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.

HIV Co-infections, hepatitis B, hepatitis C and TB

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There is ongoing optimism surrounding the evolving management for Hepatitis C.  But this is also tempered by the enormity of the epidemic of Hepatitis C around the world.  Whilst ~250,000 Australians living with Hep C will potentially have access to PBS subsidized highly effective directly acting antivirals in the coming months, there are still 80 million people worldwide living with hepatitis C with the vast majority in Africa (22 million) and Asia (12 million).  Many of these people do not know they have Hepatitis C (i.e. they are not tested).  We were also shown a sobering figure illustrating that the global burden from liver disease is increasing more rapidly than any other disease (including cardiovascular, respiratory, diabetes) and hepatitis C has now overtaken hepatitis B as the leading cause of liver-related morbidity and mortality in the world.   

An example of the mortality impact of hepatitis C was starkly demonstrated in a US study.  They showed that the median life expectancy was 78 years (without HCV or HIV), 60 years (with HCV) and 52 years (with HCV/HIV co-infection).  And as populations in high income countries like Australia grow older, the proportion of liver transplants and liver cancer due to hepatitis C continues to rise.

Well, let me end on a good note for those living in Australia.  We look forward to the first interferon and ribavirin-free single tablet regimen (Harvoni = Ledispavir + Sofosbuvir).  This drug has already been given to more than 200,000 people treated outside clinical trials and is proving to be a real game-changer for the traditionally difficult to treat patients with HCV genotype 1 (>95% SVR after 8-12 weeks in treatment naive).  Viekira-Pak has also been recommended by PBAC for those with genotype 1.  It is also exciting to see that pan-genotypic regimens like Sofosbuvir + Daclastavir has also been approved by PBAC for genotype 3.  Here's hoping that PBS listing will come in Dec 2015 or early 2016.

 

Jason Ong

Tagged in: HIVAIDS2015

Excellent plenary session lead by Ed Gane discussing an overview of the swift evolution of HCV over 25 years!

I've summarised the main points: 

- HCV first identified in 1989 as non A non B

 

Current epidemic

- 80-100 million (300,000 in Aust & NZ) and is overtaking HBV as liver mortality 

- infection leads to premature death - especially co-infected HIV/HCV

- the disease burden will continue to rise as infected (ageing) patients develop complications such as cirrhosis and liver cancer.

 

So, how do we eliminate HCV? 

Vaccination?

- genomic diversity (both virus & host)

- funding diminished now DAAs so potent 

- likely not to lead to eradicate HCV

 

Public Health interventions?

- eg harm reduction in PWID (syringe programs etc)

- can only do so much - decrease prevalence by 1/3 in countries which employ reduction methods ( and most countries don't)

 

DAA therapy?

- we need patients to be diagnosed prior to any dent being made in HCV prevalence

- currently Aust has reasonable diagnosis rates, but very poor treatment rates

- DAAs offering a new treatment paradigm for HCV by combining effective drugs with minimal SE and short durations

- e.g. Ledipasvir/Sofosbuvir (Gilead) - daily, oral, 12 week program, IFN & RBV free with excellent SVRs (97%) in GT1. Even in Pugh B/C patients, SVR nudging 90%. In the co-infected cohort the results are equally exciting

- Abbvie & Merck also have similar products 

 

We CAN eliminate HCV with:

- FUNDING

- better diagnosis rates 

- access to fibroscan 

- significant increased capacity to treat and uptake 

- employ treatment as prevention 

- make prescribing more accessible (in discussion in AUST) 

- FUNDING!!

 

Exciting to think that Australia looks to be leading the way!

This question continues to be a vexing one with our definitive answers coming in probably 5 years time.  There is increasing evidence that AIN3 is a precursor to anal cancer but the problem is that we can screen for AIN3 (anal cytology, high resolution anoscopy) BUT we don't know two fundamental pieces of information.

1)  How do we treat AIN3 effectively?  To date, we have seen many treatment modalities trialed but AIN 3 is highly recurrent.  A triple arm trial in 146 HIV+ MSM reported by Dr. De Vries examined a group of HIV+ MSM who were screened by high resolution anoscopy and histopathologically confirmed to have AIN.  He then randomized them into 3 groups (16 weeks of imiquimod, 16 weeks of 5-FU or 16 weeks of monthly electrocautery).  It was disappointing to see that recurrence rates were high for all patients at 72 weeks (67%), imiquimod users (72%), 5FU users (58%) and electrocautery (68%).  When stratified by perianal vs. intraanal lesions, the peri-anal lesions did better.  

