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.

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

 

 

In the Gollow lecture Rebecca Guy discussed the important role of new technology for STI prevention including interventions such as: -

-CASI an electronic self-registration tool has proven acceptable reduced waiting times and improved data collection.

- ACCEPT showed the need for opportunistic Sexual health screens in primary care for young people due to high prevalence of CT and presenting complaint often not being sexual health related simple computer prompts increased testing by 30%

- SMS and postal test kits have been used to improve re-testing rates

 

Mark Hayter called for collaborations within sexual health with other specialities such as family planning and drug and alcohol services. Incorporation of family increased consult time but decreased unintended pregnancy, without increasing STI rates.  In addition inks with family planning could even go someway to dispel contraception myths held by Australian men as highlighted in Mary Stewarts lecture ‘contraception and the Australian male’.

 

Craig Rigney, CEO Kornar Winmil Yunti spoke about the KWY community based response to high rates of Aboriginal family violence and a lack of accessible culturally appropriate services. The Aboriginal family violence program maintained client safety through ‘women’s business’ and ‘men’s business’. Men’s business included a perpetrator program, which was aimed to unpack perpetrators own held trauma so that they can be accountable for their own violence.  Although initially many attendees were mandated from court self-referrals are on the increase. Rigney discussed that undoubtedly valuable outcomes are hard to evaluate.

 

In ‘rethinking testing and management of sexually transmissible infections’ Catriona Bradshaw drew attention to the lack of guidelines internationally for rectal MG with treatment shifting towards doxycycline. She called for a reduction in macrolide use and improved contact tracing and TOC rates.

Jane Tomnay analysed PDPT in the Australian context drawing attention to challenges in primary care such as who will pay for PDPT? And how do you write a script for the partner if the partner has never attended the practise.

PDPT was criticised in NT in 2012 when it coincided with child abuse allegations as a way that abuse could remain hidden – something to think about especially in relation to pick up rates of family violence/ domestic violence. 

Daniel Richardson proposes HCV testing should be considered in relation to sex in certain groups even if heterosexual (namely women) and in HIV negative MSM on PrEP – when asked about increased cost due to Australian labs only performing HCV RNA, Richardson suggested lobbying for HCV antigen tests he denied value of LFT’s as a screen, referring to the MSM in PROUD and EPIGAY whom contracted HCV through sex having had no change in transaminases.

In the sexuality lectures Hilary Caldwell Challenged gender based narratives about the Australian sex industry stating that its no longer sustainable to claim only men command and objectify bodies when buying sex or that that power dependent activity is inherently oppressive. She described how women buying sex (WBS) In Australia are more likely to do so from women than men and that these women were diverse with any ethnicity and any income. WBS stay for longer and buy sex less often prioritising safety and a sexpert. Angela Davies looked at the impact of pornography on young peoples sexual lives. There are concerns that porn can normalise risk behaviour promote harmful attitude. An Online survey of 15-29y revealed both male and females used porn. Porn was considered a more detailed sex resource compared to formal sex education where pleasure is the goal instead of risk. There were positive and negative impacts. Positives impact included – positive body image, sex positive, normalising taboos, ‘a safe space to sexplore’, in some males prevented other risk behaviour. Negative impact included  - negative body image, unrealistic expectations, and limited representation of sexuality, harmful attitude and behaviour. A significant portion reported no impact of porn. Do this group have protective factors preventing impact or are these most at risk who lack insight?

 

A huge thank you to Gracelyn Smallwood who gave an inspirational talk around the importance of involving appropriate people in a community to deliver culturally appropriate health promotion that engages communities as a whole.

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Khadija was born in Sierra Leone and arrived in Australia in 2001. There is an impressive list of projects and organisations in which she is heavily involved including her long-standing involvement with ShineSA and No FGM Australia - a not-for-profit Australian organisation where she is currently the Executive Director.

She gave the opening address at the 2016 Australasian Sexual Health Conference in Adelaide and also provided a second presentation titled 'Sexuality and Female Genital Mutilation - The Psycho-Social Impact of Sexual Dysfunction due to Female Genital Mutilation'.  

Today she kindly spoke with me about FGM in the context of health settings with a particular focus on sexual health clinics.  It is with her generous permission, and that of ShineSA, that this audio interview is able to be shared.

Due to the size of this 12 minute audio file, it is hosted on the external link below:

https://soundcloud.com/user329177428/khadija-gbla

For more information on FGM and FGM in the Australian context see the following link: http://www.nofgmoz.com 

 

FAMSACA - is Forensic & Medical Sexual Assault Clinicians Australia. 

www.famsaca.org.au

Today commenced with FAMSACA breakfast which was very well attended.

The organisation is small group nationally and meets up every 2 years. It welcomes new members and provides clinical educational updates. 

The Australian media has increased its reporting on Domestic Violence (DV) in Australia.

DV has become a major topic and focus nationally, especially since Rosie Batty education campaigns and advocacy.

FAMSACA presenters discussed 4 different and highly complex Client cases.

Physical Assessment of Woman and Girls after an assault can be re-traumatising.

There is clear Pathways to E.D and Medically investigation. 

FAMILY PLANNING - Copper IUD is 1 of the most effective form of contraception. 

