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.

Thursday 21.07.2016 -Hormonal Contraception and HIV: A Review of the Science and Research, and their implications for Research, Programme and Policy.

Some studies suggest an association between specific hormonal contraception methods and HIV acquisition.   DMPA has been mostly implicated.  Information has come from observational studies alone. 

Chelsea Polis, US, presented an updated systematic review,updating their previous 2014 review, Ten new and 21 studies from past review were included in the analysis. 

 

Patches, rings, Hormonal IUDs:  no data

Implants:  very limited data on LNG implants, does not suggest increased risk.

OCPs [Oral contraceptive pills]:  substantial amount of data, does not suggest increased risk.

DMPA [depot medroxyprogesterone acetate ]:  substantial amount of data, newer data are increasingly concerning and converging around 1.2 -1.6.  

NET-EN [norethisterone enanthate (NET-EN)  ]:  limited data; less concerning than 2014 review, still worthy of investigation.  

Questions were raised regarding the reliability of the results considering the nature of the studies, none being RCTs in particular relating selection bias. ie. Women at higher risk for HIV choosing DMPA.  

Another delegate stated that pregnancy per se increases risk of HIV acquisition by around two fold and there is a need for reliable contraception; hence findings of any small increases in risk of HIV acquisition with DMPA should be considered in context.

Jared Baeten, US,  Update on ECHO Multi Centre,  Open Label, Randomised trial on HIV acquisition among users of different hormonal contraception methods [DMPA, LNG implant, Cu IUCD].

 

N=7800 f/u , 12 sites in Kenya, South Africa (9), Swaziland and Zambia.   18 mths per women. Quarterly follow up with usual standard of care.

Started in 2015 and will go on for ~36 mths.

This is a very important study.

 

Janet Hapgood, SA, Biological/immunological mechanisms for an association between HC and HIV

Very interesting presentation with regard to progestogens: different doses, methods of delivery, duration, inter-individual variation,  differ in their off-target effects via different steroid receptors which predicts different side effects.   DMPA has activity like cortisol. 

Conclusion: Collectively, clinical, animal, and ex vivo studies are broadly consistent and show that DMPA increases permeability of the female genital tract and compromises select FGT and systemic immune responses.  This most likely leads to increases in HIV acquisition via multiple mechanisms more so in some individuals than others. 

 

Andy Gray, South Africa,  presented on Interactions between HC methods and ART- updated systematic review.  This review was to update the evidence on which the WHO guidance and local policy is bases.

ART and HC effectiveness

·         Efavirenz – most clinically significant interactions were with Efavirenz. 

Implant users:  pregnancy rates from 5-15 per 100 w-y.   (c.f 0-2 per 100 w-y)

Combined oral contraceptive pill:  13-15 per 100 w-y. 

DMPA: not impactecd.

·         Nevirapine – No significant impact.

 

 

HC and ART effectivenessNo significant effect noted.

 

DMPA and PrEP – no significant effect. 

Conclusions include:

·         Current published data do not support limiting access to any HC.

·         Full range of HC options should be made available

·         More well designed studies are required to study drug interactions

 

 

Tagged in: AIDS2016

This lecture on recreational drug use by Marta Boffito from London was a nice summary of some of the trends they are seeing in the UK and how this may affect treatment.

 

Marta started by highlighting a paper from 2014 - the ASTRA study which identified significant polydrug use (of recreational drugs) amongst MSM in the UK and its association with condomless sex. Whilst this may be a risk for HIV transmissions, the potential interactions with antiretrovirals in people living with HIV should also be considered. The Liverpool website neatly summarises some of these interactions here.

 

 

Of particular concern is the use of GHB or GBL (collectively known as ‘G’) as a party drug. This synthetic version of an endogenous hormone is rapidly absorbed and has a relatively short half life, leading to people sometimes taking multiple doses to maintain their ‘high’. The main concern with it is the fact that it has a narrow therapeutic range, and doses up to 3ml can cause death. In addition, ethanol interferes with the metabolism, as do ARVs such as PIs and cobicistat. Whilst crystal meth seems to be getting much attention at the moment (and something I see in my clinical practice in central Sydney frequently), the use of ‘G’ is of significant concern, particularly in patients with these potential drug-drug interactions. When reviewing or commencing PIs or pharmaco-enhancers such as cobicistat, it is crucial to take a full drug history and warn patients about potential interactions, even if they do not freely admit to using such drugs. 

