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 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

ASHM Conference 2015 – Take home messages from a GP

 

The 2015 ASHM conference displayed all the teamwork I saw at the first conference which I attended 21 years ago.  Great presentations and choices in themes. There was friendliness and a range of stakeholders and an ongoing respect for the roles and hopes of the different parties. The meaningful involvement of all the stakeholders and especially those most affected by blood borne viruses is unique to ASHM stakeholders and I have not seen such teamwork in all the branches of medicine I know.

In a nutshell, the big message for GPs from this conference is PrEP, PrEP and PrEP. PrEP means pre exposure prophylaxis. GPs will need to get ready for what appears to be a huge ground swell of demand for PrEP. They will need to know the use of Truvada for HIV sero negative gay men.  Truvada for PrEP is not currently approved by the TGA and the PBS. So, GPs working in the MSM health area will need to know what mechanisms exist for current access.

Some issues will exist for a GP who considers prescribing PrEP, but the figures offered at this conference strongly suggest the outcome for ser negative MSM at high risk of HIV infection and  on  Truvada will be a lowering of new HIV cases.

The United Nations 90%:90%:90% goal concerning HIV was often referred to  in presentations. The UN goal is:-

- 90% of people living with HIV will know their HIV status.

- 90% of people living with HIV will receive sustained anti retroviral therapy.

- 90% of people receiving antiretroviral therapy will have durable viral suppression.

A big message was that early ART treatment is recommended - start at the time of diagnosis. Regardless of CD4 count. Many presentations supported this. The START (Strategic Timing of AntiRetroviral Treatment) Study presentation concluded that:-

=Combination antiretroviral therapy (ART) should be recommended for all HIV -persons regardless of CD4+ count.

= The START Study results align the benefits of ART to the HIV-positive individual to the benefits of ART in reducing the risk of viral transmission from HIV – positive persons to non- HIV- infected individuals. So, clinicians should regularly discuss the current state of knowledge regarding when to start ART with all individuals with HIV who are not yet on ART.

 The conference presentations reviewed current recommended ART treatment and some of their toxicities. An issue resulting from this is that all decisions to start ART should be made by the individual with HIV, in consultation with their healthcare providers and on the basis that they are fully informed and supported in their decision making. Patients makes the decisions and doctors give  good advice  for the  patients to  base their  decisions on.

The conference highlighted the importance and difficulties in long-term follow-up of people with HIV. The option in the future of a national notification system might help in this regard, but there are currently greater efforts to evaluate past and current treatments.

 Data at the conference strongly showed that mucosal damage from STDs lead to more easy HIV infection and the vigilance to treat STDs to decrease HIV spread cannot be over emphasised.

 The new treatments for Hepatitis C genotypes 1 and 3 with daclatasvir and sofosbuvir have been approved by the TGA and are awaiting PBS approval.

 Victorian data suggests that in Victoria, HIV and STD notifications are rising. There is evidence of ongoing increase in condomless anal intercourse with casual partners. There are also additional risk reduction practices in use in the community.    

 Geoff Symonds gave a presentation on gene therapy treatment for HIV. I found this fascinating and wonder how the role of gene therapy will pan out in the future. Great potential there.

 At the ASHM AGM an overwhelming number of members voted to change its formal name and affirm its current role in covering HIV, viral hepatitis and sexual health. The new name is the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine.  The good news is the logo and the associated word ASHM stays there as well.

 ASHM delivered a great conference.

 

 Darcy Smith

Tagged in: HIVAIDS2015

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