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.

Why are some common STI's neglected over others? 

Gwenda Hughes from the Centre for Infectious Disease Surveillance and Control at Public Health UK spoke about the surveillance of neglected STI's this morning. 

On average every year, there are around 358 million new infections of four curable STI's, which one do you think is the highest number?

Syphilis, Chlamydia, Gonorrhoea, or Trichomoniasis?

6.6 Million Syphillis infections, 78 Million Gonorrhoea, 131 Million Chlamydia and at the highest; 143 million Trichomoniasis.

Caused by the parasite Trichomonas vaginalis, it is nine times more prevalent in women and with the associated risk factors of lower socio economic factors, lower levels of education and increased number of partners.

With poor specificity on wet smears, limited surveillance data, and knowledge gaps in racial ethnic disparity target groups, this is an STI that would benefit further research. 

In Sydney we do see limited infections, and this is more common in rural Australian settings, and higher amount in Aboriginal Torres Strait Islanders. 

Lymphogranuloma Venerum  (LGV) - is commonly tested in Australia with positive rectal CT infections, but one point I thought was interesting the presentation was in Germany that out of 154 MSM with positive CT infection not only had 17% had LGV rectally, but 15% had pharyngeal LGV.

Would this number be similar in Australia with the Sydney study (David Templeton) showing 3 out of 75 positive LGV with rectal CT. 

Could we do pharyngeal LGV testing with positive CT Pharyngeal PCR swabs?

During lunch I attended a Roche sponsored integrated symposium titled ´Syphilis, Chlamydia, Gonorrhoea-Oh My: Diagnostic Advances, Hurdles and Considerations.

I used this opportunity to get a refresher on syphilis considering the rates we are experiencing in North Queensland and to see whether trends/testing/management vary in other parts of the world. It was a very informative talk and definitely made me consider other presentations of syphilis i.e chancres in non-genital sites ( fingers, tonsils etc).

 

Dr Marco Cusini of the University of Milan, Italy presented ´Current Trends in Syphilis Testing´. The landscape of syphilis in 2017 is that it is well and truly still present and a major public health problem. Late syphilis is rare in Europe but early syphilis still very prominent. Thankfully it is still highly sensitive to penicillin G. In terms of clinical diagnosis, syphilis can be difficult as it is `the great imitator´. Sites of the primary lesion can be extra-genital (and unusual locations), the morphology of lesions can be challenging and there may be a number of primary lesions. Occular involvement also needs to be remembered! 

The diagnosis of syphilis can be achieved through direct methods if lesions are present. This is a quick and in-expensive method but only useful if used under expert eyes. NAATs have the highest sensitivity and specificity. Serology needs always to be performed to confirm the diagnosis and for ongoing disease follow-up. 

Point of care testing are useful in developing countries and there is one FDA approved test. POC testing for syphilis shows good specificity and sensitivity but Dr Cusini stated that they were not really a substitute for serological testing if laboratory facilities are available.

Lumbar punctures need to be considered in anyone demonstrating signs or symptoms of neurosyphilis or demonstrating occular involvement.

Adequate response after treatment was discusssed. Generally an adequate response after treatment for active syphilis is considered a 4 titre decrease at six months. It was good to hear that at our clinic we follow similar guidelines.

Dr Cusini referred to the 2014 European Guidelines for the Management of Syphilis (Janier. et al, 2014) for further information regarding diagnosis and management. It is easily found on the web should anyone wish to read it.

Definitely a good refresher on syphilis and an interesting lecture.

 

 

 

The new WHO STI Treatment Guidelines were released August 2016 after 3 years of a very complex process, this was the first update since 2003. The recommendations were mostly based on very low - low quality levels of evidence but resulted in 'Strong Recommendations' or 'Conditional Recommendations'. 

Target populations were based on the same as Australian target groups but I was surprised to see the adolescent group include 10 - 19 year olds compared to Australia's young people aged 15 - 24 year olds. 

