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.

Day 4- Increasing the demand for HIV testing

Mark Stoove discussed innovative ways to improve HIV testing.  50-70% of HIV transmission among GBM are attributed to undiagnosed infection. There were policy and regulatory changes in 2012, which revolutionised HIV testing in Australia. Rapid HIV testing was introduced and there was an increase in HIV testing in community settings. The uptake of rapid HIV testing has been modest. Barriers may include funding, lack of government subsidy and some services feel testing can be time and resources heavy. The majority of HIV testing continues to occur in primary health care settings using serological laboratory testing

Community based HIV testing services such as ACON provide a comfortable, peer based service which clients find very acceptable.  ACON in Sydney provides a peer based testing model, which is supported by nursing staff. Peer based clinics have successfully attracted first time testers that were classified as ‘high risk’. Rapid HIV testing has increased testing in urban areas but more needs to be done for those living in rural areas. We need to expand the geographical reach of HIV testing. The Terence Higgins Trust provided funding to increase testing in the UK. In a 14-month pilot study over 17,500 testing kits were posted and 10,410 specimens were returned. There was a positivity rate of 1.4% and this testing was welcomed by participants with 97% reporting that they would test this way again. Self-testing kits are available in the UK and the uptake has been excellent with over 27,000 units sold between April 2015 –Feb 2016. Half of the test kit users have never had a HIV test before.

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

-Funding may be a barrier for services offering HIV testing. Government subsidies could improve rates of HIV testing

 Vickie Knight spoke about the effect a[TEST] clinics has had on HIV testing among gay and bisexual men. It was found that the clinic on Oxford Street in Sydney has increase testing and also increased the frequency of testing. Factors that make this clinic user friendly include short wait times, the service is free, CASI is used which means intrusive sexual health histories are not taken by health professionals.

 

Key messgaes

This model works and has increased testing among GBM.

 

James Ward presented evidence about the increase in HIV notifications in Aboriginal communities in 2015- 38 cases. The rate of diagnosis has more than doubled in 1 year. HIV is increasing in remote communities. There has been an overall increase in HIV testing, especially in MSM populations but more needs to be done to increase testing and promote treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) in Aboriginal communities.Ward stated that the syphilis outbreak in Northern Australia is a national shame with over 900 new infectious syphilis cases and 3 neonatal deaths.Harm minimisation services such as needle syringe programs should be expanded. In the past 5 years there has been a 43% increase in hepatitis C diagnosis, which are largely attributable to injecting drug use. Young Aboriginal clients are particularly at high risk.

Key messages

-HIV testing should be offered as part of a routine sexual health screen

-Community engagement is needed to improve the uptake of TasP and PrEP

-Timely surveillance data is needed.

-Some GPs may not be offering full BBV/STI screening as the consults may be lengthy. Work is underway to Medicare items specific toBBV/STIs

-More NSPs are needed

 Caitlin Douglass from the Burnet Institute conducted study on the sexual behaviours and Tinder usage among young Australians.

Tinder was found to be the most popular dating site. An online study of 1001 revealed that 690 participants had been sexually active in the past year and 40% (266) had used Tinder in the past 12 months-35% women and 45% men. Douglass questioned whether Tinder could be used to promote sexual health services and noted that there was a lack of sexual health content on dating apps. Grindr is the exception as there are ‘sexpert’ willing to offer health advice at the click of a button. Grindr also has a portal which can advise users of their nearest sexual health clinic.

Gemma Hearnshaw of the NSW STI Programs Unit discussed the Playsafe website. Playsafe is an interactive engagement tool, which can inform young people about safer sex practices and testing. Peer educators are trained to deliver informal education to festivalgoers and provide free condoms and advice. There has been repeat exposure of safe sex messages on the Ticketek and Live Nations website.

Viv McGregor grabbed everyone’s attention with the fabulous music video –Close: Lady Sings it better. This playful video leaves room for the imagination. I would recommend everyone have a wee look! Click on the link below.https://vimeo.com/157020994

Research by Albury and Noonan in 2001 revealed high levels of same sex sexual interactions among women, despite the fact women often identified primarily as heterosexual. The study found that there was often a lack of sexual health knowledge among this group and they often participated in riskier sexual practices such as impact play, blood play and fisting.

Key messages

More targeted, culturally appropriate information is needed. Clinicians should opportunistically invite all patients to complete sexual health screening irrelevant of sexual orientation or practice.

Claude packs are available in NSW-‘Play packs’ and ‘Blood Play Packs’.  More information is available at www.iloveclaude.com

Alison Coelho spoke about a comic based resource for young people from refugee and migrant backgrounds. It was acknowledged that change and unsettlement can cause huge upheaval among this population and many people accessing their services have had significant interruptions to their education. It was found that there was limited information regarding sexual health and a surprisingly high number of young people accessing the service had participated in transactional sex.75% of humanitarian intake is young people and a large proportion are young males. They are often unaccompanied minors and often do not have female role models in their family. Sexual health is often not a priority for this marginalised population group. Issues like housing, employment and language acquisition often seek precedence over sexual health information.

The SHARE project has published many cartoons with important sexual health information messages with little written dialogue. Fact sheets are also available.

Key messages 

This website is a must for people working with young people. Check it out @ www.ceh.org.au

Everyone Loves Concert Tickets!

Nittaya Phanuphak (Thai Red Cross AIDS Research Center, Thailand) spoke at AIDS2016 on the topic 'Prevention Equity: How Innovations in HIV Testing and Prevention Technologies can Reduce Incidence Globally'.

