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.

This IAS 2017 session was dedicated to addressing HIV in 4 main populations that have been identified as “key” around the world, including migrants, sex workers, men who have sex with men and people who inject drugs.  The studies presented had varied countries of origin which helped to demonstrate that key populations vary worldwide.

 

The first presentation presented data from the aMASE study to determine the rate of migrant acquisition of HIV in Spain. This was a multi-centre cross sectional study that collected data from both patient questionnaires and clinical notes in 6 regions around Spain of patients who had been diagnosed with HIV in the preceding five years and had lived in Spain for a minimum of six months at time of diagnosis.  A range of information was collected including socioeconomic, behavioural, migratory, previous HIV testing, CD4 and viral load levels and resulted in a statistical analysis to determine most likely time and place of acquisition.

 

Of 710 participants, there was sufficient data to estimate time of acquisition for 685.  77% of the analysed respondents were men and 60% were MSM, 20% heterosexual women and 14% heterosexual men.  Median age was 35 years and median time in Spain was 9 years.  The region of origin were Europe 17%, Latin America 64%, Sub Saharan Africa 13% and others 6%, this trend is reflective of the large numbers of Latin American people migrating to Spain and so mirrors broader population trends.  A total of 72% of the sample were estimated to have acquired HIV whilst living in Spain.  Factors associated with post migratory acquisition were Latin American origin, younger age and increased duration of stay in Spain and the proportion was also higher in MSM.  This highlights 2 key populations that are being failed with regards to prevention, migrants (especially Latin American) and MSM and suggests who needs targeting in national prevention strategies, such as PrEP.

 

The second presentation presented data collected on transactional sex in MSM from Vancouver, Canada and has been blogged about by one of my colleagues, so I will only briefly touch on this presentation as it has been covered more extensively elsewhere.  The motivation for this study was to ascertain whether transactional sex in MSM is a causative factor in HIV transmission.  The study objectives were to determine prevalence of transactional sex events and evaluate temporal trends and consequences such as HIV risk or acquisition in a prospective cohort study.  Results of 690 participants and 8990 sexual events revealed that transactional sex was rare with 2.4% reporting receiving, 1.2% reporting giving, 0.3% reporting both giving and receiving.  To assess HIV risk, the investigators focussed on condomless anal sex and HIV concordance, discordance and unknown status and there was no statistically significant difference between these groups and whether they engaged in transactional sex or not.  Factors that did increase the risk of transactional sex included low income, loneliness, substance use of the partner (GHB and methamphetamine) and meeting online.

 

A third presentation of a study nested into France’s Ipergay study presented data about the suitability of on demand PrEP for chemsex participants.  The objectives of this sub study were to better characterise chemsex participants and study the association between engagement in chemsex and PrEP use.  Chemsex participants were found to be more likely to use anxiolytic medications, be sensation seeking and have increased numbers of sexual encounters.  They were also more likely to have condomless anal sex, hardcore sexual practices and perceive themselves to be at higher risk of HIV.  What was notable was that they were also more likely to use PrEP perhaps due to their justifiably perceived higher risk.

 

Fourth was a study from south Africa on health outcomes of children of female sex workers, who have about a 60% HIV prevalence rate.  This was undertaken in the form of a cross sectional study at sex work venues and mobile health centres from September 2015- February 2016.  The mothers completed a questionnaire and HIV testing.  The children were also tested for HIV and growth parameters measured.  Results demonstrated maternal HIV prevalence at 67.5% and ART at 63.6% and overall HIV prevalence in their children was 3%, rising to 4.5% in HIV positive mothers.  Full vaccine coverage decreased as the children got older and 27% of children’s growth was stunted, a reflection of their nutritional status.  This study really highlighted that health services for sex workers would be well placed to expand into caring for the children of their key population as well.

 

The Vietnamese DRIVE-IN study presented data on HIV and HCV incidence and risk in people who inject drugs in a longitudinal follow up of 204 eligible participants.  Of the 204, 105 were HCV positive only, 94 were negative for both HIV and HCV and 5 were HIV positive only.  No HIV seroconversions occurred during the 1 year follow up period but 18 HCV seroconversions occurred.  Factors associated with HCV seroconversion included more injections and being arrested. This data supported the perception that HIV was low in this population but also brought to light that HCV needs to be addressed as a priority for this population.