N. Gonorrhoea 

Recommended treatment 

* 250mg ceftriaxone IMI + 1gm azithromycin oral stat

When asked why 250mg ceftriaxone IMI as opposed to 500mg ceftriaxone IMI as recommended in may developed countries including Australia, Prof Magnus Unemo explained that there were no adequate RCT to support the larger dose worked any better than the recommended. 

Also they advised a 'Strong Recommendation' for all neonate to receive prophylactic treatment for prevention of gonococcal and chlamydial ophthalmia neonatorum, a practice abandoned in Australia with no subsequent increase in occurrence of infection or childhood blindness.

C. Trachomatis

* Azithromycin or doxycycline remain the treatment of choice for CT

* Anogenital CT - treatment changed to 7/7 of doxycycline 100mg BD.                                                                       Australian STI Guidelines recommend 7/7 of doxycycline 100mg BD if asymptomatic and 21/7 if symptomatic

Prof. Nicola Low advocated that the doxycycline regime of 7/7 of treatment still cures CT as well as if not better than azithromycin even if the course is not completed in non compliant people. 

* There is no evidence that repeating or lengthening the course of treatment is any more effective. 

Syphilis

* Nothing has changed in Rx recommendations for syphilis

* There is very low quality evidence to support the recommended treatment

* Treatment is based on 70 years of successful treatment.

I enjoyed Dr Francis Ndowa's analogy that there were no RCT proving the use of parachutes when jumping out of a plane greatly improved survival over not using one, so proving benzathine penicillin successfully treated syphilis didnt require RCT. 

* There is a pending global shortage of benzathine penicillin so alternatives include

        * doxycycline, ceftriaxone and in special circumstances azithromycin 

Genital Herpes

The only change recommendation for treatment is to increase treatment of the first outbreak of genital herpes to 10 days as most first outbreaks are prolonged. 

These are some stand out points from the  presentations at APACC covering issues related to HIV +ve youth.

#1 cause of death in 18-25 age group in Sub Saharan Africa is HIV/AIDS

#2 cause of death in 18-25 age group globally is HIV/AIDS.

In Asia, 37% of new infections are in adolescents.  HIV +ve adolescents include those infected by MTCT and those infected through sex and IDU. 

Rates of mental health diagnoses and neurocognitive issues are high in HIV +ve adolescents.  Dr Warren Ng, a psychiatrist from Columbia University, USA has worked with HIV +ve young people for many years.  He explained that the grey matter in the brain peaks during early adolescence.  This is also a time of increases in gonodal and stress hormones. Mental capacity continues to develop during the 20s.  Those most at risk of psychological morbidity include ethnic minorities, those living in poverty, or experiencing psycho-social trauma, substance abuse and inter-generational trauma. 

Age appropriate disclosure of HIV status requires teamwork and planning.  Transition to adult services needs to be staged and should only be commenced after the young person knows their status.  Dr Rangsima Lolekha, shared the data on a cohort of MTCT HIV +ve youth in Thailand. Transition to adult care usually occurs around age 21.  The risk of death at this time for these young HIV +ve people is five times that of age matched HIV -ve young people.  This vulnerable time is characterised by issues relating to transport, economics, health insurance and less rigorous systems to track continuing care.

Tagged in: APACC 2017

 

Nurses on Placement: Primary Health Care Nurses undertaking Clinical Placements at Publicly Funded Sexual Health Services: Can it be done? Is it worthwhile? Lead author: Desreaux, C.

 

I found this poster very interesting, as STI testing seems to be limited to sexual health services and GP’s. If Primary Health Care Nurses were encouraged and educated to provide testing, would that increase testing rates? Also, how do I get a placement??

 

Introduction

 

The role of Primary Health Care Nurses (PHCN) is underutilised in sexual health care in GP settings. To expand their role, a pilot program was developed in which clinical placements at a publically funded sexual health service were offered. They were supported by mentors/supervisors, during the five half or full day observation placement. A series of questionnaires were completed by the participants and mentors before and afterwards

 

Conclusion

 

The program was well received by the participating nurses and mentors/supervisors. It is hoped that more support can be provided to the PHCN to undertake the placements and implement changes in the GP practice.

 

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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