 

Tagged in: EACS2015

Prostate cancer screening was discussed in the context of HIV at a presentation today by  L. Shepherd.

Her group showed some PSA difference perhaps in HIV positive men.

The study used conditional logistic regression models to investigate potential relationships between markers and prostate cancer. The suggestion from the study was that prostate cancer may occur at lower PSA levels in HIV positive men.

I found this suggestion remarkable given that the guidelines for the general population are so hotly debated. In this study there was no detail about how prostate cancer was defined.

It was not clear whether this was a true "screening" PSA process or whether these were symptomatic men.

 

This data will not change my view about PSA screening in all men positive or negative.

Tagged in: EACS2015

This morning's meet the experts session about drug interactions was very interesting. There are an enormous number of potential drug interactions but the significance of many of them is unknown.

New drugs are being added to the database every week.

We will be faced with a large number of patients on multiple medications and particularly with the co-infected some clinical dilemmas.

The key useful points and questions for clinical care in the primary care setting are:

1. Are the other drugs necessary?

For instance statins and low-level antihypertensives could be ceased for a 12 week treatment course.

2. Are there any alternatives with less or no predicted interactions?

If so switch

Can the DDI be managed?

If the answer is yes then dose.adjust and monitor for toxicity. There was some discussion about trying to monitor for efficacy which is a little more difficult but very important.

If the answer is no

- the risk needs to be explored and discussed with the patient to decide whether the risk is worth taking.

A very valuable clinical point was made that a large number of patients with HIV on therapy have other medications with known DDI's in the current regimen prior to starting hepatitis C treatment. These probably do not have to be approached fearfully as they have been already sorted out.

 

 

 

Tagged in: EACS2015

The Pre congress workshop was aimed at junior specialists and professionals in training and followed a theme of challenging case presentations followed by an overview of the topic by an expert. Women living with HIV seems to be a problem area in London mainly in black African backgrounds. The topic covered was contraception and take home messages were that women tend to go to their GP for contraceptive issues and tend not to disclose their HIV status and end up getting a contraceptive method which interacts with her ART.

There seems to be trend of prescribing Truimeq for women of childbearing age despite the fact that there is no data on teratogenicity of Dolutegravir, in case they have an unplanned pregnancy. Generally regimes are unchanged if they do fall pregnant mainly because by the time the pregnancy is discovered it is usually past 6 weeks. A study is currently underway in African pregnant women on Dolutegravir looking at teratogenicity and so far there have been no reports. 

Caesarean section rates seem to be still high in regional centres despite viral suppression to undetectable levels. This is party accounted for the number of women with a previous section but they are hoping it will go down in future. Considering the poor compliance of women coming back for contraception at 6 weeks post partum, intracaesarian IUD insertion had been effective both in the USA and Africa with expulsion and infection being rare and may be used for an occasional poorly compliant woman.

The session on 'Chem sex' was quite interesting as I learnt a lot of new jargon relating to sex and drugs. There is about a 15% rise in IVDU among MSM in UK in the last decade giving rise to the risk of spread of HIV, HBV, HCV, HDV, and of course STI's. Slamming is another word used for using psychoactive substances in a party or sex settings. A qualitative study done in Paris showed that men using these drugs were unaware of their HIV and HCV status rates being as high as 40-60%.

When considering the amount of MSM turning up at the clinic on Monday afternoon for PEP after a 'wild weekend', I think that chemsex would be a potential problem in Sydney and other major cities in Australia very soon. Repeated HCV infections are a major problem in this group.

For both contraception and chemsex, a most valuable site is the Liverpool drug interactions website.  www.hiv-druginteractions.org

STI session was quite interesting and increased rates of gonorrhoea, Chlamydia and syphilis were universal all across Europe in the last couple of years.

Funny fact - In the olden days gonorrhoea was treated by hitting the penis with a bible! :)

Tagged in: EACS2015