on behalf of the END RHD CRE Investigators Collaborators Acknowledgements: • Children, families and communities living with RHD-We thank the Aboriginal and Torres Strait Islander people for sharing their stories in the Endgame Strategy, and acknowledge that the research and data in this publication reflect the experiences of Aboriginal and Torres Strait Islander people and communities affected by the ongoing trauma of ARF and RHD. • END RHD Review Working Group-We thank the following members of the END RHD Alliance, who formed an expert working group to review content of the Endgame Strategy for feasibility and acceptability, including review from a cultural perspective:

Background Rheumatic heart disease (RHD) is a preventable yet deadly condition resulting from untreated Group A Streptococcus infection. Despite being eliminated from most high-income countries, RHD and its precursor acute rheumatic fever (ARF) persist in developing countries and settings of disadvantage. In Australia, Aboriginal and Torres Strait Islander people experience among the world's highest rates. Following five years of research, investigation and advocacy, the Endgame Strategy provides a technical foundation to eliminate RHD in Australia by 2031. Methods A range of potential strategies to reduce ARF and RHD were identified. Approaches at the social and environmental, primary, secondary and tertiary prevention levels were evaluated using the GRADE Evidence to Decision framework, together with structural review of the health system. Recommendations were made according to level of prevention opportunity and responsibility. Modelling was undertaken to estimate the health and economic impact of an indicative bundle of the most promising strategies. Results Reducing household crowding, improving health infrastructure, strengthening primary healthcare and enhancing delivery of secondary prophylaxis were identified as having the greatest potential impact on RHD. They are also largely acceptable, practical and readily implementable with investment. Modelling indicates that this approach would reduce ARF and RHD by 69% and 71% respectively, preventing 471 deaths and saving $188 million on healthcare expenditure to 2031. Conclusions Eliminating RHD is only possible with a holistic approach led by Aboriginal and Torres Strait Islander people with communities at the core. This will entail funding communities to develop programs, resourcing a national RHD unit to coordinate efforts across Australia, guaranteeing access to healthy housing and built environments, establishing comprehensive skin and throat programs and improving the health of those living with ARF and RHD. Key messages RHD demands responses from the health sector strengthened by political advocacy and engagement to drive evidence-based decision making. The evidence and collective experience now exist to eliminate RHD, an exemplar of the gap in health outcomes between Aboriginal and Torres Strait Islander peoples and the non-Indigenous population.

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Issue addressed: Aboriginal and Torres Strait Islander peoples inAustralia have an inequitable burden of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), concentrated among young people and necessitating ongoing medical care during adolescence. There is an unmet need for improved well-being and support for these young people to complement current biomedical management. Methods: This pilot program initiative aimed to determine the suitability and appropriate format of an ongoing peer support program to address the needs of young people living with RHD in urban Darwin. Results: Five participants took part in three sessions. Findings demonstrated the peer-support setting was conducive to offering support and enabled participants to share their experiences of living with RHD with facilitators and each other. Satisfaction rates for each session, including both educational components and support activities, were high. Conclusions: Learnings from the pilot program can inform the following elements of an ongoing peer-support program: characteristics of co-facilitators and external presenters; program format and session outlines; possible session locations; and resourcing. So what?: Peer support programs for chronic conditions have demonstrated a wide range of benefits including high levels of satisfaction by participants, improved social and emotional wellbeing and reductions in patient care time required by health professionals. This pilot program demonstrates the same benefits could result for young people living with RHD.

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