this is just a test... please ignore this.
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.
This conference is a marathon. Day 4 and I am exhausted. So many people, protests and presentations to attend - it's quite overwhelming. One of the highlights for me yesterday was a packed oral poster session on PEP, PrEP and HIV testing held over lunch. The presenters only had 5 minutes each to present their key findings, and there was spirited discussion from the audience. A presentation by Antonio Urbina (St Luke's Roosevelt Hospital) reviewed the delivery of non-occupational post-exposure-prophylaxis (PEP) in emergency departments in New York City. 216 cases were reviewed. While apparently very successful (94% completed the course and only one person seroconverted), the audience questioned the intensity and length of the PEP regime - a 4 week course based on Combivir, which often causes nausea. There was debate about whether a shorter and better tolerated regime could be used. One of the other presenters in the session, Kristen Underhill (Yale) picked up on how negative experiences of antiretroviral drugs from a course of PEP can have lasting consequences. Kristen had conducted group interviews with gay and bisexual men in Rhode Island to explore the acceptability of HIV pre-exposure prophylaxis (PrEP). She found that men who had had a previous bad experience with PEP found the idea of PrEP very unappealing.
The other standout presentation was from Alex Carballo-Diéguez (HIV Center for Clinical and Behavioral Studies, NYC). Alex was reporting the results of his study of home HIV testing among 'high risk' HIV-negative gay men in New York City. A small group of men (n=32) was enrolled and given OraQuick oral fluid rapid test kits to use at home (the test has just been approved by the US FDA for sale over-the-counter). The men were encouraged to test themselves and their casual sex partners. Around 100 tests were performed. Telephone support/counselling was offered but rarely used. Five sexual partners tested positive for HIV during the study. Very few adverse incidents were reported. When quizzed by a member of the audience who was concerned about relying on a test with a longer window period than a lab-based HIV test, Alex noted, "Sometimes when looking for the optimal, we overlook the good enough." While debate will undoubtedly continue about the merits of home-based testing, I think this research illustrates that home testing can function pretty well as a harm reduction tool and, as Alex noted, can give gay men a greater sense of control over their health and HIV status. It's certainly motivated me to work with my colleagues in Sydney and Melbourne to do a similar study of home-based HIV testing.
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.
Session 35: New Frontiers in HIV Testing
Bernie Branson from CDC gave a fabulous talk on HIV Diagnosis: New Tests and New Algorithms. Those of us involved in any of the current disucssion about testing really should view this whole talk. It should be up on the CROI Website shortly.
His slides are most informative, particulaly a graph which plots back from when a Western Blot would detect HIV infection, indicating how many days before a Western Blot 2nd, 3rd and 4th generation tests can identify infection.
He describes a number of the initiatives to increase testing and is encouraging the adoption of the recently updated algorithm for HIV testing in the laboratory. The algorithm and supporting evidence is published in the December 2011 issue of The Journal of Clinical Virology. He also disucsses mechanisms to get conventional testing more available and review a number of Point of Care Tests.
He raises the issue of the implications of new tests including home based tests. He is cautious about some of the tests failing to identify new sero-conversions and makes reference to findings that men are reporting they would use test results to assist them in sero-sorting (so having the wrong result could have significant implications).
It is a great talk I suggest you view it and share it with your colleagues.
The second talk in the symposium is by Blayne Cutler, from New York City Health and Mental Hygiene. She reviews a number of strategies which have been put in place in the Bronx and more recently Brooklyn to increase HIV testing. She approaches this from the point of who has never tested and their attempts to reverse this. 60% of people have never tested and of these the majority are adult men. She also examines some strategies to move testing into the community and get programs supported at implementation level.
These two talks have been hugely informative.
People who know me will know that this is a particular interest of mine. There are a number of posters focusing on the role of very early infection in onward transmission of HIV and it has been mentioned by a number of speakers.You can access the poster abstracts from the CROI Website but I will give you a few points about particularly interesting ones here.
Poster 1107 A French analysis of genotypic profiles for 987 patients between 1999 and 2010. Identified manyclustered transmission ranging up to 24 months, Often associated with younger MSM, while 54% were in Paris, 19 or 56 were in distant French regions and 13 of the 19 involved at least one person from Paris. Their conclusion is that primary HIV infection is a significant source of onward transmission especially in MSM and contributed to regional as well as Paris-base infections.
Poster 557 Acute infection would be missed in a small but important number of cases using Architect HIV Ab+ p24 Combo. 5 of 14 early not detected. Interestingly this 5 were in ramping up fase and had distinguishably different HIV dynamics. The do an analysis of cost on the basis of onward infections and argue the case for HIV NAAT.
Poster 552 Chance of transmission in early HIV infection 13 x higher via UAI. In a San Francisco sample early is considered less than 100 days. Gay men with acute infection comprise 2% of the infeted population (49% untreated and 49% on treatment) but account for 22% of new infections.