental multidisciplinary care model which supports these women in multiple ways including antenatal care and opiate agonist therapy such as methadone and suboxone. KRC provides a dedicated antenatal clinic staffed by a part-time midwife. The aim is to engage women to attend for antenatal care as well as case management and to form a holistic health relationship that extends beyond the birth of their child. KRC works opportunistically, as typically these women do not engage with conventional hospital-based antenatal services. Furthermore, KRC’s community outreach program reaches women who cannot or do not want to engage with the fixed-site service. Integral to the model are strong relationships with services in our area health district such as the Chemical Use in Pregnancy program and direct referral pathways to the Royal Hospital for Women, and to the Malabar Midwives for Aboriginal women. KRCs model of care is able reach and provide much needed antenatal care and SUD treatment to marginalised and at risk women with SUD. This is achieved through a flexible and non-judgmental approach to health care delivery, in partnership with relevant community and tertiary based services.

O4 - Providing unplanned pregnancy care and Early Medical Abortion to marginalised groups at the Kirketon Road Centre (KRC) - a walk in targeted primary health care service in Kings Cross, Sydney

Social and financial marginalisation are barriers to accessing reproductive health services including medical abortion. KRC’s multidisciplinary team provides unplanned pregnancy care and Early Medical Abortion (EMA) to targeted population groups in a walk in clinic, at lower cost, making EMA more accessible. Eligibility is assessed using KRC EMA guidelines by an appropriately qualified nurse, midwife or doctor. People attend low cost imaging and clinical assessments and pathology tests are free. Medication packs and MS-2 Step are supplied by a local pharmacy for a dispensing fee, or at cost price if without Medicare. Appointments are face-to-face and telehealth. People who are not eligible for EMA at KRC are referred to appropriate services. Since November 2021, nurses, midwives and doctors from KRC have worked collaboratively to provide unplanned pregnancy care. Eight people, including one who travelled 95 km, have accessed EMA at KRC. People have been referred by a peer-based sex worker organisation, or have attended KRC for unplanned pregnancy support unaware that EMA was available. Aboriginal people, people who sex work, at risk youth, homeless people and people from culturally diverse backgrounds have attended. EMA would otherwise have been inaccessible to these people. Feedback has been overwhelmingly positive with many people expressing a sense of relief their needs were being met. Some clients opted for long acting reversible contraception (LARC) insertion which led to upskilling of staff and the development of a working group to expand nursing and midwife involvement in contraception provision at KRC. Access to safe medical abortions is a critical part of sexual and reproductive health yet access to these services is often hampered by social marginalization, stigma and cost. Implementing EMA services which address these barriers is a priority if we are to provide universal access to comprehensive abortion care.

Treatment adherence and support for people who inject drugs taking direct-acting antiviral therapy for hepatitis C infection.

A community-based public health facility in Sydney, Australia, the Kirketon Road Centre (KRC), provides health care to people who inject drugs (PWID), homeless and other marginalized people. Since March 2016, KRC has provided treatment for chronic hepatitis C virus (HCV) with direct-acting antivirals (DAAs). We aimed to evaluate treatment adherence amongst clients taking DAAs in a highly marginalized population. All clients who commenced DAA therapy prior to March 2018 at KRC were included in this observational cohort with a subset of clients attending daily or weekly for enhanced adherence support and dosing. Demographic, behavioural, clinical measures and medication dosing were recorded, and adherence was calculated as the proportion of doses taken during the expected treatment duration. Factors associated with adherence were examined using logistic regression. A total of 242 individuals commenced DAA therapy, of whom 79 (32%) received enhanced adherence support. Enhanced support was associated with homelessness, daily injecting, Aboriginality, mental health co-morbidity and poly-drug use (all P<.001). Overall adherence was 86%, and 92% of patients missed one or more doses (median 10, IQR 4-24). At least 90% adherence during planned duration was seen in 38%, but increased to 66% by continuing therapy beyond planned duration. Intention-to-treat SVR12 was 68% and 66% in the enhanced adherence support sub-population, with 29% lost to follow-up by SVR12 testing. There were only 2 (0.8%) documented virological failures. Per-protocol SVR12 was 99% and 96% in the enhanced adherence support sub-population. In conclusion, adherence support may benefit those with multiple markers of marginalization. Extension of therapy beyond planned duration is a pragmatic strategy to enhance completion. Strategies to improve follow-up, particularly post-treatment are required.

