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.

HIV co-morbidities – are we measuring and responding them appropriately?

KEY POINTS

People living with HIV

-       Have increased frailty compared with the general population as they age calling for MDT/ holistic approach as a response [Jenifer Hoy]

-       More at risk of polypharmacy (>5 meds). Polypharmacy can lead to non-adherence, morbidly, Side effects, and interactions. The PAART study showed that >75% took >1 concomitant medication. The most commonly prescribed concomitant medications included lipid lowering medications, antidepressant, antiviral, PPI, anticoagulant, PDE5i, anti-diabetogenic and anticonvulsant. Many of these have serious interactions with ART. >700 interactions were found and 18.9% were on a CI regimen. Showing the importance of coordinated care, rationalising medications and regular good drug histories to prevent interactions.. [Krista Siefried]

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-       Increased risk of renal disease (historically due to HIV now shifting to ART and advancing age). Renal disease is associated with worse patient outcome and people with risk factors/ renal disease benefit from early intervention, screening and management. There are no guidelines in Australia that look at  monitoring for renal disease in PLHIV. However, there are international guidelines (EACS) that propose U&E and protein creatinine ratio (PCR) to stratify PLHIV into risk categories and then refer to specialist as appropriate. In a retrospective case review n=229 mainly male 30-39 with Low prevalence of known renal disease. Only 34% had PCR despite high prevalence of renal risk factors including smoking, HTN, HCV and low CD4/ high VL. Lack of simple urine dip signified a missed opportunity to pick up early disease/ proteinuria. Screening for renal disease fell below recommendations and should be considered in PLHIV [Tahiya Amin]

Professor Gracelyn Smallwood 'Aunty' delivered a highly emotional discussion about the realities faced by many Aboriginal People and Communities across Australia.

Most of the Closing the Gap money (75%) is not going to grassroots level of the people.

it is been swallowed up by university research, and provides jobs to non-aboriginal people.

Gracelyn said that poverty is widespread and needs to be cleaned up.

Many don't have running water and sanitation is poor. 

Food is marked up 200%

Most are unemployed and on Centrelink benefits.

ICE/ substance/drug use is high, including injection.

Concerns about HIV reaching remote and rural communities.

High rate of imprisonment  

Aboriginal Health & Community Services need culturally appropriate programs.

Non-Aboriginal people involved in programs deliver need to go into communities before and consult and talk with keys players/stakeholders and elders. 

Local grass root program delivery don't have to cost lots of money,                                                             such as the 'deadly program' and 'grog kills skills' delivered on a  shoe-string budget. 

Gracelyn talked about her us of the (world famous) Condom man.

This health promotion/prevention strategy was used successful and widely as a healthy alternative to the scary 'grim reaper' advertisements to assist combating HIV/AIDS. 

 Non-Aboriginal People need to speak out more and advocate for ABSTI People by keeping it on the agenda.

Australia needs to reconcile with the past and the ongoing injustices against Aboriginal and Torres Strait Islanders People's. 

Please read Gracelyn thesis which she addresses these multilevel issues in Australia's Indigenous People. http://www.atsiwlsnq.org.au/reports/Gracelyn_Smallwood_2011_thesis.pdf

Thankyou Aunty, your inspirational presentation. It was the highlight of the conference for me and together we can all individually and collectively help to improve the health and lives of Australians Aboriginal and Torres Strait Islanders People. 

 

 

 

Day 3 – Joint Symposium Session: Prevention of Anal Cancer in gay and Bisexual Men: The Current State-of-Play and Future Directions.

“What should we be doing for our patients now?”  Dr Jason Ong, Monash University, The Alfred – Melbourne Sexual Health Centre, VIC, Australia

Dr Ong acknowledged the HPV vaccine as a game-changer in the prevention of HPV-associated anal cancer however there is still a cohort of males who remain unvaccinated and therefore will continue to be at risk of anal cancer for many years to come.

Many ask the question: if screening for cervical cancer using the PAP smear works so well in early detection of cervical pre-cancerous lesions, then why can’t we take this methodology and apply it to anal screening of MSM for pre-cancerous lesions (aka ‘CHAP smears’)?

