Morbidity, African Female Sex Workes, Cervical Screening in South Africa

Greetings

 

My apologies for not getting this blog out earlier (time travel and jet lag)

 

What a great conference.  It has been great pleasure to meet many of the 2015 CROI ASHM bloggers.

 

There has been a lot of research and data looking at HIV infection and chronic systemic inflammation measured by an array of inflammatory biomarkers to predict HIV morbidity from cardiovascular disease, Neuro cognitive disease and cancers to name a few.  This research has highlighted the importance of HIV infection and the risk of HIV morbidities especially in older age groups and that predictive value of traditional markers in HIV infection such as CD4 and VL must be further evaluated.

 

To continue on this theme of HIV morbidity; Steven Grindspoon of Massachusetts General Hospital.

Presented cardiovascular disease in HIV patients – An emerging Paradigm and call to action

This plenary session presented that the understanding of current CVD risk in HIV is limited as are treatment preventions. Chronic inflammatory biomarkers can be used as predictive markers. HIV individuals at risk of CVD risk are not identified through traditional screening pathways. We should not forget the HIV drug combination and other factors such as smoking, body fat composition, type 2 diabetes, platelet dysfunction, endothelial, renal function that contribute to CVD.

 

HIV immune activation relates to novel atherosclerotic phenotype in HIV. It is therefore vital to identify these individuals who may be at risk of CVD. With the current CVD risk stratification many individuals would not receive recommendation for statin treatment under current guidelines.

 

It is known that statins decrease CVD events in non HIV patients with low LDL and raised CRP (LDL lowering and dampening immune activation)

 

Newer statins do not effect glucose and less likely to have drug interactions with ARVs. Pitavastatin is primarily metabolised by glucoronidation. Minimally metabolised by CYP3A which have very little drug interaction with ARVs and no dose reduction needed

REPRIEVE a RCT, looking at Pitavastatin versus placebo in asymptomatic HIV participants with a cardiac risk score of less than 7.5

 

Conclusion – Traditional and non tradition risk factors contribute to CVD, modulation of these factors needed. Atherosclerotic plaque formation in HIV positive individuals has unique pathophysiology and characteristics.  Significant challenges remain to identify at risk individuals and prevention strategies.

 

Cynthia Firnhaber presented a one year follow up cervical screening in HIV positive women in South Africa, this is significantly poignant as Cervical cancer is the highest cancer in women in Africa and responsible for 23% of all cancers. The risk of cervical cancer in HIV positive women is 3-6% higher than the general population.

 

In this cohort of 671 women 392, 92% were on ARVs, 80% were fully suppressed, average CD4.

 

Cynthia Furnhaber, University of Witswatersrand, Johannesburg, South Africa

One year follow up of HIV positive women, screen with VIA (visual inspection with
acetic acid), HPV and cytology

Cervical cancer is the leading cause of death in South Africa, with the risk of developing cervical cancer in HIV cancer 3-6 times the general population. In the WHO Africa region AFRO in 2012, 250,317 died of cancer (23% cervical cancer).

 

Screening for cervical cancer has proven preventable measure

1202 HIV positive women screen from a Johannesburg Clinic. All positive PAP smears and VIA had a colposcopy. Abnormal cervical areas got cryotherapy with CO2 or NO2.

837 women enrolled at baseline and 677 reviewed at one year. Characteristics such as age, CD4, VL, HPV were analysed separately.

Baseline 33% HSIL, 40%LSIL, 27% Normal a

One year follow up HSIL 7%, LSIL 70%, and Normal 23%

Average CD4 387, 87% VL< 1000, 93% ARVs

16% New HPV infection, 48% cleared HPV infection,

22% Progressed, 63% regressed via VIA

 

This study concluded that even HIV positive women who are on treatment have a significant risk of CIN progression and that cervical screening and access to healthcare is imperative to ensure gains in health for HIV positive women.

 

 

A eye opening plenary by Frances M Cowan, University College London, London, United Kingdom

The Price of Selling Sex: HIV Among Female Sex Workers—The Context and the Public Health Response

 

Globally female sex workers (FSW) are more 15% more likely to have HIV than general population. Meta-Analysis of the Burden of HIV in FSW –Asia 29% (countries not defined), Latin America 12%, Sub Saharan Africa 12% and modes of HIV transmission probably underestimate the effect of FSW in HIV transmission globally.

 

This talk then looked at prevention framework, legislation against violence against sex worker could reduce HIV transmission by 17-20% 0ver next decade, decrimalising sex work reduce HIV transmissions by 33-46% over the next decade.