New Emergency Contraception Pill, Ulipristal acetate is 99% effective. Ideally to be administered ASAP and within 4 days of an event. After this time it's efficiently declines rapidly. Cost is approximately $50.00 AUD and will become available over the counter in 2017. Please refer to  www.ellaone.com 

Reporting Violence to Police and relevant Authorities in relation to Children.

We spoke about the potential difficulties of reporting if the victim refuses to consent in providing this information and requests confidentiality. 

Woman may often feel unsafe reporting to Police due to fears of retribution from men/boys. This can include threats to their children. Victims dislike reporting directly to the Police, an option would be to report this on-line, but the Police require the victim (witness) to provide details, otherwise they lack powers to investigate. 

Other challenges to services and clinicians are re-current presenters. This often presents in context of people with an Intellectual Disability or mental health, with a history of childhood sexual abuse. It is hard to establish safety with ongoing abuse. 

Under age children/young people with abuse, even under Guardianship present particularly difficult challenges. When they become of legal age of sexual consent the police are not so interested. 

Drugs and Alcohol are frequently seen but it’s also can be common not remember things/details. 

Clinicians need to celebrate small changes to cope and manage working in this area of trauma. 

It is important for Clinicians and Community Workers to know where to refer Clients and Patients to these Specialised Services. 

 

 

 

 

 

 

 

 

 

Day one of the Australasian Sexual Health Conference 2016 included presentations showing: advances in resistance testing and POCT for common STI’s, novel treatments of MG, possible reasons why Australia lags behind in LARC uptake, Australia-specific barriers to termination of pregnancy, as-well as issues such as the importance of a multi-layered representation of aboriginal men to aid with engagement around sexual health and how policy is protective of LGBTIQ young people in Australia.

 

Associate Professor Rebecca Guy discussed the challenges of STI testing amongst aboriginal communities in remote areas. She reported the average time to treatment being 21 days due to population mobility and distance to lab, with 1 in 5 not receiving treatment at all. 

In 2011 12 rural health services trained aboriginal nurses and health-workers to perform a POCT for CT/NG (‘Xpert’). This meant results could be given within 90 minutes. Treatment uptake increased to 96.2% (treatment uptake for the standard was 88.3%). The mean time to treatment reduced from 19 to 4 days with 80% being treated within 7 days (compared with 48.5% previously). Future studies will look at POCT for NG/CT cost effectiveness.

 

MG remains a concern with increasing resistance to azithromycin and moxifloxacin. Associate Professor Catriona Bradshaw explained how Pristinamycin could not be considered an alternative treatment in those where azithromycin had already failed due to a disappointing cure rate of only 75%. However, Pristinamycin may have a role in special circumstances such as pregnancy as it is safe with few side effects.

 

Dr Elina Trembizki proposed PCR resistance testing could individualise NG treatment by accurately predicting ciprofloxacin susceptibility through TCC/ TTC wild type detection. It possible NG resistance to ciprofloxacin may by over represented through traditional culture methods though this should only be interpreted in an Australia context.

 

In the reproductive health lectures Mary Stewert highlighted the need for contraception education in men as although survey through a dating website revealed high rates of contraception use there was a lack of awareness of LARC’s and many believed hormonal contraception especially the ECP to be harmful which could negatively influence female partner decision.

 

Australia still lags behind in LARC with only a 3.2% uptake compared with 13.9% worldwide. Dr Amy Moten dispelled myths about IUDs explaining that PID rates are now <1-2% regardless of age and only in first 20 days post insertion after which time risks go back to baseline. Studies have even shown that there is no benefit of removing IUD in PID unless there is no improvement in clinical status after 48-72hours. Therefore PID should not be a barrier to IUD’s. Gabrielle Lodge looked at GP perspectives towards IUD insertion revealing barriers to include cost to train, minimal Medicare rebate and de-skilling due to small patient load.

 

There was a call to make MTOP de-centralised and so more accessible and affordable.  As despite misoprostol being available on PBS professor Angela Taft found many women find cost a significant barrier. Spontaneous discussion highlighted women’s experiences can vary widely depending on the state. Lauren Coelli described a successful nurse-led approach used in Victoria and emphasised importance in training all members of the MDT including receptionist staff to de-stigmatise.

 

Other interesting lectures included Dr Deborah Bateson speaking about POP (75mcg desogesterol  - not available in Australia) as a treatment for migraine possibly due to anovulation. Associate professor David Templeton who presented the increased follow up of victims of sexual assault due to improved relationship between sexual assault and sexual health services, councillors calling individuals to make appointment, separate waiting room, councillor obtaining sexual history, and personal phone call with negative results. >10% of these patients had an STI showing the importance and benefit of proactive follow up.  Todd Fernando discussed how the media/ literature fuelled view of aboriginal men either being heterosexual or hyper-sexualised MSM needs to be remedied to aid engagement with sexual health services and Tiffany Jones talked about how policy made LGBTIQ young people feel safe. Lack of policy and poor education in schools around LGBTIQT leads to increased bullying, days off school, self harm and suicide whereas promoting activism can me protective.  

 

 

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RT @AlfredHealth: New research from Melbourne Sexual Health Centre shows rates of syphilis & gonorrhea have reached levels not seen since t…

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