Some similarities and differences between anal and cervical anatomy and lesions were described:

Similarities:

-       Both have transformational zones

-       HPV responsible for a significant proportion of pre-cancerous changes

-       Pre-cancerous lesions are histologically similar

Differences:

-       The anal canal is a much larger area to swab (approx. 5cm tube)

-       It is more difficult to visualise anal lesions

-       Natural history of lesions between each site is different (up to 30% of anal smears are positive for abnormal changes)

-       Progression of changes is different as many more anal intraepithelial neoplasia (AIN) resolve over time compared to cervical intraepithelial neoplasia (CIN)

-       Different referral rates (only approx. 3% of cervical PAP smear result in onward referral for colposcopy but up to 60% of men undergoing anal screening would need referral due to the increased rate of high grade anal lesions.  This has implications for the workforce as it does not have the capacity to deal with such a large volume of referral for anoscopy or further investigation). 

High-grade anal intraepithelial neoplasia (HGAIN) regress at a rate of 36/100 person years so if left alone, many would disappear.

In answering the question of whether we should screen for early anal cancer, Dr Ong explained that the best annual screening tool for MSM would be the digital anorectal examination (DARE).  As approx. 50% of anal cancers are externally visible and approx. 2.9cm in size, and due to the fact that many HGAIN resolve spontaneously over time without intervention, DARE is a most cost-effective and simple early detection technique.

In another study, Dr Ong also explored the acceptability of a DARE for men with favourable findings.  82% of men felt relaxed during the procedure and 99% were willing to have another DARE in a years time.

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As a side note, Dr Ong will be conducting a teaching session on Friday 16th Nov from 10:30am-11:00am using his plastic bum segment for this wishing to perfect their DARE technique …sadly I will miss out!

Divergent rates of HIV in Aboriginal and Torre Strait Islander

Dr James Ward gave us a thought provoking opening speech outlining the recent increase (i.e. divergence) of HIV infection rates among Aboriginal and Torres Strait Islanders compared with the general population.  Here are the take home messages from the talk:

 

  • initially rates of HIV infection were similar between Indigenous and TSI, but numbers are now increasing
  • 2015 marked the highest rate of new diagnoses (n=38)
  • new diagnoses of HIV are occurring in rural and remote areas, which has never been seen before
  • why?
    • background: young, more mobile, more regional
    • risks: injecting equipment, high background of STIs
    • success in non-indigenous diagnosis
    • failure to engage with community
  • how to improve?
    • increasing workforce rather than downsizing
    • timely surveillance data (absurd that we deal with 2015 data in Nov 2016)
    • implementation of a national KPIs reportable for STIs by Aboriginal PHC
    • change to AHC, make STI/BBV checks more mandatory
    • Medicare items specific to BBV/STIs
    • improved testing strategies
      • only 32% of people with a positive STI screen had an HIV test within 30 days

 

I found the session a real eye opener and saw that there were plenty of areas that we could improve in. Simply increasing the rigor at which we conduct testing would seemingly make a big difference.

This year the HIV conference has been dominated by presentations on anal cancer in men who have sex with men, particularly those living with HIV.

A/Prof David Templeton presented the interim findings from the SPANC study, which assessed the utility of cytologic screening for anal cancer.

Dr Jason Ong presented an interesting overview of what clinicians can do currently to screen for anal cancer, given how little evidence we currently have on the usefulness of screening.

Dr Amber D'Souza presented on the epidemiology of anal cancer

Ben Wilcox and Lance Feeney presented on community perspectives and education on anal cancer.

Brad Atkins gave a moving presentation on his personal experience of anal cancer.

 

Perhaps the key messages are:

- Modelling has shown that anal cancer screening by a digital anorectal examination has shown it to be cost-effective only for HIV-positive MSM over the age of 25. In that scenario, it is currently recommended to perform anorectal examinations annually. However, an argument could be made to offer screening also to those MSM who are HIV-negative.

- Cytologic screening is problematic, in that it lacks sufficient specificity, resulting in a very large proportion of referrals to high-resolution anoscopy.

- We need to offer HPV vaccination to all MSM under the age of 25, and whilst there is no evidence of benefit over the age of 25 it would be reasonable to offer is to those MSM also (keeping in mind the cost to the patient).

- Much more work remains to be done to determine the best strategies to screen for anal cancer in MSM.

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

ASHM ASHM