She highlighted the inequality of health care in Thailand and outlined that the populations at highest risk for HIV have been missing out. She is involved in a 'Test and Start' program for MSM and Transgender Women in Thailand. The program provides clients with HIV rapid testing, with provision of PrEP (or ART) on the same day.

They have trained up MSM and Transgender Women to provide services for the LGBTI community through the clinic. By design, this creates a work force that is compassionate, caring and culturally aware of the target population.

Their clinic has enrolled over 300 patients in the PrEP Program so far, but they plan to roll this out to a further 3000 MSM and Transgender Women over the next 3 years.

They created the website www.adamslove.org to provide sexual health information and encourage clients to attend the clinic. Everyone loves tickets, so they provide online Eventbrite "concert tickets" that are exchanged for STI tests (Please note that a visit to the clinic is more important, but is much less fun than seeing a show).

Most clients have a phone or webcam and the clinic's sexual health nurse utilises this to conduct online medical consults, providing education in sexual health, counselling and guides patients through performing a home HIV screening test.

Nittaya Phanuphak gave a shout out to NSW in her talk, stating "NSW must be congratulated for their efforts to use PrEP. We hope to learn more from NSW in the next few years" - and we hope to learn more from you Nittaya. 

We came to this meeting in part to hold a round table discussion about the role of DBS sample collection. Excitingly for us, further exploration of DBS, including through multi-centre collaborations made it onto the list of 4 priorities coming from the meeting.

Dry Blood Spots are a simple way to collect a biological sample for analysis in the laboratory. You use a lancet to pierce the finger-tip and drip blood onto one or more target sites on a sheet of blotting paper. This sample is then dried, sent to the lab (through the mail or easily transported at room temperature) and then analysed in the lab. The spot is punched out of the blotting paper and eluted The lab can test for any number of things including the presence of antibody, molecular, and serological tests. Labs can use their own tests or test which are marketed through diagnostics companies using a variety of analysers.

In order to be approved (and rebated), a DBS claim needs to be made by a producer/supplier when the product is registered. This has been something which has held back DBS sample collection for some time. As tests became more sophisticated and analysers more mechanised, the operator-involved steps in processing a DBS sample probably seemed overwhelming.

But there are many factors which place a DBS sample in good light. Transportablity, durability and stability are all excellent in remote, hard to reach or poorly serviced areas. They also appear to provide an alternative for people who are, for whatever reason, avoiding testing through conventional means.

Two posters which also looked at DBS, both its use in one of the larger format analysers, and as an acceptable sample collection technique for consumers are below.

Validation of the GEN-PROBE® APTIMA® HIV-1 RNA Qualitative Assay for use with Dried Blood Spots.pdf

Diminishing Return on Increasing DBS Sample Quantity.pdf

 

 

The presentations from the HIV Diagnostics Conference have now been put on line. They are accessible at

http://hivtestingconference.org/2016-hiv-diagnostics-conference/oral-presentations/

You can access the full program from this link and simply click on the desired presentations.

Those who pay much attention to the HIV testing landscape in the USA will be aware that there was a long period where the testing algorithm was debated, discussed and reviewed, resulting in the 'New' algorithm coming into effect in 2014. At this conference it was suggested a number of times that the new algorithm should now be redrafted.

Largely the reason for this is the shift in treatment guidelines and the relationship between testing and treatment. The 'new' guideline was written against a background of selective CD4 and viral load based decisions about when to start treatment. Now, with the emphasis being on starting people on treatment as soon as feasible after diagnosis, the need for repeat testing was questioned. This is an important shift, where one can see treatment and clinical practice driving precursor testing. These issues are discussed in 

Session C: CDC/APHL Laboratory Testing Algorithm and 

Session D: CDC/APHL Laboratory Testing Algorithm (Part 2)

There was a very good round table discussion on Wednesday morning which looked at matching testing approaches to the HIV cascade. Joanne Steckler raised the issue about the large differential between people tested and people lost to follow-up. This comes from work in Washington state, where a great many people who were thought to be lost to follow-up were in fact legitimately in care somewhere else, often no longer in the county or state.  

At the same time, rapid tests, which have been widely used in the USA for many years as part of the testing strategy, particularly in community settings, but also in more remote areas (Alaska, Midwestern and north states) where laboratory access is limited, are becoming less popular.

One of the major reasons driving this is the problems associated with false negatives. As always there was some discussion about the amount of transmission associated with very early infection, and it was interesting that there was a greater linkage between efforts to get people to test, particularly very early after infection, and recognising the limitation of point of care or rapid tests in these contexts. 

Session F: Performance of CLIA-Waived HIV Tests and the session immediately before this examined some of these issues.

Testing was very much seen as the vehicle facilitating the linkage of patients to care. A presentation from Eugene Martin, New Jersey, demonstrated that high level linkage could occur with timely intervention.

The laboratory instrument providers also attend this conference. It seems that many of the analysts have the capacity to perform multiple tests (concurrently, but not yet necessarily all the tests we would like to see in the one run). But this really did seem the next step where the largest leap could be made. This particularly emphasised the need to link HIV testing with related testing in the STI and viral hepatitis areas.

The closing remark gives a good coverage of the scope of the meeting. It was thought there was ongoing need for the meeting and that it would have to, in the context of HIV PrEP, include STI in its agenda. 

 

 

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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