2)  Which men with AIN 3 should we treat?  As Dr. Mary Poynthn from the SPANC team demonstrated, nearly half of HIV+ MSM had detectable high-grad SIL (HSIL) and there was a high regression rate for AIN3 (~39 per 100 person years).  These figures almost match the "success rates" of many treatment modalities.  We need better tools to distinguish the AIN3 that are more likely to progress onto anal cancer (e.g. use of biomarkers like E6/7?).

Until the above 2 questions are answered, I would not suggest implementation of anal cancer screening using anal cytology/HRA.  The alternative is to undergo tertiary screening (i.e. early cancer detection) through regular DARE for those at highest risk (HIV+ MSM who have 100 times greater incidence rates compared to the general population) until more evidence is established for anal cancer screening.

Tagged in: HIVAIDS2015

An interesting first day with varied sessions. It was great to hear about a number of very positive treatment approaches using the newer drug options for HCV, the direct acting antivirals. The afternoon session "Ending HCV in Populations" included Professor Greg Dore on HCV treatment as prevention in prisons and Professor Margaret Hellard on treatment and prevention to eliminate HCV in people who inject drugs.

Prof Dore indicated that of the 30,775 Australian prison population there is 30% HCV prevalence but with HCV antibody prevalence in prisoners varying across the states e.g. 52% in QLD, 26% in NSW, 25% in VIC. In prisons there is 60% prevalence of injecting drug use, with 10-15% annual transmission of HCV yet currently no preventative vaccines available, no needle and syringe programs and limited harm reduction methods available. With the new treatment options there is a much greater scope for targeting treatment of larger numbers of prisoners, with the SToP-C study addressing this. 

Margaret Hellard highlighted a shift in focus of who to target in treatment of HCV and expectations re the impact it produces. With 8,000 to 10,000 new HCV infections annually and PWID key drivers of HCV transmission, she stressed that you don't need to treat everybody with HCV to get a reduction in prevalence. If 40 out of 1,000 PWID are treated it can have a significant impact - it would reduce HCV prevalence by 50% over 15 years.  

With the new and future HCV treatment regimes having fewer side effects, high effectiveness, allowing improved dosing schedules and shorter treatment duration it will allow different models of treatment. From work by the Burnet Institute it has been found that social networks of PWID substantially impact transmission rates. A "treat your friends" strategy - treating certain individuals of the network they inject with - could lead to reductions in risk of HCV reinfection post-treatment, and reduce HCV transmission through the network. The TAP study will assess community based treatment of PWID and their injecting networks, looking at rates of HCV primary infection and reinfection.

The take home message from these talks is that with direct acting antivirals for HCV there are now new opportunities to scale up treatments and look at different approaches to treating populations in need. 

 

 

Tagged in: HIVAIDS2015

There were many highlights today but I will focus on some of the topics that resonated most with me related to technologies or interventions which could benefit marginalised groups in Australia. 

 

- Shoena Mitchell-Foster spoke on the higher uptake of self collected specimens versus othere traditional methods for cervical screening in a low income country setting in both HIV positive  and negative women. This study identified some of the barriers to traditional testing including the invasive nature of a pelvic examination and cultural considerations. Also to consider is ease of access to a primary health care provider particularly in very remote areas. Self collected specimens could negate the need for nurses or doctors to perform a Pap test. Considering the lower rates of cervical screening in Australian indigenous women, a national screening program using self collected specimens could be of great benefit in both urban and rural settings.

- Gail Matthews spoke about the CEASE study. She showed an excellent slide which illustrated the dense concentration of people co-infected with HIV and HCV in Sydney, NSW.. The slide also supported the idea that this would mean access to most of the clients could occur through only five or so health services where many of these individuals were already linked in. There are also a number of community S100 prescribers in the area. Eradication of HCV in this group seems a realistic prospect as many are well engaged with services however there is possibly a subgroup of very marginalised individuals who may find adherence more challenging and may require additional support to access and complete treatment. Definitely exciting times ahead in relation to HCV treatment!

- Prof Greg Dore spoke about HCV prevention and treatment in the criminal justice setting. Although not without its challenges, prison is quite a good setting to initiate, if not complete HCV treatment. The overall prevalence rate is a staggering 50% including the inmates who do not reporting injecting drug use. The nurse-led model is a fantastic way to increase access for  a population in great need and it's also a wonderful opportunity for nurses to use and develop skills and to work in an autonomous role. 

Looking forward to tomorrow's sessions!

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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