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 symposia session was the only session in the conference focussed entirely on women's health. It was a fantastic introduction for me to the management issues of HIV positive women from adolescence to menopause as I have had minimal exposure especially to adolescent HIV. Yesterday we heard from Associate Professor Darren Russell regarding the increase in HIV diagnoses in Aboriginal and Torres Strait Islanders in Northern Australia and I am concerned that being based in this region I unfortunately will be involved in more cases of adolescent HIV in the near future. Globally two thirds of new HIV infections are in adolescent girls.

I was surprised when I learned the epidemiology of HIV in women.

HIV is the leading cause of death among women aged 30-49 years globally. 

In hundred thousands:

HIV 241.9

Ischaemic heart disease 150.5

Maternal conditions 148.4

Stroke 139.5

Breast cancer 130.9

Tuberculosis 96.4

and the third cause of death globally for those aged 15-29 years.

Does ART modify hypertensive disorders in pregnancy? Or obstetric haemorrhage? Data is inconclusive.

But the take home message is there is more to antenatal care than prevention of mother to child transmission.

There was a slide regarding the global burden of disease in adolescents. As a GP I feel I am in an ideal setting to screen for many of these issues as I see a higher proportion of young females. These include vaccine preventable diseases, under nutrition, sexual health, violence and injuries, mental health and substance use disorders.

 

 

 

Tagged in: 2017 IAS Conference

Key population talk

 Is “on-demand” PrEP a suitable tool for MSM who participate in Chemsex?  From ANRS-Ipergay.

 This was in an IPERGAY sub-study of 331 participants during the open-label extension (OLE) phase of the study who reported drug use during at least one sexual encounter.

 2 monthly data was collected regarding drug and alcohol use, sexual behaviors and PrEP adherence during the participant’s most recent sexual encounter(s) and analyzed with a multivariate regression model. PrEP use was self-reported by participants.

Among the MSM participants, 29% reported Chemsex at least once during the follow up period and16% reported chemsex at all visits.

Socio-demographics between those labeled chemsexers were not different from those labeled non-chemsexers, other than a higher use of anxiolytics in chemsexers.

 After adjustment, chemsexers were found to be more likely to use PrEP (OR (95% CI = 2.18 (1.04; 4.49)) and less likely to use condoms (p< 0.001)

Of note, when MSM reported chemsex during their most recent sexual encounter there was a grater likelihood of receptive anal sex, hardcore sexual practices, casual sexual partnerships and a higher perception of risk. All p-values <0.001

This important and interesting sub-study suggests that PrEP may therefore be a suitable tool for HIV prevention people practicing chemsex.

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Tagged in: 2017 IAS Conference

There was a flavor of dual therapy around Mondays Plenary. An interesting study for Australian audience was the ACTG A5353 study which is a pilot study of Dolutegravir  + lamivudine for the initial treatment of HIV-1 infected individuals with viral loads of less than 500,000 copies/mL.  The 24 weeks data was presented using the FDA snapshot definition. There were 120 participants with no baseline resistance identified. There were no discontinuations. This regimen demonstrated potent virilogical efficacy at 24 weeks. 3 patients met the criteria for a protocol defined virilogical failure (PDVF), one had emergent M184V.

 

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The other interesting update was the 48 week data for Bictegravir(B)/F/TAF vs. ABC/DTG/3TC. This is a phase 3 RCT for treatment naïve adults. The primary endpoint HIV-1 RNA < 50 copies, powered for non-inferiority. B/F/TAF was non-inferior at 48 weeks. It was well tolerated and there were no adverse events leading to discontinuation. Nausea was significantly greater in patients taking ABC/DTG/3TC.  Gastrointestinal, Neuropsychiatric and sleep related problems were also more common in the ABC/DTG/3TC patients. Changes in BMD and renal function were comparable. The speaker felt that B/F/TAF was an “attractive” option for rapid commencement of antiretroviral therapy as no HLA status is needed and it could likely be commenced irrespective of Hepatitis B status and renal function.

Tagged in: 2017 IAS Conference
Mind the Gap: Filling knowledge gaps in Paediatric and Adolescent HIV for an AIDS free generation

I am reporting back from the IAS2017 session Mind the Gap: Filling knowledge gaps in Paediatric and Adolescent HIV for an AIDS free generation -- the first satellite session at 8 am on Sunday morning, well attended with standing room only.

