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.

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.

HPV vaccination has been a major success in Australia.

“Cervical cancer vaccine”, not HPV vaccine - unsure how the public would respond to a vaccine against an STI.

Introduced in 2007 in females, and 2013 in males in schools.

Vaccination in schools is much more effective than trying to get the same people into consulting rooms.

3-dose coverage in 70% of females, and 60% of males.

4v-HPV quadrivalent vaccine effective against types 6, 11, 16, and 18.

Moving to a 2 dose schedule as other countries have.

Easier to roll out.

2 doses spaced > 6 months apart just as immunogenic as 3 doses in adults.

Approved by WHO in 2014.

Increasing interest in the 9-valent vaccine which includes all the oncogenic types.

Implementation of a 2 dose schedule likely to occur at same time as a switch to 9-valent vaccine.

Incredibly safe, no evidence of autoimmune diseases.

Incredibly immunogenic, with high levels of antibodies sustained for over a decade.

Incredibly effective, dramatic drop in types 6, 11 incidence rates since vaccine introduced. Now we are seeing a decline in high grade abnormalities (CIN grade III, carcinoma in-situ).

 

National cervical screening program: 2-yearly PAP test for women aged 18-69 years.

Uptake: 2-yearly 58%, 5-yearly 83%.

Effect: 50% reduction in incidence and deaths from cervical cancer.

80% of cervical cancer in women in Australia occurs in women never screened or under-screened.

 

New cervical screening test will be implemented from May 2017.

Why? - newer technologies (HVP tests and liquid based cytology), allowing us to target more risky lesions and test low risk lesions less frequently reducing cost, while at the same time predicted to reduce cervical cancer cases by 30%.

Primary HPV test with partial genotyping (HPV 16/18 DNA/RNA PCR), alongside liquid based cytology (LBC), i.e. two screening tests in one.

Five-year screening interval because of lower risk of progression to significant disease within that period.

Starting at age 25 years, up to age 74 years, because of a very low risk of disease < 25 years and that surveillance in this group has had no impact on survival.

Self collection is an option (just tests for HPV PCR, need to recall patient if positive for physician to take a swab for LBC, may reach those never screened or under-screened).

Still need a speculum vaginal examination but 9 in a lifetime rather than 26.

 

New terminology - Lower Anogenital Squamous Terminology (LAST):

HSIL - high-grade squamous intraepithelial lesion (CIN II, CIN III).

LSIL - low-grade squamous intraepithelial lesion (consistent with HPV infection).

SISCCA - superficially invasive squamous cell carcinoma.

Squamous cell carcinoma.

 

The test is reported:

High risk - HPV types 16 or 18 are detected regardless of liquid based cytology.

High risk - HPV types other than 18 or 18 and HSIL.

High grade lesions are referred for colposcopy.

Intermediate risk if HPV types other than 16 or 18 and LSIL.

Intermediate risk is screened annually.

Low risk - HPV not detected.

Low risk is screened in 5 yearly intervals if immunocompetent. “Immunodeficient” (CD4 count < 400, unclear what this means for those on immunosuppressive therapy) - screened at 3-yearly intervals.

 

See the slides: https://www.eiseverywhere.com/file_uploads/89ee372457dbcb849d3cd1077dfc871e_1010MonMarionSaville.pdf

 

 

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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