 

Prevention framework should be through (individual, peers, community, public policy, and environment)

1)      Structural. Social justice and human rights.

2)      Behavioural

3)      Biomedical ART and Non ART

 

Implementation through social cohesion and safe space, collective power and sex worker participation.  (lubrication and condoms, STI treatment, HIV treatment, contraception, drug education, peer review, violence reduction and community empowerment.

Systemic review and met analysis of 22 studies and 33,000 FSW, showed a significant reduction in HIV, STIs (Gonorrhea, Chlamydia, Syphilis) and an increase in consistent condom usage with new and regular clients. Also discussed were newer biomedical interventions such as PrEP, PEP and HIV treatment to prevent MTCT.

 

WHO Guidelines - HIV diagnosis, treatment and care for key populations 2014

This talk focused on Sisters with a Voice  started in 2012 HIV and STI programme for FSW based at 5 sites in Zimbabwe –  Clinical services, health education, peer educators, community empowerment

24,000 women seen, 20,000 STI treatments, 7500 HIV tests, 3,200 HIV diagnoses and referred fro treatment. 1.4 million Condoms distributed (M) 96 000 (W) in 2014. 10 new HIV infections per 100 yrs follow up.

HIV prevalence in FSW in Zimbabwe 50-70%, minority are

SAPPIRE (Sisters Anti retroviral Programme for Prevention of HIV-an Integrated Response)

14 outreach sites in Zimbabwe, 200 FSW per site, 2800 in total

Random allocation of usual care sites to intervention sites

Usual care – (condoms, health education and HIV referral, Syndromic STI treatment, contraception, cervical screening and legal advice)

Intervention sites – (all usual care plus –HIV negative  HTC and PrEP, HIV positive – POC CD4 and onsite ART, community mobilisation – SMS and adherence support,  Adherence sisters programme.

 

Conclusions

Global epidemiology FSW 13.5 times higher risk of HIV than general population, effective HIV prevention and treatment programmes, novel biomedical approaches.

 Proper inclusion of sex workers and other key populations is essential to reach 90:90:90

 

The Thursday Afternoon Themed discussion  PEP- Remember me?

Kenneth H. Mayer

Fenway Health, Boston, MA, United States

 

Overview – Changes with PEP is transmission risk is one off event which needs prompt response with treatment, mostly conducted with animal studies and occupational studies, HIV transmission is relatively inefficient <1%. Guidelines are based on peer review studies. PEP guidelines vary with country to country even centre to centre.

Other options such as Behavioural/exposure/adherence, decrease host susceptibility, decrease source HIV infection

 

2014 WHO HIV PEP guidelines FOR Adults, adolescents and children 2014

PEP drugs 3> 2 is better

In adults and adolescents

-      2 ARVs is effective but evidence strength is low

-      TDF/3TC as preferred backbone evidence low- moderate

-      LPV/r or ATV/r as 3^rd drug Evidence very low (where available RAL, DRV/r, EFR considered as alternate options)

-      28 days good strength but evidence low

-      Adherence support conditional but evidence

Children

-      AZT/3TC preferred evidence low (ABC/3TC or TDF/FTC if available)

-      LPV/r (ATV/r/RAL/EFR/NVP) alternatives evidence low

-       

This looked at data from Tenofovir/Emtricitabine Plus LPV/r vs. MVC or Raltegravir for PEP: 2 Randomized Trials

Lorna Leal, Hospital Clinic Barcelona, Barcelona, Spain

 

Rilpivirine-Emtricitabine-Tenofovir for HIV No occupational Post exposure Prophylaxis

Rosalind Foster

Sydney Sexual Health Centre, Sydney, Australia

Significant Intolerability of Efavirenz in HIV Occupational Post exposure Prophylaxis

Surasak Wiboonchutikul

Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand

Management of Acute HIV After Initiation of Postexposure Prophylaxis: Challenges and Lessons Learnt

Goli Haidari

St Mary's Hospital–Imperial College Healthcare NHS Trust, London, United Kingdom

 

There were many good questions directed at the panel.

Drug tolerability and good adherence

Cost effectiveness and cost 2 drugs vs 3 drugs

No clear guidelines on HIV seroconversion during PEP

POC HIV tests  vs  4^th generation tests at baseline

Time to treatment similar to Occupational PEP

Genital tissue drug levels in men versus women - PrEP studies and long acting agents

This session concluded that there is very little evidence behind PEP especially with the newer drugs, WHO recommends 3 drugs  in PEP 2014 guidelines

Tolerability of drugs ( side effects and pill burden) impact on completion and adherence

More work is needed in this field