This satellite, organised by the Elizabeth Glaser Pediatric AIDS Foundation will launch the research agendas and discuss considerations emerging from the process such as the use of observational data, optimising clinical trials design, the roles of basic and implementation science, and the role of community engagement, with a focus on the meaningful engagement of youth.

As a General Practitioner previously involved with youth sexual health screens in North Queensland where there is a relatively large proportion of teenage patients, I found this session quite useful. 

The most useful discussions were personal anecdotes by the speakers and from questions asked by the audience.

One question was asked to Carlo André Oliveras Rodriguez from Adolescent HIV Treatment Coalition (ATC), Puerto Rico, regarding the use of non-monetary incentives. He described using transport and internet access as alternatives.

I have myself seen the impact of using monetary incentives as impacting on future testing and treatment and it was great to get alternatives.

The delegate next to me, from the London School of Hygiene, said that ethics committees strongly restricted them to the use of food and drink or transport only for incentives. 

There was a flyer in my welcome pack for a program in the United States called the Undetectables which also touched on incentives for maintaining an undetectable viral load.

Visit the website: 
www.liveundetectable.org

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The discussions were mainly in the context of research but I would like to transfer this knowledge to youth engagement in primary care such as a youth drop in clinic.

They also discussed barriers such intellectually disabled youth and hearing impaired such as youth officers trained with this in mind.

They talked about some young people preferring twice daily smaller pills rather than once daily larger sized pills. But also that the options for treatment of younger people with low body weight were a barrier due to limited single pill combinations.

The Elizabeth Glaser Pediatric AIDS Foundation host again another satellite session this afternoon with the goal of the satellite to raise awareness and facilitate discourse regarding adolescent-specific needs as a part of a comprehensive national HIV/AIDS care and treatment package.

See: Nonstop Journey: Delivering an Uninterrupted Continuum of HIV Services to Adolescents and Youth

Tagged in: 2017 IAS Conference

Evolution and global spread of resistance in STIs- a very useful and insightful topic and very relevant working clinically in the field of STIs. 

The session started with Dr Magnus Unemo who presented ´Evolution and global spread of resistance in Neisseria Gonorrhoeae´. Antimicrobial resistance (AMR) has mostly emerged in post- modern times due to both SNPs and recombinations. Specific linegaes are more prone to develop resistance and remain susceptible.  Extended spectrum cephalosporin (ESC) resistance has emerged from Japan as highlighted in the paper by Shimuta et. al 2015 (BMC Infectious Diseases). Genotype 1407 has accounted for most decreased susceptibility to ESCs worldwide. Most microbial resistance is due to use or misuse of antimicrobials. AMR is a global concern requiring enhanced surveillance, need for new antimicrobials and development of a vaccine is crucial.

Dr Catriona Bradshaw discussed ´Evolution and Global Spread of Resistance in Mycoplasma Genitalium´.

Mycoplasma Genitalium (MG) is a fastidious and slow growing organism making NAAT the only diagnostic solution (difficult to culture). Treatment options are limited as mycoplasma lack a cell wall and are unaffected by many antimicrobials.

Doxycyline is used as first line treatment in many areas of the world but it exhibits low overall efficacy with cure rates of 20-40%. Azithromycin however is widely recommended as first line treatment but there has been a notable decline in efficacy over the past decade. Selected macrolide resistance has been demonstrated, at least 10% of the time following 1g of azithromycin. 

Widespread use of azithromycin for syndromic management of STIs has likely contributed to resistance. Prevalence of resistance is worse in the Asia Pacific region.  Prevalence of resistance to azithromycin appears to be less in countries that preference doxycycline for 1st line treatment of MG.

Moxifloxacin is most commonly used as 2nd line treatment in NG. The recommended dose is 400mg daily for 7-10 days. However in 2007 there were the first reports of moxifloxacin treatment failures for MG.

The experience in Melbourne has been a 12-15% moxifloxacin treatment failure rate. These treatment failures have been associated with ParC mutations. ParC mutations have been observed at low rates in Europse when compared to the Asia Pacific region.

What is concerning is that dual class resistance is emerging which will have huge clinical implications. The priorities now are review of using azithromycin for STIs and syndromal management, development of new antimicrobials and evaluating the use of exiting registered antimicrobials. This particular talk was followed up later in the day with a session from Dr Jorgen Jensen and a late breaker session which I will blog about later on. 

These particular sessions I feel were extremely worthwhile and will have a huge impact on clinical practice. It reiterated the need to be mindful of antibiotic prescribing and be aware of emerging resistance.