P54 Treatment adherence among people who inject drugs taking directly observed direct acting antiviral therapy at Kirketon Road Centre

P54 Treatment adherence among people who inject drugs taking directly observed direct acting antiviral therapy at Kirketon Road Centre

P55 Client acceptability and feasibility of expanded access to direct acting antiviral therapy for hepatitis at the Kirketon Road Centre

P55 Client acceptability and feasibility of expanded access to direct acting antiviral therapy for hepatitis at the Kirketon Road Centre

O10 Treatment of Aboriginal and Torres Strait Islander clients with direct acting antivirals at the Kirketon Road Centre

O10 Treatment of Aboriginal and Torres Strait Islander clients with direct acting antivirals at the Kirketon Road Centre

Delivering direct acting antiviral therapy for hepatitis C to highly marginalised and current drug injecting populations in a targeted primary health care setting

BackgroundThe Kirketon Road Centre (KRC) is a community-based public health facility in Sydney, Australia, that provides healthcare to people who inject drugs (PWID), including hepatitis C virus (HCV) treatment. From March 2016, the Australian Government has provided access to direct-acting antivirals (DAA) for adults with chronic HCV, without liver disease stage or drug and alcohol use restrictions. The aim of this study was to report DAA treatment outcomes among highly marginalised PWID treated at KRC. MethodsAll individuals initiating DAA treatment at KRC and due for sustained virological response (SVR12) testing by end 2016 were included. Demographic, drug use behaviour, clinical parameters, adherence support and HCV treatment outcomes, including SVR12 were recorded. Factors associated with SVR12, loss-to-follow-up (LTFU) and delayed SVR12 testing (>SVR16) were assessed by multivariate analysis. SVR12 was assessed by intention-to-treat (ITT) and modified ITT, the latter excluding individuals with an end-of-treatment response (ETR) but no SVR12 assessment, or who postponed their SVR12 date due to treatment interruption. ResultsA total of 72 individuals commencing DAAs were included, of whom 67% were male, 30% homeless, and 32% Aboriginal. All had a lifetime history of injecting drug use, with 75% having injected within the last six months, and 44% injecting at least weekly; 25% were also enrolled in opioid substitution therapy. Twenty-five (35%) individuals elected to receive an enhanced adherence-support package. Fifty-nine of 72 (82%) individuals due for SVR12 attended for testing, of whom 59/59 (100%) achieved SVR, providing an ITT SVR of 82%. A further six individuals had undetectable HCV RNA at ETR, but no SVR12 assessment, and one interrupted treatment, providing a mITT SVR of 91%. Homelessness was associated with delayed SVR12 testing (OR 24.9 95%CI 2.9–212.8, p=0.003). There was no association between LTFU and frequency of drug injection, last drug injected, or planned treatment duration. ConclusionThis study confirms that PWID can be successfully treated for HCV in a real-world setting using an integrated primary health care model. It also demonstrates feasibility to upscale DAA therapy in high-risk PWID populations, with potential individual and population-level public health benefits. Enhanced efforts are required to optimise post-treatment follow-up.

Australian research investigating the role of nurse practitioners: A view from implementation science

Summary The catalyst for the paper was a rapid review of the literature which identified Australian research on nurse practitioners. This paper reports on those studies investigating individual nurse practitioner roles, framed in terms of the implementation science literature and three stages of implementation: exploration and adoption of the role, initial implementation of the role, and full operation of the role. Database searching of the peer-reviewed literature was supplemented with searching relevant web sites. Most studies focused on certain aspects of the nurse practitioner role rather than undertaking a comprehensive evaluation. There was no consistency in the way the roles were described, making it difficult to compare what may be similar roles in different studies. The research generally treats the nurse practitioner role as the independent variable, rather than the care provided by the nurse practitioner. The concept of implementation fidelity was absent from all studies, except for one which addressed the issue indirectly. Many studies included little contextual information, making it difficult to judge the role of context in influencing both implementation and patient outcomes and establish plausible links between the activities of the nurse practitioners and patient outcomes. Based on the findings, a checklist is recommended for use in future studies which would enhance the ability to make judgements about implementing nurse practitioner models of care; facilitate comparison of similar roles and increase the capacity to make informed decisions about the prospects for wider implementation of nurse practitioner roles or models of care.

Findings and lessons learnt from implementing Australia's first health service based take-home naloxone program.

Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting. The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance. Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%). Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation.

