Volume 210 Issue 6

Lifting the special drug status applied to medical abortion medications will enable equitable access

Caroline M de Costa · Kirsten I Black · Darren B Russell

There have been many advances in sexual and reproductive health and rights in Australia but we must also recognise the gaps that affect our most vulnerable populations

Deborah J Bateson · Kirsten I Black · Shailendra Sawleshwarkar

The basic premise of a stepped wedge cluster randomised trial (SW- CRT) is that all clusters start in the control condition

Michael J Campbell · Karla Hemming · Monica Taljaard

Lessons from practice

Anthony M Whitfield · Ai Van B Tran Nguyen · Kashif Sheikh

55- year- old otherwise healthy woman presented with the first episode of syncope

Vahid Moosavi · Mohammad Paymard

A mind that is stretched by a new experience can never go back to its old dimensions (Oliver Wendell Holmes)

Sandra C Thompson · Rosalie D Thackrah

Starting antiretroviral therapy as early as possible is crucial at both the individual and the public health levels

Kasha P Singh · Sharon R Lewin

The known: The gap in life expectancy between Indigenous and non‐Indigenous Australians remains large. Urban Indigenous Australian‐controlled health services are under‐resourced, and mainstream primary care services are often not culturally sensitive.

Siaw‐Teng Liaw · Vicki Wade · John S Furler · Iqbal Hasan · Phyllis Lau · Margaret Kelaher · Wei Xuan · Mark F Harris

The known Treatment of people infected with human immunodeficiency virus (HIV) soon after diagnosis reduces the risk of transmission and HIV‐related morbidity. The proportion and characteristics of people who receive early treatment are not well described.

Hamish McManus · Denton Callander · Basil Donovan · Darren B Russell · Catherine C O'Connor · Stephen C Davies · David A Lewis · Margaret E Hellard · Marcus Y Chen · Kathy Petoumenos · Rick Varma · Aaron Cogle · Mark Alastair Boyd · Andrew Grulich · James Pollard · Nick Medland · Christopher K Fairley · Rebecca J Guy

The peak incidence of IBD overlaps with the prime childbearing years; thus, the issue of medication use and disease control in pregnancy is of particular relevance for both patient wellbeing and all treating physicians.The most important factor in optimising pregnancy outcomes for women with IBD is to ensure their disease is in remission before and during pregnancy. Patients should be encouraged to continue their IBD medications in order to maintain disease remission. Patients with IBD require clinician‐initiated pre‐conception counselling and a consistent message regarding these factors. It is recommended that patients are reviewed regularly by their gastroenterologist during pregnancy and assessment of disease activity is performed in the form of objective, non‐invasive markers, such as faecal calprotectin. In the event of a disease flare during pregnancy, the patient's gastroenterologist should be contacted promptly and appropriate escalation of therapy should be arranged.

Sally J Bell · Emma K Flanagan

Despite pregnancy being identified as a time of increased HIV susceptibility, with risks to both the mother and unborn infant of HIV acquisition, there is a paucity of guidelines, eligibility criteria and risk assessment tools pertaining specifically to the usage of PrEP in pregnancy and lactation. Existing local and international guidelines suggest a low threshold for the initiation of PrEP in serodiscordant HIV‐negative women. It is imperative that the needs of such patients be met through the implementation of strategies to enable appropriate and timely prescription of PrEP.Moreover, with the commencement of availability of Pharmaceutical Benefits Scheme‐subsidised PrEP, the financial and practical obstacles to PrEP provision will be reduced and a subsequent increase in patient awareness and acceptance of PrEP is anticipated. However, the logistics and responsibility of providing PrEP and subsequent necessary follow‐up for pregnant and lactating women at risk of HIV infection has not been sufficiently considered or formalised (ie, general practice versus antenatal clinic).We therefore recommend development of multidisciplinary guidelines on the prevention of mother‐to‐child transmission of HIV among Australian pregnant and lactating women. These guidelines should include information about PrEP. Development of the guidelines must also engage with clinicians treating male patients to ensure that uninfected female partners of child‐bearing potential are not forgotten. The guidelines will require multidisciplinary input including expertise in the areas of HIV, obstetrics, midwifery, general practice and paediatrics, and commitment to: outlining the appropriate circumstances for the provision of PrEP during peri‐conception, pregnancy and lactation; creation of behavioural eligibility criteria and risk assessment tools which recognise the risks specific to pregnant and lactating women; outlining the appropriate follow‐up of patients commenced on PrEP during pregnancy and lactation; defining the setting in which PrEP will be prescribed and post‐prescription surveillance will be undertaken for the pregnant and lactating patient cohort; targeted education of health professionals tasked with the provision of PrEP to the pregnant and breastfeeding patient group; and creation of patient information resources to maximise serodiscordant couple awareness of the requirement for pre‐conception counselling and treatment options available. We believe such a framework is vital to guide and empower medical professionals in the appropriate usage of PrEP in this patient cohort and ultimately provide the best patient care.

Lisa Horgan · Christopher C Blyth · Asha C Bowen · David A Nolan · Andrew P McLean‐Tooke

To the Editor: Norman and Teede outline the new international guidelines on polycystic ovary syndrome (PCOS), led by Australia and involving 37 societies and patient support groups and 71 countries.1 These guidelines highlight gaps in evidence and emphasise the critical need for more research into PCOS.2 In the United States, a recent analysis of National Institutes of Health (NIH) research funding from 2006 to 2015 for PCOS concluded that PCOS research may be underfunded by the NIH.3 In Australia, the National Health and Medical Research Council (NHMRC) is the premier funder of medical research and its main funding mechanism is by way of project grants, with over 500 granted annually. Using NHMRC online data (https://www.nhmrc.gov.au/grants-funding/outcomes-funding-rounds/previous-outcomes-project-grants-funding-rounds) and searching for “polycystic” or “PCOS” in the titles of funded project grants, we found only nine grants associated with PCOS from 2003 to 2018. Additionally, while there are many not‐for‐profit organisations raising funds for medical conditions, there are none for PCOS. We have considered the issues that may affect funding for PCOS. It could be that the name PCOS does not accurately describe the condition because having polycystic ovaries is neither needed nor sufficient in order to diagnose PCOS, and the name does not indicate any of the condition's important metabolic symptoms.4 This could potentially lead to grants being assigned to panels without the full expertise required to handle such grants. Barriers to funding in Australia could also potentially include a lack of internationally competitive researchers in PCOS in Australia, but this is not the case. Australia has established an international network in PCOS and led the world by producing the first evidence‐based guidelines.2 Three individual Australian researchers are listed in the top ten in the world in PCOS research (http://expertscape.com/ex/polycystic+ovary+syndrome). This attests to the calibre of Australian researchers in PCOS. We acknowledge that the international guidelines were funded in part by the NHMRC via a Centre for Research Excellence in PCOS. The Centre's efforts have positioned Australia at the forefront of international PCOS activities and have highlighted the vital need for specific dedicated research funding. However, given Australia's leading global role in the development of PCOS guidelines and identification of knowledge gaps, we, along with patient support groups, believe that greater efforts are required to recognise the prevalence, diverse clinical impact and health and economic burdens of PCOS, and to prioritise funding for research into PCOS.

Raymond J Rodgers · Jodie Avery · Veryan McAllister

In reply

Helena J Teede · Robert J Norman · Rhonda M Garad

Dr Jessica Foley is a full-time doctor and part-time professional football player

Cate Swannell

Med J Aust 2019; 210 (6 Suppl).