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.

An early morning blog spawned by a salty dash of guilt for not having reported back much this time around and a state of not-being-able-to sleep.

This is the final day of the conference.

Last night a symposium was held that was organised by ASHM and supported by the Victorian Government: ‘Working towards AIDS 2014 in Melbourne: a partnership approach- symposium on priority issues in HIV.’ The meeting was chaired by Sharon Lewin and speakers were Gary Quinlan, Australia’s Ambassador to the UN, Tony Fauci, Paul De Lay, Deputy Executive Director, Program UNAIDS, Myron Cohen who led HPTN052, Dede Oetomo, Trustee of GAYaNUSANTARA, from Indonesia and the President of ASHM. The symposium tightly focused upon what might be deliverable over the next few years leading up to World AIDS 2014.  Key messages included: 1. Paul De Lay: countries need to work quickly and efficiently to meet the targets set by UNAIDS in 2011; 2. Tony Fauci: we can have an AIDS-free generation using HIV prevention and treatment without necessarily having a cure and vice versa; also he cautioned against us conceptualizing that we have ended the scientific era and that we are now entering the implementation era as he believes that a number of important scientific discoveries lie ahead of us in HIV medicine; 3. Myron Cohen: new, promising agents for HIV prevention are in view including long-acting injectable drugs and cervical rings for PrEP and data on these should be available in 2014; 4. Dede Oetomo: we need to continue to use social science to understand the cultural and sociological/ anthropological aspects of human behaviour in order to make any roll out of HIV care and treatment effective. 5. ASHM President: future challenges for managing the HIV epidemic in the Asia Pacific region include increasing country ownership of the HIV response, ongoing decriminalization to end discrimination against MSM, people who inject drugs, sex workers and transgender people, the need for high quality home-based HIV testing and linkage of HIV care with diagnosis and management of non-AIDS illnesses.

We really look forward to a great World AIDS Asia Pacific regional conference in Melbourne 2014.

Tagged in: AIDS 2012
Including sex workers, drug users and MSM in prevention and treatment

Fabulous plenary session in more way than one this morning. The first three speakers spoke passionately about the inclusion of marginalised populations in the response to HIV, reminding us that strategies that are developed without the full participation of affected communities are likely to fail.

Dr Paul Semugoma from Uganda highlighted how many countries are failing to provide adequate access to prevention and care for men who have sex with men, resulting in higher rates of HIV among most MSM populations, particularly in the developing world. Prejudice and homophobia remain major barriers to effectively working with MSM, and Semugoma argued we need to "fight stigma with data" to counter misinformation. Dr Semugoma argued that donors should insist that countries' HIV strategies address MSM and paid tribute to activists who have suffered and died trying to achieve rights for MSM, including the late David Kato.

Cheryl Overs (Monash), founder of the Global Network of Sex Work Projects, sounded a warning note about rolling out new prevention and testing technologies without adequate consultation with and protections for sex workers. She suggested that developments such as PrEP and rapid testing could be used to coerce sex workers into having unprotected sex, with the industry seeing a market opportunity to use new technologies to sell unprotected sex. Overs reminded the conference, to much applause, that although the US decision's to allow entry of HIV-positive people into the country is long overdue and welcome, people who admit to being current sex workers or injecting drug users remain barred from entry. This means that the conference is failing to represent affected populations, undermining the response.

This criticism, summed up in the slogan, "No drug users? No sex workers? No International AIDS Conference", was taken up by Debbie McMillan. As McMillan put it, as an African American transgender woman, former drug user and sex worker who has been incarcerated, her chances of avoiding HIV were slim - but that does not mean she could not or cannot address HIV, which she now does as a counsellor. McMillan criticised the continuing US ban on federal funding for needle and syringe programs, despite the overwhelming research showing their beneficial effects - as she put it, "I don't need the research to know this is true." Debbie's testimony of growing up in poverty, wrestling with her sexual identity, doing sex work, becoming drug addicted and being incarcerated was powerful, and starkly illustrated the inequities faced by many in the US. McMillan spoke convincingly about the value of non-judgmental drug treatment programs, specifically designed for LGBT people, that helped her manage her addiction, come to terms with being a transgender woman, and fire her enthusiasm for activism.