Needs-based public health service provision ensures equity

We welcome the contribution of Iversen, Hope, and McVeigh (2016) to the debate about the allocation of scarce HIV prevention resources. In our paper we raised the dilemma posed by competing demands for the Kirketon Road Centre’s needle syringe program (NSP) in Sydney’s Kings Cross. Iversen et al. suggest that the more targeted approach we adopted recently to preventing blood borne infections (BBIs) among people who inject performance and image enhancing drugs (PIEDs) is inequitable and discriminatory (Iversen et al., 2016). We feel they may have over interpreted its ‘‘restrictiveness’’. They also appear to conflate demand with need for such services, and being discriminatory with being discriminating in the use of scarce resources. While Iversen et al. point to the WHO/UNODC/UNAIDS Technical Guide, which advocates universal access among people who inject drugs (PWID) and recommends that services should be equitable and non-discriminatory (without exclusion criteria), being inequitable and discriminatory would also contravene KRC’s own longstanding explicit commitment to WHO’s Primary Health Care philosophy stating that health care should be accessible, acceptable, affordable and equitable (van Beek, 1994, 2007; World Health Organization, 1978). We would like to point out that this Technical Guide goes on to state that: ‘supply should be determined by need’ (World Health Organization, 2012), which we strongly endorse. We suggest that the Needle Syringe Program (NSP) supply to PIEDs injectors in Australia has primarily been driven by demand, which does not necessarily coincide with need, and can even be inversely proportional in the case of socially marginalised populations. A R T I C L E I N F O

Access to needle and syringe programs by people who inject image and performance enhancing drugs

We appreciate van Beek and Chronister's concerns regarding the funding of harm reduction interventions in an environment of diminishing resources (van Beek & Chronister, 2015), however we disagree with their conclusion and support the international guidelines for equitable and non-discriminatory NSP provision for all people who inject drugs. van Beek and Chronister outline the response of the Kirketon Road Centre (KRC), an established primary health care facility in Sydney, New South Wales (NSW), to a potential “public policy dilemma” resulting from an increase in the injection of drugs with the primary purpose of enhancing image and/or performance in Australia (van Beek & Chronister, 2015). Using data from surveys of 102 men injecting image and performance enhancing drugs (IPEDs) attending the KRC Needle and Syringe Program (NSP), they assessed the risk of blood-borne viral (BBV) infections in this group to be lower than among people who inject drugs primarily for their psychoactive effects. The KRC subsequently implemented a policy decision to limit the availability of injecting equipment from their NSP to people who inject IPEDs. The authors also encouraged other NSP services to undertake local assessments

P13.03 Targeted primary health care and sexual health services can deliver the hepatitis c strategy: one year of fibroscans at the kirketon road centre (krc)

Introduction National and NSW Hepatitis C (HCV) strategies identify primary health care and sexual health services as crucial for expanded assessment and treatment of HCV. KRC is a targeted primary health care facility in Sydney’s Kings Cross, involved in the prevention, treatment and care of HIV, STIs and viral hepatitis to people who inject drugs. Since April 2014 KRC has used a portable fibroscan on site and at outreach clinics held at The Langton Centre (drug and alcohol service), NSW Users and AIDS Association, the Medically Supervised Injecting Centre, and the Sydney Sexual Health Centre to assess clients for liver disease. The aim of this study was to describe clients receiving a fibroscan during the first year, their fibroscan results and retention in care. Methods All clients who underwent a fibroscan from April 2014 through March 2015 were included. Clients’ demographics, fibroscan results, HCV genotype, HIV co-infection and follow-up data were analysed. Results Fibroscans were performed among 161 clients: 106 male, 51 female, 4 transgender. Median age was 43, and 12 (7%) identified as Aboriginal; 146 (91%) reported having injected drugs; 72% (n = 116) were HCV PCR positive (58% genotype 1, 38% genotype 3; 7 were HIV co-infected); 17 were hepatitis B sAg positive (1 HIV co-infected); 28 were of unknown status. Fibroscans showed F0–1 liver fibrosis in 105 (65%), F2 = 28(17%), F3 = 16(10%) and F4 = 12(8%). Follow-up occurred in 122(76%), clients including 26/28 with F3–4 fibrosis. Thirteen clients were able to access clinical trials of HCV treatment. Conclusion This study demonstrates the utility of delivering a fibroscan service by a health facility that focusses on STIs, HIV and hepatitis. Uptake and retention in care was achieved for this marginalised population. The Hepatitis C strategies’ focus on primary health care and sexual health services for HCV care and treatment in an era of interferon-free therapy appears feasible. Disclosure of interest statement No conflicts of interest to declare.