 

Finally, data from a Kirby institute run, multi-site Opposites Attract trial presented more data to support treatment as prevention in male serodiscordant couples.  A total of 358 couples enrolled worldwide and the total couple year follow up was 591 years.  During this time, 3 seroconversions occurred.  All 3 seroconversions reported condomless anal sex outside the principal relationship and phylogenetic analysis of the seroconverted participants and their principal partner demonstrated overwhelmingly that there were no linked transmissions.  The data demonstrated that in over 12,000 acts of condomless anal sex with a virally suppressed HIV positive partner and a HIV negative partner not on PrEP, there were no transmissions of HIV.

Tagged in: 2017 IAS Conference

Dr Kevin De Cock delivered an insightful keynote lecture which has set the tone for what should be a very valuable conference. 

He presented the lecture titled " HIV, STIs and evolution in global health". Global health involves a a complex interplay of many different facets and although gains have been made in some areas, there is still unfinished business to contend with. These include finding a cure for HIV, vaccine development for HIV, TB and malaria and shorter answer simpler treatments for TB. 

In terms of STIs there are changes and goals to be achieved. This was highlighted with the numbers of cases of syphilis, rising in the US since 2001.  Of these increased numbers the majority of those affected are men, particularly MSM. Rate of congenital syphilis have risen by 35% ( did I hear that right?!) since 2013. What are we doing to decrease this burden? How did this happen? Is screening for syphilis occurring where the burden is highest?

Clearly there is no easy solution to these issues however it was concluded the forging alliances, stronger networks, deeper epidemiology and stronger science are part of the answer.

A very thought provoking keynote lecture....

Day 1 of APACC 2017

Other bloggers have written eloquently on sessions on day 1 at this meeting so I thought I might report on my impressions on the 'first 24 hours' of APACC 2017.

At conferences such as these, i am constantly reminded how lucky I am to be practising HIV Medicine in Australia, with universal healthcare and the PBS system for access to medications.

Australian clinicians and leaders in HIV Medicine (both in policy, research and mentoring) have been providing significant, and exemplary, leadership in the Asia Pacific region. This is certainly seen in the high regard and respect that is extended to Australian clinicians present at APACC. I had not realised this, but now wonder if there has been any interchange of knowledge at the 'grassroots' level of HIV care. I believe that we have a fantastic model of primary care management of HIV in Australia, and wonder if that is translatable to our regional neighbours. This may be an area for further exploration in the future, esp. as the RACGP already has associations with primary care groups in Malaysia and Hong Kong 

Many Asia Pacific countries can be considered 'resource limited' in terms of support from their government/health agencies and limited access to medications eg. China's public health clinicians do not have access to INSTI's or ANY STR's. The Chinese National Free Antiretroviral Treatment Program only has access to 3TC, AZT, d4T, ddI, NVP, TDF and EFV. Most recently LPV/r was added as the 2nd line option. Contrast this to Australian clinicians who are mostly proactively getting rid of Atripla from our medical armamentarium, switching to TAF containing STRs and have access to INSTI's.

Chemsex is also an issue in Hong Kong, as it is in Australia. A poster presentation which surveyed 30 HIV positive men diagnosed recently, revealed that all had used methamphetamine in the context of sex, and 73% of participants fulfilled DSM-IV criteria for stimulant dependence syndrome.

There is a ART backbone 'turf war' going on in the region due to the rise of the concept of dual drug therapy in HIV. In their industry-sponsored symposia, arguments were put forth for maintaining a 3-drug backbone esp with TAF which is not currently in widespread use in the region vs. moving to a 2-drug regimen for naive or switch therapies which has appeal to the region ie less cost. 

Tagged in: APACC 2017
APACC 2017—Key note lecture

Where is the epidemic heading?

Chris Beyrer opened the conference with his keynote lecture entitled, HIV/AIDS in the Asia Pacific: Where is the epidemic heading?

