ASHM Report Back
Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.
Adam Bourne (La Trobe University, Melbourne) defined “chem sex” as recreational drugs, (usually crystal meth, methedrone, GHB , GBL, or ketamine) taken immediately before and/or during sex between men. It is facilitated by sexual networking apps and SOP venues. In his study of MSM: 6.6% had used in the previous 4/52 but 21.95 of HIV+ve men. The figure rose to 32.7% in London.
The figures varied from 5-15% in a European MSM internet survey. Participating in chem sex was strongly associated with previous drug use, STI, PEP use and group sex. It came with an increased risk of UAI and new partners. It may be used to overcome a reduced libido but once indulged can lead to difficulty in enjoying “sober”sex.
Dominic Rowley (consultant in sexual health and HIV medicine at The GUIDE Clinic at St James’s Hospital in Dublin) talked about emerging STI’s and resistance:
50% of HIV diagnosis in 2014 were late presenters and synergy with STI’s is well known. For example the presence of urethritis is associated with an 8 fold increase in vRNA. He reviewed the state of play of STI’s:
NG 80,000 in Europe 2015. MSM majority and increasing. Ceftriaxone resistance emerged in Japan in 2012 and is a great concern.
CT 350000, and commoner in heterosexual population. There is a 10% failure oral infection clearance with azithromycin when compared to 2% with doxycycline. It has been suggested that a single dose of azithromycin may not be enough. He recommended a test for cure in all patients or to use doxycycline 100mg BD for 1/52. He highlighted the anomaly of not performing anal/throat swabs in heterosexual females despite the knowledge that UAI/oral sex is common.
MG he referred to the Melbourne study recommending an initial 1/52 doxycycline course followed by azith or moxifloxacin.
Syph increasing incidence and increasing macrolide resistance
Shigella emerging as an STI associated with oro/anal contact like HepA
LGV increasing incidence in Europe
Luisa Salazar-Vizcaya (Postdoctoral researcher; Inselspital, Bern University Hospital, University of Bern ) looked at nsCAI (condomless AI with non steady partner) in MSM. she found a general increase over the past 10yrs. She described 4 behavioural clusters and postulated that awareness of reduced HIV transmission with ART, and awareness/availability of PrEP had led to this finding.
David Zucman (Internal Medicine, Hopital Foch, Suresnes, France) reported a recent Hepatitis A outbreak in MSM , the largest in history and an emerging worldwide problem. There is now a worldwide shortage of HepA vaccine as well as HepB which I was unaware of; I suggest ordering supplies immediately! He found that although 76% of HIV +ve were immune only 39% of HIV-ve were.
David Stuart (ChemSex support programmes at 56 Dean Street sexual health clinic in London) and David Atefi (Atlanta Gastroenterology Associates) described the provision of chem-sex support at the Dean St Clinic in London. This has been running since 2011 as a walk-in clinic. They see 40-50 clients/week. His study showed significantly higher rates of STI/HIV testing rates and self-reported improvement in confidence in managing their chem use and risk taking behaviour.
Teymur Noori (European Centre for Disease Prevention and Control Solna, Sweden) reported from the Hornet/ECDC study showing attitudes to take up of PrEP. 17 questions were presented in 8 languages via the Hornet MSM app. They had 12,053 responders of which 11%HIV+ve. 10% were using PrEP of which 50% was from a doctor but 50% was informal supply. 31% had not informed their health provider.
Of those taking PrEP, 50% had also taken PEP, were more likely to be tested for, and diagnosed with STI’s. They also reported greater happiness with their sex life!
Valentina Cambiano (Research Associate in the Department of Infection & Population Health at the Institute of Epidemiology & Health Care at University College London) presented some results from the aurah2 study. This study was conducted in three sexual health clinics in U.K. Between 2013-2017. 668 completed annual questionnaires. She found increased PrEP awareness from 43-92% in the period and 23% rate of use. she made the point that these clinics had taken part in the PROUD study and that awareness may have been higher. I was also surprised at the 85%+ caucasian / 75% tertiary educated demographic which I thought underrepresented the lower SE classes in London particularly.
Overall this was a very interesting session although, as one of the chairs mentioned: no one had addressed the definition of “bad sex!”
Robert Zangerle (Austrian Society of Dermatology and Venereology) found thatanal cancer is 300x more common in HIV+ MSM in Austria. He studied the extensive database of the HIV cohort 2003-2015 where he identified invasive anal Ca in 47/7500 patients; of these, 7 died of their cancer and 4 of AIDS related illness. There was no information available on sexual habits and HPV vaccination rates (assumed to be very low.)
Carmen Hidalgo-Tenorio (Infectious Disease Unit, University Hospital Virgen de las Nieves, Granada, Spain) looked at HSIL in HIV +ve women in Spain. Of the 95 women, 28.4% had had anal intercourse. Anal cytology was normal in 46%, 22.1% were positive for HPV with a negative smear, and 13% were atypical. She found HSIL IN 16/100,000. Significant predictors for HSIL were number of sexual partners >3 and abnormal cytology. Interestingly atypical anal cytology was commoner than cervical in HIV positive women.
Alessandra Vergori (Rome, Italy) reminded us that PLWH have 15-25 x rate for anal ca and 2.1 x that for oral. She studied 395 HIV +ve men. 96% were on ART, 47% were smokers. The average number of sexual partners were 100 for MSM and 12% in heterosexual men. HPV was present in 20% oral, 83% anal testing and 50% of anoscopy samples showed atypia. Significant associations were the number of sexual partners and a low CD4 count.
