1. Treatment and Care, and Clinical Research Basil Donovan National Centre in HIV Epidemiology and Clinical Research, University of New South Wales; and Sydney Sexual Health Centre, Sydney Hospital

2. Treatment and care of HIV: what’s different about Australia? Medicare (since 1984/5) Previously, cash or private insurance required to pay for GPs, specialists, and pathology tests Skeletal public sector in sexual health/HIV Inner city pharmacists treated many STIs MSM encouraged to use Blood Bank for syphilis and hepatitis screening

3. Treatment and care of HIV: what’s different about Australia? Medicare (since 1984/5) Previously, cash or private insurance required to pay for GPs, specialists, and pathology tests Skeletal public sector in sexual health/HIV Inner city pharmacists treated many STIs MSM encouraged to use Blood Bank for syphilis and hepatitis screening Fee-for-service structure of Medicare permitted rapid growth in primary care for HIV/AIDS Strategic (proactive) growth in public sector

4. Education of the Australian public: 1987 Indicated that there was a serious problem Addressed basic misconceptions Referral for information Probably little direct effect on behaviour. Bell RA et al AIDS 1990; 2: 71-84 Fuelled Australian appetite for HIV testing

5. c.1983/4 Pre-ACON

6. ACON, mid 80s

7. Sydney’s network of clinical care for people with or at risk of HIV Anyone with a Medicare Card – anywhere

8. Sydney’s network of clinical care for people with or at risk of HIV Anyone with a Medicare Card – anywhere Travelers, migrants, sex workers – sexual health clinics (SHCs) and Kirketon Road Centre (KRC) Street youth/IDUs - KRC People with STIs – GPs, SHCs, KRC

9. Sydney’s network of clinical care for people with or at risk of HIV Anyone with a Medicare Card – anywhere Travelers, migrants, sex workers – sexual health clinics (SHCs) and Kirketon Road Centre (KRC) Street youth/IDUs - KRC People with STIs – GPs, SHCs, KRC People with HIV/ADS – anywhere, especially GPs, as well as dedicated services

10. Sydney’s network of clinical care for people with or at risk of HIV Anyone with a Medicare Card – anywhere Travelers, migrants, sex workers – sexual health clinics (SHCs) and Kirketon Road Centre (KRC) Street youth/IDUs - KRC People with STIs – GPs, SHCs, KRC People with HIV/ADS – anywhere, especially GPs, as well as dedicated services Complex clinical care – tertiary hospitals and dementia service Respite/palliative care – Sacred Heart Hospice In summary, a very heterogeneous system

11. Implications of a heterogeneous system A degree of duplication (often over-estimated), iniquitous funding structures, communication gaps

12. Implications of a heterogeneous system A degree of duplication (often over-estimated), iniquitous funding structures, communication gaps The ‘drift’ between services raises standards Capacity for growth and better targeting Clinical safety net

13. Implications of a heterogeneous system A degree of duplication (often over-estimated), iniquitous funding structures, communication gaps The ‘drift’ between services raises standards Capacity for growth and better targeting Clinical safety net Professional education and accreditation (ASHM) Research has to be collaborative

14. Evolution of medical specialties Increasing overlap between infectious disease physicians and immunologists Special-interest GPs have become the new ‘general physicians’ in private practice Sexual health physicians more population-focused HIV and sexual health services have become models of multi-disciplinary client-focused care within hospitals; with nurses, counselors, researchers, and health promoters all seen as essential

15. Clinical research St Vincents Hospital 1985/6

16. Australia’s HIV/AIDS research response Initially small, but timely – natural history cohorts in Sydney and Melbourne

18. Australia’s HIV/AIDS research response Initially small, but timely – natural history cohorts in Sydney and Melbourne National Centres in Epidemiology and Clinical Research, Social Research, and Virology (‘tall poppy’ syndrome)

19. Australia’s HIV/AIDS research response Initially small, but timely – natural history cohorts in Sydney and Melbourne National Centres in Epidemiology and Clinical Research, Social Research, and Virology (‘tall poppy’ syndrome) Commonwealth AIDS Research Grants scheme

20. Australia’s HIV/AIDS research response Initially small, but timely – natural history cohorts in Sydney and Melbourne National Centres in Epidemiology and Clinical Research, Social Research, and Virology (‘tall poppy’ syndrome) Commonwealth AIDS Research Grants scheme Now, mainstream NHMRC and other sources

21. Some research landmarks Primary HIV Novel modes of transmission; for example, artificial insemination and breast feeding Community involvement leading to rapid implementation of findings Immunological mechanisms, inc. reconstitution Intricacies and trends in MSM behaviour Role of non-nucleoside reverse transcriptase inhibitors Metabolic complications of anti-viral drugs Pharmacogenomics (HLA-B*5701)

22. Current research status Diversified funding base, including NHMRC Community involvement now seen as an asset All HIV clinicians value and are involved in research, including enhanced surveillance Substantial body of expertise and infrastructure now involved in other infectious diseases and other countries

23. 1992