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.

Reproductive Health: Contraception, Access and Equity

 

Amy Moten from ShineSA dispelled some myths regarding intrauterine devices (IUDs) causing pelvic inflammatory disease (PID). Amy explained the reasons behind the poor uptake of IUDs in Australia in comparison to other countries.

The legacy of the Dalkon Shield has cast a shadow on the use of IUDs in Australia. The Dalkon Shield was an intrauterine device manufactured in the 1970’s. It became infamous for its serious design flaw-a porous, multifilament string upon which bacteria could travel into the uterus causing sepsis, miscarriage and in some cases death.  There are three intrauterine devices available in Australia- the progesterone IUD called Mirena and the non-hormonal IUD’s-copper T 380A and Multiload. IUDs are extremely effective long acting methods of contraception, which are under utilised in Australia. Only 3.2% of Australian women use IUDs V 35% of Vietnamese women.

Data from 12 randomised studies revealed that modern IUDs showed an overall rate of PID of 1.6 cases per 1,000 woman-years of use.

 There is strong evidence to indicate PID is related to the insertion process. 20 days post insertion the risk of having PID is the same as a non IUD user.

 Take home messages

·      There is no difference in outcome for women with PID who retained the IUD compared to those who had it removed

·      All women who are diagnosed with PID should be reviewed in 24-72 hours

·      IUDs can be used in nullips and there is no increased risk of complications in younger women

·      IUDs are a cost effective method of contraception and clinicians can help by dispelling myths regarding side effects

·      Contraception is very much a very personal choice. It is important that clinicians suggest appropriate contraceptive options for their patients/clients. Long active contraceptive options can be a great choice for women of all walks of life, especially those with chaotic lifestyles. I often suggest LARC for our ‘at risk’ young clients who are often homeless and using drugs.

      Angela Taft (La Trope University)-Medication abortion: access and equity following Mifepristone on the PBS

Medical termination of pregnancy (MTOP) has become more available Australia since restrictions were lifted on mifepristone. Mifepristone can be taken for 63 days/9 weeks after conception. Women can now choose their preferred method and the MTOP can be preferred over surgical interventions for many reasons. Taft explores access and equity in obtaining a termination, including reported challenges, preferred methods and out of pocket expense. The data was from Marie Stopes clinics from November 2014 to April 2015.

Demographics @ Marie Stopes clinics-

·      49% nulliparous but 35% had previous abortions

·      Over 83 % attended for TOP within the first trimester

·      Little difference in the cost of surgical terminations and medical terminations at  Marie Stopes clinics- non Medicare holders can pay up to $1160

·      Identified factors associated to late presentations include distance to clinic, not aware that MTOP was available, and financial difficulties

      Take home messages

Mifepristone is now available in Australia but there can be a significant cost involved which reduces access to lower income earners. 1 in 5 study participants expressed concerns about the cost of abortion and relied on the financial assistance of others. 

35% of clients attending for TOP have had previous abortions. It would be great if contraceptive advice and free LARC could be offered on the day women attend for terminations.  Angela Taft’s talk sparked some debate on why the price of medical termination of pregnancy (MTOP) was so expensive.

 KRC can offer free contraception to ‘at risk’ young people and other target populations. Free contraceptive options include the combined contraceptive pill, emergency contraception, implanon and mirena or copper IUD. Clinicians at KRC often refer clients for TOP and with the clients permission can liaise with the clinic and make a plan regarding contraception options post procedure.

 This session was followed on nicely by the amazing initiative of Lauren Coelli who established Clinic 35 in the Hume region. Her work has undoubtedly improved access for marginalised population groups.

 Increasing access to medical terminations of pregnancy through nurse-led models of care/Decentralising abortion services: The Integration of Medical Termination of pregnancy into a Rural Primary Health Care Setting-Lauren Coelli

Commenced MTOP in 2015

·      Accessible and equitable service-no Medicare required

·      Nurse-led model excellent opportunity to increase access to MTOP

·      Requires good working relationship with GP + Pharmacy who has undertaken MS2Step Training

·      Few GPs complete training as consultations associated with MTOP are lengthy (>45 mins) and there is suboptimal remuneration for GP.

·      The nurse’s role includes triage, pregnancy options, holistic assessment, investigations and referrals for ultrasound and specialist referrals.

·      The cost of MTOP at Clinic 35 costs between $0 and $38.20

·      In-depth planning process and ongoing communication is essential for the program to be successful

 Take home messages

This service is awesome. It is a step forward in the movement for sexual and reproductive empowerment of women in Australia and hopefully it can be emulated in other countries worldwide

 

 

 

 

Enjoyable last day, great morning sessions discussing PrEP and The way forward. I managed to sit through all presentations as I felt that I may pick up on some information which I found interesting and I could take home. I have truely enjoyed this conference and feel I have learnt so much and can't wait to share to anyone who will listen.

I feel I could make a difference in Refugee Health as I would like to commence education on my return. Where and how could I commence this? Currently, I believe NSW refugee nurses aren't discussing Sexual Health to the extent it needs to be discussed. I am going to talk about HIV and STI's at my initial nurse assessment and would like to talk about this conference to other Refugee nurses. Humanitarian refugees have already had a HIV test prior to coming to Australia. Depending on the country of origin, depends on the clients sexual health knowledge and from experience, I have found that most refugees and the CALD populations have had no sex education prior to coming to Australia. 