Performance and image enhancing drug injectors’ access to needle syringe programs: Responding to a public policy dilemma

BackgroundThe number of people who inject performance and image enhancing drugs (PIEDs) attending Australian needle syringe programs (NSPs) has increased recently with cost and capacity implications for this already stretched public health program. The need to prioritise populations’ NSP access poses dilemmas for a program that has always sought to minimise entry barriers. MethodsTo assess their injecting-related risk of HIV and HCV, the Kirketon Road Centre (KRC) surveyed PIEDs injectors attending its two NSPs in inner Sydney in late 2013. Demographic, injecting risk, HIV and HCV testing, and NSP access data were analysed and then compared with similar data collected in the Australian Needle Syringe Program Survey (ANSPS) and the NSW NSP Enhanced Data Collection (NNEDC) survey conducted in the state of NSW in the same time period. ResultsPIEDs injectors surveyed (n=103) were predominantly male (99%) and only one reported ever receptive needle syringe sharing any injecting equipment. KRC participants were similar to the other survey populations in having rarely ever injected intravenously (6%); being tested for HIV and HCV in the last year (44% and 32% respectively), and reporting low rates of HCV (0%). But they were much more likely to be gay or bisexual (42% vs 2% and 4% in the NSW surveys, p<0.001). Compared to their heterosexual counterparts at KRC, this subgroup was older (35 vs 31 years, p=0.011), and more likely to: have been injecting for <3 years (70% vs 44%, p=0.025); to have ever been tested for HIV (88% vs 46%, p<0.001); to have been tested for HIV and HCV in the last year (72% vs 24%, p<0.001 and 51% vs 19%, p=0.001 respectively); and to report being HIV positive (9% vs 0%, p<0.001). ConclusionsPIEDs injectors with no other risk factors were at low risk of HIV and HCV, informing KRC's more targeted approach to their health needs. This included providing PIEDs-focused health information and promoting more frequent BBI testing, while encouraging injecting equipment access through other legal sources. This is a case study of how evidence can help resolve public policy dilemmas at the local level, thereby ensuring that scarce public health resources continue to be directed towards those people who inject drugs most at risk of BBIs.

Methadone, Counselling and Literacy: A health literacy partnership for Aboriginal clients

This paper describes a literacy program delivered at the Kirketon Road Centre (KRC), a primary health centre located in Kings Cross, Sydney. KRC was established to meet the health needs of ‘at risk’ young people, sex workers, and people who inject drugs. The literacy program was initiated from within an Aboriginal health group at KRC, following a request from clients in the group. A teacher from Tranby Aboriginal College delivered the literacy program one afternoon every fortnight over a period of approximately one year. This paper is based on recorded and transcribed ‘reflection’ discussions undertaken over several months between the literacy teacher, a KRC counsellor and the researcher immediately following the literacy sessions. Of particular interest is the nature of the literacy program and its pedagogical approach which is based largely on the delivery of popularly themed worksheet exercises. These activities represent in some ways an approach to adult literacy education that we term ‘autonomous’, that is, as a single set of skills generalisable to other life contexts. This pedagogical approach, however, needs to be understood in relation to the social capital outcomes of the course which take into account the complex and varying relationships and networks of the client group. The real value of the course can be seen largely in terms of the social capital outcomes for individual participants.

Case study: Accessible primary health care—A foundation to improve health outcomes for people who inject drugs

Issue Injecting drug users (IDUs) represent a large part of the population with HIV globally, however, IDUs continue to have less access to HIV treatment than non-IDUs. While IDUs with HIV potentially fare as well on anti-retroviral therapy (ART) as non-IDUs in terms of HIV disease progression, ART adherence is critical. Opioid dependent IDUs may experience lifestyle instability affecting ART adherence. IDUs often have a range of complex health and social welfare needs beyond HIV. The approach Opioid agonist pharmacotherapies such as methadone maintenance treatment, improve overall health and psychosocial stability among opioid-dependent IDUs. The integration of pharmacotherapies into primary health care settings also allows the direct observation of the concomitant administration of HIV treatments. This dual treatment approach maximises HIV treatment adherence and enables the timely management of other clinical issues. Where relevant, sexual and reproductive, infant and maternal health services should also be incorporated alongside HIV and hepatitis B and C prevention services. Services should be anonymous and confidential, and be provided by a multidisciplinary team in a non-judgemental way. Involvement of IDUs in service planning should also be promoted to ensure the acceptability of the model to the target population. A case study The Kirketon Road Centre (KRC) in Kings Cross, Australia, is an example of a community-based primary health care service delivery model that comprehensively addresses a range of complex health and social welfare needs IDUs may have. Established in 1987 to prevent HIV/AIDS and other transmissible infections among “at risk” young people, IDUs and commercial sex workers, the KRC model has also proven versatile in upscaling to meet hepatitis C and other emerging health needs of IDUs in a timely way. Conclusion Integrated primary health care models should be promoted more widely as a foundation to improve the health outcomes of IDUs.