Deborah Konopnicki (Centre Hospitalier Universitaire Saint-Pierre, Brussels) gavethe stark statistic that the mortality rate for invasive anal Ca is 31%. Screening for anal and oral HPV is difficult and a more practical approach is vaccination. HPV vaccines are virus-like particles and completely non- infectious. 9vHPV is now available covering serotypes 16/18/31/33/45/52/58/6/11. Good AB levels persist for at least 12 yrs following vaccination. Vaccination has been proved to be safe and effective in HIV+ Patients but vaccination is much more effective in everyone when given before significant HPV exposure ie. in early teens. EACS recommendations are to vaccinate all women up to age 26y and all MSM to 40y if HIV +ve or 26 if -ve
Vaccination reduces relapses in treated HPV by 65% in women and 50% in men.
It has been shown that if vaccinated under 15yrs, 2 doses and probably 1 dose are as effective as the triple dose regime. The consensus appears to be that single dose vaccination will be recommended in primary vaccination of teens but 3 doses are still required in HIV patients.
Laura Benjamin (Wellcome Trust Liverpool Glasgow Centre for Global Health Research) presented her research on a cohort of HIV patients suffering stroke in Malawi. She found an increased risk associated with lower CD4 count but not with viral load. The strokes were mainly ischaemic rather than haemorrhagic. There is increasing evidence of stroke as a co-morbidity and it is thought to be due to HIV- related vasculopathy causing inflammation and endothelial dysfunction. It is important to consider treatment failure with opportunistic infection if stroke occurs in someone on ART.
Neurocognitive impairment remains an important problem in HIV patients despite ART. Carmela Pinnetti (Italian Ministry of Health) presented a study exploring the association between neuronal injury markers and NCI. She confirmed that plasma and CSF markers were important indicators of impending NCI. Valentina De Zan (Department of Microbiology, Verona University) then pointed out that despite ART, the HIV virus may persist in CSF and can escape causing neurological symptoms. She studied 46 neuro-symptomatic. She found CSF viral detection at a higher rate than plasma as well as undiscovered viral resistance. Optimisation of ART led to 65% recovery although a few relapsed at a later date.
Aoife Cotter (Consultant in Infectious Diseases at the Mater Misericordiae and St Vincent’s University Hospitals)presented the POPPY study. This looked at an aging group of HIV patients, over and under 50yrs against controls over 50yrs. The older patients had lower BMD after correcting for other variables. A higher CD4 count and current ART were associated with lower BMD. Tara McGinty (Clinical Research Fellow, UCD School of Medicine, Dublin) confirmed HIV as an independent predictor of reduced BMD but stressed the need to assess trabecular bone score as well, (this is also reduced in HIV.) The lumbar spine is more effected and predictably smoking, and prior fracture were the most important predictors of more severe osteoporosis
Pablo Ryan (Hospital Universitario infant Leonor, Madrid) pointed out that osteonecrosis is more common in people living with HIV (PLWH.) They require THR. He compared complication rates in HIV vs controls in 348,000 patients who underwent THR in Spain including 1018 HIV+ve. ON rates were higher in HIV but there were no differences in surgical complication rates.
Diagnosis and management of Non-Alcoholic Steatohepatitis (NASH) & Non-Alcoholic Fatty Liver Disease (NAFLD)
Sanjay Bhagany (Consultant physician/honorary senior lecturer in infectious diseases/HIV medicine, Royal Free Hospital, London)
Emmanuel Tsochatzis (senior clinical lecturer and consultant hepatologist at the UCL Institute for Liver and Digestive Health, Royal Free Hospital, London)
Abnormal liver function (LFT) tests and fatty liver are common and often frustrating conditions seen in general practice. I see a significant number of refugees who have abnormal LFTs as well as managing patients with HIV with abnormal LFTs so I was keen to get up early and get to this 7:30am lecture!
Emmanuel made the important point that you can’t always trust the LFTs. Patients can have severe disease with normal LFTs and grossly abnormal LFTs with just fatty liver. It is important to remember that 25% of general population have fatty liver and of those 10% develop cirrhosis.
Fibroscan is important for assessing liver disease although for rural towns like mine, access can be an issue.
Steatosis can cause over-estimation of stiffness in fibroscan. A fibroscan result of >7 is worrying in fatty liver.
Important strategies for everyone with abnormal LFTs associated with fatty liver include addressing CVD risk factors, there is some evidence this will improve fatty liver. We should be considering fatty liver as part of metabolic syndrome, commonly managed in general practice. Extending this to people living with HIV is important as HIV infection itself is fibrogenic.
NASH/NAFLD prevalence in people living HIV is up to 50%. Causes are multifactorial and include HAART therapy plus virus protein inflammation plus lifestyle. Nadir CD4 count and a history of use of older HIV drugs are risk factors for liver disease.
Emmanuel talked about some of the difficulties in making an accurate diagnosis of fatty liver including ultrasound and biological markers as well as non-invasive assessments, all of which have their limitations.
Treatment essentially is about reducing weight including bariatric surgery if appropriate. Emmanuel talked about the experimental use of maroviroc.
In summary, it is important to think of NASH/NAFLD in people living with HIV and reducing cardiovascular risk and monitoring of progression are the mainstay of management.