I would invite other organisations such as FPA and the Sexual Health service to help with education. Another possibility would be to educate at my outreach clinic at TAFE Newcastle. I am unsure of the numbers of NESB clients living in the Newcastle area with HIV. Don't forget to use interpreters for NESB's and give houndouts in their first language.

My role will now include discussion around safe sex, sexual health, informing clients of services which can provide testing, online websites and Apps and to provide this information in their first language if they are literate. 

2017 celebrates 30 years of ART's and I look forward to immersing myself in new literature and research. Very exciting research and clinical trials looking at durable remission/cure which may also include the 're-building of the immune system'.

Thankyou to ASHM for this scholarship which has made me so excited and full of energy to go and educate Refugee nurses around Australia in all that is offered regarding sexual health. There are so many exciting trials happening around the world and I am optimistic that someone will find a cure. I also want to look into the App world more to see how we can use the tool for research. Since HIV has been classed as a chronic illness, I wonder how clinicians are keeping their clients on a happy, healthy pathway since the clients are living longer? This is a discussion that we should have later. It is difficult to motivate clients to continue medication regimes when they feel well and we see this in psychiatry and clients with diabetes. Just 'food for thought' . Cheers Karinne

The session . On. HIV and cancer  was a rapid overview anD quite  focussed on the French experience -

HIV and cancer - DR Jen Philippe Spano -france 

RIsk factors- Age, HIV, oncogenic infections (HPV, EBV, HCV, HBV, HHV8), smoking, inflammation, sun (melanoma), low CD4
 
cART relative risk -non AIDS cancer with inc risk - inc Hodgkins 19 RR, anus and liver and lung - often occurs at YOUNGER Age  than HIV neg counterparts (Not inc risk of breast ca, prostate or colon ca) 
 
SMOKING is the trigger for the oncogenic viral infections to have their effects; 
-HIV contributes to inc risk of non aids cancer when adjust for smoking and oncogenic viral infections cf the general population;
 
LUNG cancer-in HIV pos pt in France, this is the highest ca diagnosed; 
Screening in the Gen pop- - CT scan- false positive nodules, may lead to false pos, used for diagnosis;
One study showed (not specifically HIV pts) annual low dose CT scan was better than CXR and resulted in reduced mortality 
 
-in France did a study in HIV pos smokers , low dose CT annually, 400 pts, 10 pts were diagnosed with lung Ca, mean CD4 high, problem  is the high  rate of other pulmonary comorbidities and false pos rate and biopsy, anxiety etc to investigate these further 
 
SKIN malignancies- eg BCC, SCC - should have regular annual examination;
RFx -Sun , FH, aging 
 
IN France, all patients in Gen population diagnosed with these cancers recommended to have HIV test . 

Was greeted by a Scottish Piper this morning on my way into the SECC. Really enjoyed the morning sessions and particularly enjoyed the 'Transition to adult care' by Pablo Rojo, PaediatricIan from Spain. His clinic tends to hold onto young patients until they are possibly more mature and are more likely to make their own appointments and continue their own care. Depending on their maturity and knowledge of their health care needs depends on them transitioning across to adult care. With over 350 posters to view after lunch, I spent the afternoon perusing and soaking up what I thought was interesting. I did met a lovely young Dr/researcher  from Mumbai a few days ago and he was exhibiting his poster. He wanted to explain his fabulous work to me. Title of his poster "Association of SLCO1B1 521T>C (rs4149056) with darunavir/ritonavir (DRV/r) plasma concentrations in HIV-infected individuals enrolled in the NEAT001/ANRS143 Study". Once he had finished explaining his research, I thanked him for his patience in explaining his very in depth and scientific work to me. I still can' t get over the lecture yesterday given by Dr Andrew Hill from London, his work inspired the audience and I want to research more about his work on my return. I look forward to tomorrow's sessions in PrEP and the way forward. I suspect I will enjoy these sessions. Cheers Karinne

Amazing 1st day at this conference, enjoyed most of the sessions, very scientific and to be totally honest, some of it 'over my head'. What did I learn and want to bring back to my peers in Refugee/Sexual health?

1) the push to have more community HIV clinics, where clients can access without the stigma attached to hospital clinics.

2) some research is looking at 'inplanontype devices which leak the drug slowly over a 12 month period and could be removed if unable to tolerate.

3) some research also showed that clients would prefer to self administer injections rather than taking tablets for their illness. Clients were able to forget about their daily regime of tablet taking, were able to be more spontaneous, felt the injections were safe and the fear of needles was not a major concern.

4) Implantable PrEP (silicon tubing implant) which would have a minimum 1 year insertion and then dissolve!!

5) Lower cost of medications for the treatment of cancer, HIV & Viral Hepatitis by Andrew Hill was very interesting. He discussed the cost of drugs in reality if made in India which is far cheaper than other options. I think we should all be looking at his research/discussions and possibly buying our drugs from India which I believe is legal in Australia.

Lastly, as you know, there has been an increase in Australia in HIV cases and I wonder if we are doing enough to educate our population? Clearly not. The last speaker of the evening was Linda-Gail Becker who talked out the 'kids born after 2000' the 'i-generation' who are using technology for everything. Maybe we should be educating  this population via devices!!

If there is something you would love to know and couldn't be here, let me know and I will endeavour to find out for you. Cheers Karinne and thanks to ASHM for my scholarship.

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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