Predictors of completion of a hepatitis B vaccination schedule in attendees at a primary health care centre

In Australia, rates of hepatitis B (HBV) transmission continue to be higher in certain populations, including commercial sex workers and injecting drug users (IDU). This study aims to identify rates and predictors of completion of a HBV vaccination schedule in 'high-risk' attendees of a primary health care centre in Sydney. All clients who attended Kirketon Road Centre, a primary health care centre located in Kings Cross, Sydney, with no evidence of HBV immunity were included in the cohort. The study design was observational with historical controls. The main outcome measure was completion of a three-dose HBV vaccine schedule in the study period. Among 2085 clients who received a first vaccination, 1013 (49%) received a second and 435 (21%) received a third vaccination. Univariate analysis found that significant predictors of completion of the vaccine schedule were intention to administer an accelerated schedule (OR 1.49, P = 0.004), not being an IDU (OR 1.29, P = 0.02) and shorter time between first visit and first vaccine dose (OR 1.24, P for trend <0.0001); however, on multivariate analysis, not being an IDU was no longer a predictor of vaccine completion. Implementation of an accelerated vaccination schedule improved completion rates but they were still low, despite the provision of free vaccination in a service specifically targeting the needs of sex workers, IDU and other marginalised populations. Increasing HBV vaccine uptake and completion rates in Australian adults is an important public health issue not only for the prevention of HBV but also for the future application of other potential vaccines, including those against HIV and hepatitis C.

Prevalence of tuberculosis infection among homeless young people in central and eastern Sydney.

To determine the prevalence of tuberculosis (TB) infection among homeless young people (aged 12-25 years) in central and eastern Sydney. A cross-sectional survey was conducted in 16 youth refuges and four drop-in centres in Central and Eastern Sydney Health Areas and at the Cellblock Youth Health Centre, Glebe and the Kirketon Road Centre, Darlinghurst, New South Wales (NSW). Participants completed a questionnaire and underwent Mantoux testing. One hundred and forty-one young people completed questionnaires and 139 received a Mantoux test; 112 (80. 6%) had their Mantoux read and 10 (8.9%) were Mantoux positive (95% confidence interval 3.6-14.2). None of the risk factors examined were found to be associated with increased risk for TB infection. In this sample of homeless young people in central and eastern Sydney, the Mantoux positivity rate appears to be higher than the general population in NSW, but they would not currently be considered a high-risk group for TB infection.

Hepatitis C prevalence among Australian injecting drug users in the 1970s and profiles of virus genotypes in the 1970s and 1990s.

To examine the seroprevalence of hepatitis C virus (HCV) in the Australian injecting drug-using community in the 1970s, and to compare the profile of HCV genotypes with that seen in the 1990s. Investigation of stored sera that were collected from injecting drug users in the 1970s and comparison with sera collected in the 1990s. Inner Sydney, 1974-1975 and 1994-1996. The 1970s group comprised 141 consecutive injecting drug users who attended the Brisbane Street Methadone Clinic. The 1990s group comprised 88 consecutive, injecting drug users of European origin who were HCV antibody-positive and attended a primary healthcare facility (the Kirketon Road Centre). HCV antibody prevalence (1970s); profile of HCV serotypes (1970s and 1990s); and serological evidence of hepatitis A and B. 84% of the 1970s group were HCV antibody-positive, of whom 92% were infected with HCV serotype 1 and 1% with serotype 3. In contrast, in the 1990s group, 69% were infected with HCV serotype 1 and 25% with serotype 3. The HCV-positive subjects from the early group were more likely than those from the recent group to have serological evidence of previous HBV infection. The high prevalence of HCV among injecting drug users in the 1970s in Australia confirms an epidemic that has been present for at least 25 years. Over this period, the proportion of HCV genotype 1 infections has decreased and genotype 3 infections have emerged.