He told us that there are 5.1 million people living with HIV in the region, this is actually a low prevalence. However, only 41% living with HIV get ARV, which means approximately 3 million of these people don't get access to ARV's. Only Australia provides adequate levels of ARV coverage.

He went on to discuss key populations, these were defined as groups who have a disproportionate burden of HIV and also lack access to services, including:

  • MSM (Men who have Sex with Men)
  • Sex workers of all genders
  • Trans females who have sex with men
  • Discordant partners
  • Adolescents from all key populations

He went on to tell us that the major strain of HIV has also changed within the region and that a strain predominant in Bangkok is driving the increase in HIV in the Asia Pacific area.

Health as a human right was also touched on with Chris telling us that a low proportion of PWID are receiving ARV. Despite the efficacy of HIV PrEP being proved in 2011, the roll out of this HIV prevention strategy was yet to happen.

Chris discussed how dealing with stigma and discrimination issues is a valubale tool in the fight against HIV. He highlighted how the 'war on drugs' drives PWID underground and this in turn fuels HIV/HCV rates. He drew attention to the appalling treatment of MSM as well as PWID In countries such as Indonesia and the Phillipines. In a bid to end discrimination, UNAIDS has appointed a 'SOGI' (Sexual Orientation and Gender Identity) Officer to monitor rights abuses of the LGTBIQ community. Whether this officer has any powers or impact remains to be seen.

Chris' take home message about fighting HIV in the Asia Pacific region was clear: 'MORE NEEDS TO HAPPEN IN THIS REGION'.

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Tagged in: APACC 2017

Delinkage of the cost of research and development from drug prices

James Love, Director of Knowledge Ecology International

This was a fascinating talk that proposed an alternative model for R+D of new drugs that would reduce the cost of new drugs and improve access for all.

Love outlines how the current drug patent and monopoly for funding the R+D of new drugs has many challenges. Pharmaceutical companies invariably set prices for maximum profitability and costs have risen dramatically even over the past 10 years. The current trajectory means that high and middle-income countries will likely limit access and impose restrictions on those who receive these treatments, and resource-limited settings will face further inequities.

Love proposes an alternative model that funds R+D by “delinkage” of the cost or R+D of new drugs, from the final price of the product.  Alternative funding models for R+D have been proposed; drug research grants and contracts, R+D subsidies, incentives and innovation prize funds.

Some of the above initiatives already exist. There are NIH and EU framework grants, R+D subsidies such as the Orphan Drug tax-credits which are funds available for R+D on drugs for rare diseases (apparently 47% of new US drug approvals in 2015 fell under this model).

Love proposes expansion of current incentives, and progressively switching from the current system of monopolies to alternative models of funding. Progressive delinkage mechanisms could be introduced by governments over time that sequentially move prices closer to the marginal cost of production of the drug.

Love talked about the $15 billion spent on HIV drugs in the US annually with the return of on average one new HIV drug per year. Recently Bernie Sanders in his US election campaign proposed that $3 billion of this money be set aside to fund R+D for new HIV drugs and at the same time eliminate monopolies. He also advocated setting aside funds to reward scientists and researchers who contributed to the development of a drug via open source platforms. 

There seems to be growing support for Love’s model with many seeing the current system as unfair and ridiculously expensive. Apparently several members of the European parliament have expressed interest in the delinkage model, the Human Rights Council has asked states to support the principles of delinkage, India and the World Health Assembly have endorsed the model, the CEO of GSK has endorsed the delinkage model in the context of expensive drugs for rare diseases and several companies have endorsed it for the development of new antibiotics.

This issue has repercussions the world over, and is pertinent at a conference being hosted in sub-Saharan Africa that addresses the HIV and viral Hepatitis epidemics. While we come from a relatively privileged position in Australia, we do face shortages in provision of access to many of the new cancer medications, and one wonders how our health budget will fund the escalating pharmaceutical costs in the future.  This talk outlined an elegant alternative model of funding R+D that would be more equitable and allow universal access to new drugs for all.