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 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.

GP chlamydia testing has doubled in the last few years, but remains low.

75% of chlamydia cases were in asymptomatic patients attending for non-sexual health reasons.

 

A trend worldwide of increasing syphilis notifications after 2000.

About half were in gay men who were HIV positive, and half who were HIV negative associated with increasing HIV testing and monitoring.

Syphilis monitoring was done routinely with HIV testing.

The proportion of patients who were asymptomatic increased at the same time to > 80% of cases being asymptomatic, from most cases being symptomatic.

Such opt-in health checks have had benefits elsewhere.

Opt-in STI testing in Aboriginals resulted in positive STI rates of 9.7%.

 

Contact tracing websites for anonymous notification of partners: inspot, sugestatest, thedramadownunder, letthemknow.

Of those intending to use these websites, 23% actually did.

Of all the partners notified, 20% actually got tested.

 

Retesting for those who test positive.

1 in 5 will get reinfected within 12 months, most likely from an infected partner.

Reinfection increases the likelihood of PID by 5-fold.

Reinfection increases the likelihood of transmission of HIV.

Of men not returning for a retest, some were sent an SMS reminder.

60% of those sent a reminder attended for retest, compared with 30% of those who did not receive a reminder.

Pregnancy testing should be routine in women of childbearing age who test positive for syphilis.

Women with syphilis present late.

The earlier a pregnant woman is treated for syphilis the better the outcome.

Up to 20% of women with syphilis are pregnant.

Women with syphilis are more likely to have other STIs.

Pregnant women identified as having syphilis are regularly tested throughout their pregnancy for evidence of ongoing infection to reduce the likelihood of congenital syphilis.

One case of confirmed congenital syphilis and 2 suspected cases where the baby required 10 days of iv penicillin in Northern Territory in the year described.

These rates are typical per state per year in Australia.

Anal cancer is the most common non-AIDS cancer in HIV positive MSM.

Up to 100 times the risk compared with the general population.

90-92% show HPV types 16 (or 18), second only to cervical cancer in its association with this virus.

29% of positive MSM test positive for HPV type 16.

1 in 5 go on to Incident HPV16 (test positive at 12 months) - 4% in total.

Higher risk with anal STIs.

Clearance of most HPV types is common - 50% will clear per year.

HPV16 is twice as difficult to clear than the other HPV types (only happens in 20%).

Predictors of clearance - younger age, smaller lesions, low risk lesions.

 

30-50% of HIV positive men have HSIL (high-grade squamous intraepithelial lesions).

 

It is not standard of care to treat these (unproven effectiveness).

New Zealand surveillance data from 2006.

55% (1 in 2) report any drug use.

21% (i in 5) report harder drugs (excluding cannabis and poppers).

44% of those used stimulants.

Polydrug users much more commonly report condomless anal intercourse and have higher STI incidence.

Drug use universally associated with increased risk behaviors (consistent with disinhibition) and decreased adherence to ARVs.

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