The final speaker, Gottfried Hirnschall (WHO), gave an overview of the achievements to date in promoting global treatment access for HIV, suggesting that while current targets are aiming for 15 million people on ART by 2015, we need to start thinking about bigger and bolder targets. Acknowledging the previous speakers, he noted the huge disparities in roll-out and access, particularly among stigmatised groups. For example, it is estimated globally no more than 10% of HIV-positive IDU have access to treatment. Hirnschall went on to discuss another hot topic - treatment guidelines and when to initiate treatment. He noted that even a compromise guideline to initiate treatment at ≤350CD4 with treatment as prevention for people in discordant couples (for example) would include 23 million people globally - which is why scale-up needs to be considered now. Hirnschall noted that none of this will work without universal access to HIV testing, and that it has become vital to broaden access to testing. He referred the audience to the WHO's new strategic policy framework for HIV testing and counselling, released today (download here). The framework emphasises that all countries trying to boost uptake of testing need to consider a range of approaches in addition to clinic-based testing, most notably community-based testing and self-testing. I think this framework will be a valuable tool as we plan for Australia to offer rapid testing in a range of settings, and consider the merits and risks of home-based testing.

Tagged in: AIDS 2012

The issue of breastfeeding for HIV positive mums was discussed in detail at a special session today. I tend to forget the legacy of previous advice to not breastfeed, combined with heavy marketing of formula feed. Would you have ever guessed that breastfeeding rates in some parts of South Africa are 6-8%! The WHO guidelines recommend exclusive breastfeeding for at least 6 months, since the mortality of HIV negative bottle-fed babies was increased 6 fold in resource poor settings. Plus the Mma Bana and Kisumu breastfeeding studies showed that cART could reduce the postnatal MTCT transmission rates.

How to tackle re-educate and change practice was discussed by Yogen Pillay from South Africa. They have taken both a top down (ministerial statements and the restriction of formula to prescription-only), and a bottom up approach (involvement of traditional healers and community peer workers), and are reaping slow but steady success. Ensuring time and space for women to breastfeed was key.  Prof Tyllaskar from Norway’s group also showed that a focus on the whole community was crucial to changing breastfeeding practice, not just targeting HIV positive women. He doubled breastfeeding rates over a year with a program of peer-counsellors as part of the larger PROMISE study in South Africa, Burkina Faso and Uganda. 

Not so relevant in the Australian context when safe, affordable, reliable and quality formulas are available if necessary for HIV positive mums, but a sobering insight into the impact the guidelines of the WHO and the advertising from formula companies can have on a vulnerable population who just want to protect their babies from HIV.

Tagged in: AIDS 2012
Reach for the stars, keep your feet on the ground

... So said the former American president Roosevelt. The opening ceremony is going well. It is a hot Washington day.

It is now feasible once again for this conference to be held in the USA after more than two decades. The recent policy  change in allowing international openly positive HIV people to be welcomed in the USA is an important and much needed step forward.
The AIDS 2012 theme is "Turning the Tide Together".

The platform speakers - scientists, community leaders, faith based leaders, celebrities and importantly those infected and affected share much enthusiasm and encouragement as well as messages of hope. There is a repeated call that ongoing political and  community responses and resources are needed to allow science to continue to increase the knowledge needed to deliver progress in searching for cures and vaccines, and to continue to make available the essential education, prevention and treatment services. For me, the image of hope that most resonates is the image of the AIDS quilt panel - "The Last One". See attachment. I saw this yesterday at a preconference event.

Platform speakers included a 24 year old HIV infected woman from Zimbabwe, the Washington gay men's choir, two recently imprisoned Iranian physicians, an African - American pastor, HIV program leaders, the president of the World Bank, an actress and the UNAIDS director with more to follow...

Tagged in: AIDS 2012
Twitter response: "Could not authenticate you."