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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.
Testing questions and treatment as prevention
DC is hotting up. The opening plenary last night was long and impassioned, with various speakers exhorting the audience to 'end AIDS now'. Michel Sidibé (UNAIDS Executive Director) summed up the push to maintain international funding levels and deliver treatment to those who need it when he said, "The end of AIDS is not free, it is not too expensive, it is priceless."
I'm stepping back to earlier in the day to consider a different but no less important issue: HIV testing. The whole push for 'treatment as prevention' will, of course, fail if people do not present for testing and find out their HIV status. Françoise Barré-Sinoussi, President-elect of the IAS, introduced a satellite session by the French NGO, Sidaction, titled "Confronting the hidden epidemic: HIV testing science and implementation". Professor Barré-Sinoussi noted that internationally many at-risk groups have poor access to testing, and there is a need to diversify testing to engage people and make it more efficient, using a variety of methods such as community-based testing, self-testing and outreach. The session had a particular focus on undiagnosed infection and engaging hard-to-reach groups, particularly in France. I felt that many of the observations had relevance for Australia.
Virginie Supervie (U943 Inserm) presented a mathematical model of the French HIV epidemic and undiagnosed infection. For the statisticians among you, she used a modified back-calculation method based on the number of new HIV cases over time. No, I don't know what that means either. The model indicates that there are 29000 people with undiagnosed HIV in France, 9000 of whom are men who have sex with men (MSM) and 9800 are French-born heterosexual people. Because the MSM population is relatively small, their prevalence rate is the highest, at 314 per 10000. This means it is much easier to find undiagnosed MSM through testing; huge numbers of heterosexuals need to be tested to find undiagnosed people. The analysis suggested that median time from infection to diagnosis is ~2 years and that 59% of undiagnosed people have a CD4 count below 500 i.e. they are undiagnosed but already eligible for ART. Supervie went on to talk about the broader French epidemic and reported that, because there is good access to ART in France (once people are diagnosed), they estimate that 56% of PLHIV are virally suppressed (as opposed to only 28% in the US). It would be interesting to know the figure in Australia - hopefully closer to the French figure than the US one.
Sandrine Fournier (Sidaction) reported on an innovative community-based, outreach testing strategy to engage gay, bisexual and other MSM in the Paris area. The Flash Test program offered rapid HIV testing (using the INSTI test) to MSM at 39 gay venues, beats, NGOs, general practices and health centres during a one week period. Intensively publicised with the tagline, "Et toi, tu sais?" (And you, you know?), the aim was to engage men who had not tested for a long time (or ever) and to make testing easy and attractive. Over a hundred health care workers and activists were trained to work in the program. 556 tests were performed during the week, identifying 7 new HIV diagnoses. The locations that were rated as most attractive by MSM were gay venues (because it was convenient and social). Cruising areas were found to be difficult places to recruit. NGOs found they had increased attendance at their sites during the test period; GPs were not particularly proactive at offering tests, but it was difficult for them to offer appointments during the testing period. The success of the project means that Sidaction is considering promoting an Annual Testing Week in France. In Australia, we seem a long way off such a project - we don't even have one rapid test licenced yet!
A highly topical subject, and one that is sure to get more attention in Australia in the coming months, is home-based testing for HIV. Tim Greasen (EPS Maison Blanche) reported on a survey of over 9000 French MSM about attitudes to self-testing and the use of HIV home test kits ordered online. Greasen noted that the US has leapt ahead of other countries in liberalising access to testing with the recent FDA approval of the OraSure home test kit, but the US has had a version of home HIV testing for 16 years (!), using a system in which people send in dried finger prick specimens for testing at a lab, backed up with telephone results and counselling. As in Australia, home HIV testing is not legal in France, but there is suspicion that MSM in particular are ordering test kits over the internet. Greasen's survey of MSM found low numbers who had ordered home test kits (~1% of MSM), but a whopping 87% were interested in the idea, citing convenience, rapidity and anonymity as the main attractions. Men who more secretive about their same-sex activities and had never tested (or had not tested for a long time) were more interested in home testing. There was no association with suicidality (a concern of those who worry about men testing by themselves). Among the 69 men who had used a self-test, who tended to report more HIV risks, 62 tested negative, 3 tested positive (1 result was subsequently disconfirmed), and 4 were uncertain of the test result. Greasen noted that in France there is a perception that HIV testing is 'owned' by health professionals and there is resistance to citizens controlling their own health. However, he still thought (when quizzed by me) that home rapid tests are likely to become available in a year or so, backed up by telephone counselling (as in the US). It will be very interesting to see how this debate is taken up in Australia, in advance of Melbourne 2014.